Patient Information
Mr. Zeng, male, 40 years old. Transport company manager.

Medical History
Denies medication or food allergies. Denies a history of chronic illness.

Presenting Complaint
Experienced discomfort and bloating in the stomach for about 4 months, especially after meals. Has a history of gastric problems, often irregular eating due to busy work schedule. Reports that around April of this year, his gastric issues flared up after overeating hotpot and seafood (patient's terminology). Initially experienced bloating and belching, sought medical attention from a western doctor, diagnosed with gastritis, prescribed anti-inflammatory and pain relief medication. Pain subsided after medication, but bloating persisted. Due to reluctance to take western medicine again, came for consultation based on a friend's recommendation.

8.8.2021 First Consultation
Complains of bloating in the upper abdomen, not painful, slight tightness upon palpation. Reports slight relief with warmth and slight relief upon pressure. Bloating worsens after meals. Clear consciousness. Speaks rapidly and loudly. Lean physique. Sleeps well, wakes up at 1 AM, easily falls asleep, no dreams. Appetite good, feels hungry, belches frequently, occasionally experiences acid reflux. Prefers warm drinks. No chest or rib discomfort, occasional dry mouth, no bitter taste, no dry or itchy eyes, no headaches or dizziness. Bowel movement once a day, formed stool, occasionally loose, normal frequency and quantity, soft stool, frequent passing of gas, occasional abdominal bloating. Urinates frequently, clear and copious, occasionally nocturia once a night. Sweats less. Cold intolerance, cold hands and feet, especially cold feet. Occasionally experiences lower back soreness. Tongue slightly red with thin white coating; pulse wiry and slightly tight. Advised to consume bland diet to nourish the stomach, avoid cold and chilled foods to prevent spleen yang deficiency.

Diagnosis:
Gastric distension (cold type). Spleen and stomach deficient in yang qi, spleen deficiency with liver hyperactivity, kidney yang insufficiency. Treatment aims to soothe the liver, tonify the spleen, warm the stomach, dispel cold, and warm the kidneys to assist the spleen.

Treatment:
Prescribed concentrated Chinese herbal powder (same for subsequent prescriptions) as follows:
Atractylodes macrocephala, Paeonia lactiflora, Saposhnikovia divaricata, Citrus reticulata, Magnolia officinalis, Areca catechu, Citrus medica, Psoralea corylifolia, Evodia rutaecarpa, Aconitum carmichaelii (processed), Cinnamomum cassia, Glycyrrhiza uralensis. 4 days, 1 sachet after breakfast and dinner.

Treatment Principle:
Aiming to gently soothe the liver and tonify the spleen, using
Citrus reticulata, Magnolia officinalis, Areca catechu, and Citrus medica to move qi and invigorate the spleen, supplemented by Psoralea corylifolia, Evodia rutaecarpa (main ingredients of Si Shen Wan), Aconitum carmichaelii, and Cinnamomum cassia to warm and tonify the spleen and kidneys, with Glycyrrhiza uralensis for harmonizing effects.

13.8.2021 Second Consultation
Reported slight improvement in stomach discomfort and belching after medication, reduced sensation of coldness. Experiences mild symptoms of excessive internal heat, resolved spontaneously after two days. Other symptoms remain the same, acid reflux not alleviated, slight adjustment to prescription medication continued. Tongue and pulse unchanged. Prescription as follows:
Paeonia lactiflora, Saposhnikovia divaricata, Citrus reticulata, Magnolia officinalis, Areca catechu, Citrus medica, Psoralea corylifolia, Coptis chinensis, Aconitum carmichaelii (processed), Zingiber officinale, Cinnamomum cassia, Sepia esculenta, Glehnia littoralis, Ligustrum lucidum, Nelumbo nucifera (processed). 5 days, 1 sachet after breakfast and dinner.

Treatment Principle:
No change in prescription as symptoms improved with current medication. Due to slight signs of excessive internal heat, consider reducing or eliminating warming herbs; however, doing so might exacerbate lingering cold evil. As the symptoms of excessive internal heat resolved spontaneously, maintaining balance between the two, hence adding herbs to nourish liver and kidneys’ yin, as strengthening yin prevents excessive yang rising. Additionally, adding Sepia esculenta to address symptoms of acid reflux.

20.8.2021 Third Consultation
Continued improvement reported after medication, distension in the stomach has resolved. Coldness in hands and feet persists, acid reflux slightly improved. Continued minor adjustment to prescription medication to further address spleen and kidney deficiency. Tongue slightly red with thin white coating; pulse wiry and relaxed. Prescription as follows:
Paeonia lactiflora, Saposhnikovia divaricata, Citrus reticulata, Magnolia officinalis, Areca catechu, Psoralea corylifolia, Evodia rutaecarpa, Coptis chinensis, Aconitum carmichaelii (processed), Zingiber officinale, Cinnamomum cassia, Sepia esculenta, Glehnia littoralis, Epimedium brevicornu, Eucommia ulmoides. 5 days, 1 sachet after breakfast and dinner.

Treatment Principle:
Main symptoms of gastric distension have resolved, but coldness in hands and feet and mild acid reflux persist. In addition to maintaining the previous prescription, herbs to warm the spleen and kidneys are slightly increased. Tongue and pulse findings guide adjustments.

Pathophysiological Summary
Gastric distension, also known as epigastric fullness, refers to a feeling of fullness and discomfort in the epigastric region. Gastric distension can be caused by improper diet leading to spleen and stomach disharmony, emotional imbalances affecting organ function, or complications arising from improper treatment of febrile diseases, among other factors. The underlying pathology often involves disharmony in the ascending and descending functions of spleen and stomach qi, as described in the "Discussion on Cold Damage" where it states, "If there is fullness without pain, this is called distension" and "Palpation feels dampness, indicating gas distension." These descriptions indicate that gastric distension is a manifestation of stagnation and obstruction due to imbalances in spleen and stomach qi. Therefore, treatment focuses on regulating spleen and stomach function, promoting the ascending and descending movements of clear and turbid qi, and restoring smooth flow of middle qi to alleviate the distension.