Dachaihu Tang and Fuzi Gancao Tang TCM Medical Record

Author: Nan Kaiyang  Editor: Gu Yuxi Translator: Gu Yuxi

Gender: Female Age: 50 Height: 152cm Weight: 80KG (converted from 160 jin) Occupation: Teacher

Q: What is the most important physical problem you want to solve right now? Please explain in detail.

A: Rheumatoid arthritis, night sweats, uncomfortable heart, knee and ankle joints sometimes hurt at night when falling asleep but feel better after morning activity, lower back pain in the morning, sometimes drooling at night. Body has damp-phlegm and cold, memory decline. Had one ovary surgically removed in 2015 due to an ovarian cyst. Usually exercises little, easily fatigued and weak, average appetite, has muddy gallstones, prone to bitter taste in mouth and dry throat, dislikes drinking water. Sometimes has chest distension; took Xiaoyao Wan yesterday. Urine has a strong odor, sweat is occasionally yellow, armpit sweat has an odor, feet sweat year-round. Drank ice water 15 years ago, which damaged the spleen and stomach and has never fully recovered, leading to many body problems, including lumbar disc herniation. Feels heavy dampness in the body, occasional allergies, small blisters on ankle joints.

(I) Head and Body Hot/Cold

1. Recently, have you experienced aversion to cold, aversion to wind, or aversion to heat?

A: Night sweats, aversion to wind.

2. If yes, which specific body part experiences aversion to cold, aversion to wind, or aversion to heat?

A: Night sweats and aversion to wind and heat around the epigastrium and lower limbs.

3. Do you have headaches? Where is the pain located, and what is its severity?

A: Occasionally pain in the temples and around the eyes.

4. Do you have a fever? What is your temperature? Do you feel feverish even if a thermometer doesn’t show it? Do you feel restless and irritable?

A: Irritable and disheartened.

5. Do you experience alternating chills and fever?

A: Rarely.

6. Do you have nasal discharge, cough, or nasal congestion?

A: No.

7. Recently, is there stiffness or discomfort in your shoulders and neck?

A: Yes.

(II) Sweat

8. Recently, are you able to sweat? If so, is the sweat abundant or scant?

A: Abundant.

9. Do you sweat during exercise, or do you sweat spontaneously at rest?

A: During exercise.

10. Where does sweating primarily occur?

A: Back and armpits.

(III) Mouth

11. Recently, do you have a dry mouth all day? Do you frequently have oral ulcers?

A: Occasionally dry mouth, no ulcers.

12. Recently, do you feel like drinking water all day? Does drinking water quench your thirst?

A: No, it quenches thirst.

13. Recently, do you prefer warm water or cold water?

A: Always drink warm water, never cold water.

14. Recently, do you have bad breath? Do you have a bitter taste in your mouth?

A: Both.

15. Recently, are your lips dry and peeling? Do they appear purplish?

A: Not peeling.

(IV) Urination and Defecation

16. Recently, is urination frequent? How many times a day? Is the urine volume large?

A: Once a day, not much volume.

17. Recently, is your urine white or yellow?

A: Yellow, occasionally foamy.

18. Do you experience dribbling urination or a feeling of incomplete emptying? Is there stinging pain? Frequent, urgent, or painful urination? Do you have a burning sensation? Do you wake up at night to urinate?

A: Yes, feeling of incomplete emptying. Must wake up every night to urinate. Occasional vulvar itching.

19. Recently, do you have a bowel movement every day? If not, how often?

A: Yes, once a day.

20. Recently, are your bowel movements smooth?

A: Smooth.

21. Recently, are your stools hard, or soft and loose? Do they stick to the toilet bowl?

A: Soft, thin, loose, sticky.

22. Is your anus itchy? Do you have a bearing-down sensation? What is the color? Is there blood in the stool?

A: No.

23. Do you frequently pass gas? Do symptoms lessen after passing gas? Do you frequently have diarrhea?

A: No. Abdominal distension lessens. No.

(V) Chest and Abdomen

24. Recently, do you have chest tightness? Do your flanks under the armpits hurt?

A: Both.

25. Recently, do you feel like vomiting?

A: No.

26. Recently, is there pain when you press on your epigastrium with moderate force a few times? Do you have phlegm? Are you easily angered?

A: Have phlegm. Burp with one press. Prone to holding in anger.

27. Recently, is there any pain when you press on the upper, lower, left, or right areas around your navel with moderate force a few times?

A: Upper, lower, and right sides all hurt.

(VI) Hands and Feet

28. Recently, do your hands and feet feel warm or cold to the touch?

A: Warm.

29. Recently, do your limbs have pain or weakness? Do you feel it in the muscles or in the bones/joints?

A: Ankle pain. Feels like bones are not moving smoothly. Pain lessens with activity.

30. Do you experience limited flexion/extension of limbs, swelling, contracture, numbness, vexing heat in palms and soles, joint swelling and pain, hot hands and cold feet?

A: Limited flexion/extension of limbs. Occasional joint pain in hands and feet. Since youth, feet would sweat hot in summer, and in winter, sweat would make feet cold, continuing to this day. Have athlete’s foot.

31. Is there pain or other discomfort in your lower back? How does it specifically feel? Is turning left and right smooth?

A: Lower back feels like a stiff board, not flexible.

32. Do you experience body pain or other discomfort with changes in weather? Do symptoms worsen with changes in weather? Which symptoms worsen? Do your knees hurt? (Where is the pain located, to what extent?)

A: Knees hurt with changes in weather, so painful it affects sleep.

(VII) Diet

33. How is your appetite recently? Do you feel energetic?

A: Okay. Not energetic. Poor memory.

34. Do you eat eggs, dairy, or fruit, milk tea every day?

A: No.

35. What was your last regular meal?

A: Rice and lamb.

36. Do you prefer warm or cold food? Does drinking cold beverages upset your stomach?

A: Don’t dare to drink.

(VIII) Sleep

37. Recently, is it easy to fall asleep?

A: Difficult to fall asleep, don’t dare to drink cold beverages.

38. Recently, do you wake up easily after falling asleep?

A: Wake up easily.

39. Recently, do you dream a lot? What kind of scenes do you usually dream about?

A: Dream a lot, random things.

(IX) Other

40. (Female patient) When was your last menstrual period, and what is your cycle length? Color, are there blood clots? Do you have dysmenorrhea? Are you pregnant?

A: Monthly, pale or dark black dysmenorrhea, not pregnant.

41. Do you experience discomfort before or after menstruation? For how many days? Is there breast distention and pain?

A: Distention and pain for one or two days.

42. Have you donated blood recently, or had bleeding?

A: No.

43. Do you have a history of surgery? Have any important organs been removed? (Very important)

A: One ovary removed.

44. Are there any other discomforts in your body? Please explain in detail.

A: (No additional answer provided)

45. What medications have you taken for this condition before? What was the effect? Can you send photos of used prescriptions or medications?

A: Xiaoyao Wan.

Prescription：

Dachaihu Tang (Major Bupleurum Decoction) combined with Fuzi Gancao Tang (Prepared Aconite and Licorice Decoction) with modifications:

• Radix Bupleuri (Beichaifu): 25g
• Fructus Aurantii Immaturus (Zhishi): 12g
• Radix Glycyrrhizae Preparata (Zhigancao), Radix Scutellariae (Huangqin), Radix Codonopsis (Dangshen): 9g each
• Rhizoma Pinelliae Preparata (Jiang Banxia), Fructus Gardeniae (Zhizi): 10g each
• Ramulus Cinnamomi (Guizhijan): 25g
• Radix Aconiti Lateralis Preparata (Paofuzi): 20g
• Rhizoma Zingiberis Recens (Shengjiang Pian): 8 slices
• Endothelium Corneum Gigeriae Galli (Chaojineijin): 15g
• Fructus Jujubae (Dazao): 3 pieces (pitted)

Five doses, one dose taken once in the morning, noon, and evening, before meals. Decoct in 10 bowls of water over low heat for one hour.

Follow-up：

The patient’s complexion became more radiant (before drinking, the patient had puffy under-eye bags and a sallow, dark complexion). Joint pain was significantly reduced, chest and flank pain disappeared, facial paralysis disappeared, and overall improvement was significant. An ultrasound at the hospital showed the gallstones were gone.

Disclaimer:​

The experiences and insights shared above represent the author’s personal usage and understanding, and are provided for reference only as part of academic exchange. Please do not blindly replicate or apply them; any consequences arising from such actions are solely your responsibility. As individual constitutions vary, medication should be tailored accordingly. It is advisable to use such treatments under the guidance of a qualified physician. If you have additional experiences to share, comments and submissions are welcome.​
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