Patient Information:
Ms. Luo, female, 47 years old. Salesperson, often enters refrigerators.

Past medical history:
Denies drug or food allergies. History of anemia, uterine fibroids, and underwent a hysterectomy in 2018.

Present illness history:
Chronic diarrhea for 1 year.
Long-standing history of diarrhea, with some periods of improvement. However, after the surgery in 2018, symptoms relapsed. Reports having 2-3 bowel movements per day (while continuing fiber supplementation), loose stools, often after meals, leading to reduced meal frequency (2 meals per day), light diet, and reduced fluid intake (increased at home), supplemented with long-term fiber intake to reduce the impact of diarrhea. States that this condition significantly affects daily life and desires treatment.

Initial Consultation on July 20, 2021
2-3 bowel movements per day, loose stools, occasional incomplete digestion of grains, accompanied by abdominal pain during diarrhea, no flatulence or abdominal distension. If fiber supplements are not taken, diarrhea becomes more prominent. Alert, slightly rapid speech, clear voice. Thin body type. Poor sleep, difficulty falling asleep, waking up easily (4 AM), occasional ability to fall back asleep after waking up, no dreams. Normal appetite, eats two meals from 7 AM to 4 PM, no belching or acid reflux. Prefers warm drinks. No chest or rib discomfort, occasional dry mouth, significant daytime bitterness in the mouth, no dry or gritty sensation in the eyes, no headaches or dizziness. Urination normal, occasional nocturia. Rarely sweats. Cold intolerance, cold feet. Occasional back and leg soreness. Pulse: string-like and fine; tongue: red edges, white and greasy coating, moist, teeth marks.

Diagnosis:
Diarrhea (Irritable Bowel Syndrome), spleen deficiency and liver hyperactivity, liver invading the spleen. Treatment: Suppress liver and tonify spleen, invigorate the middle and boost qi method.

Prescription: Powdered Chinese herbal medicine (same below):

Stir-fried Bai Zhu (White Atractylodes), Bai Shao (White Peony Root), Fang Feng (Ledebouriella root), Chen Pi (Tangerine Peel), Wu Zhu Yu (Evodia fruit), Qian Shi (Euryale seeds), and Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction). 1 dose after breakfast and dinner for 3 days.

Second Consultation on July 23, 2021
Reports no change in symptoms after taking the medicine, diarrhea persists as before, no adverse reactions to the medicine. Examination of tongue, pulse, and symptoms remains unchanged. Recognizing that the medication does not match the symptoms, a detailed review of the symptoms was conducted, as well as an inquiry into dietary habits. Reports feeling hungry in the evenings and often eating fruits or lightly steamed vegetables to satisfy hunger. Also considering the symptoms of cold intolerance, cold limbs, preference for warm drinks, combined with the tongue coating of white and greasy, moist, and teeth marks, it is recognized as a pattern of spleen stagnation due to cold and dampness, rather than liver overacting on the spleen. Treatment and prescription are changed to focus on warming the middle, dispelling cold, tonifying qi, and strengthening the spleen, with the addition of herbs to promote diuresis, dispel dampness, and ascend yang.

Prescription:
Gan Jiang (Dried Ginger), Dang Shen (Codonopsis), Stir-fried Bai Zhu (White Atractylodes), Da Zao (Jujube), Wu Zhu Yu (Evodia fruit), Qian Shi (Euryale seeds), Ge Gen (Kudzu root), Sheng Ma (Cimicifuga), and Yi Yi Ren (Coix seed). 1 dose after breakfast and dinner for 3 days.

Third Consultation on July 30, 2021
Reports slight improvement in diarrhea after taking the medicine, stools are slightly more solid, and abdominal cramps are reduced. However, dry throat after taking the medicine is more severe than before, indicating signs of rising internal heat. Other symptoms remain unchanged.
Pulse: string-like and fine, weak at the right pulse position
Tongue: red edges, thin yellow and greasy coating, slightly reduced teeth marks
Continuing previous treatment with minor adjustments.

Prescription:
Bu Gu Zhi (Psoralea fruit), Wu Zhu Yu (Evodia fruit), Wu Wei Zi (Schisandra fruit), Qian Shi (Euryale seeds), Ge Gen (Kudzu root), Shan Yao (Chinese yam), Bai Zhu (White Atractylodes), Gan Jiang (Dried Ginger), and Xiao Jian Zhong Tang (Minor Construct the Middle Decoction). 1 dose after breakfast and dinner for 3 days.

Patient self-administers the prescribed medication for 4 days as instructed.

August 8, 2021, Fourth Consultation
Symptoms continue to improve after medication: stools are becoming solid, abdominal cramps are decreasing, postprandial urgency and frequency are decreasing, and fiber supplements can be discontinued without causing diarrhea. No signs of internal heat after adjusting the medication. Minor adjustments to previous treatment. Sleep and appetite are normal. Can eat vegetables (doctor previously advised the patient to add ginger) and chicken without causing diarrhea. Also advised to engage in jogging (at a moderate pace to induce slight sweating) to invigorate lung qi.
Pulse: string-like and fine
Tongue: red edges, thin yellow coating, slightly greasy, moist, and reduced teeth marks
Continue with previous prescription. Medicine given for 7 days, 1 dose after breakfast and dinner.

August 17, 2021, Fifth Consultation
Continued improvement after medication, no diarrhea after meals. After stopping medication for 3 days, experienced a desire to have a bowel movement after meals but did not have one. Came back for continued treatment to consolidate improvement. Reports feeling more energetic and increased appetite. Other symptoms remain unchanged. Pulse: string-like, slightly fine; tongue: red edges, thin yellow and greasy coating. Also reported that the medicine taken on July 23 reduced the feeling of cold sensitivity, allowing the patient to work in the refrigerated area without feeling cold. However, after changing the medication, the feeling of cold sensitivity returned and wishes to address it as before.

Prescription:
Bu Gu Zhi (Psoralea fruit), Wu Zhu Yu (Evodia fruit), Wu Wei Zi (Schisandra fruit), Qian Shi (Euryale seeds), Ge Gen (Kudzu root), Shan Yao (Chinese yam), Bai Zhu (White Atractylodes), Gan Jiang (Dried Ginger), and Xiao Jian Zhong Tang (Minor Construct the Middle Decoction). 1 dose after breakfast and dinner for 7 days.

August 26, 2021: Patient self-administered the prescribed medication for 10 days.

Summary of Pathology
Diarrhea, known in Western medicine as Irritable Bowel Syndrome (IBS), or commonly referred to as "gastrointestinal sensitivity," is a collective term for symptoms caused by gastrointestinal dysfunction, imbalance, or hypersensitivity. Patients may experience abdominal pain, bloating, or discomfort. The frequency and consistency of bowel movements may increase or decrease, and stools may become hard or loose. These symptoms usually provide some relief after defecation. However, if the symptoms are frequent (three times or more per month) or affect daily life, and no cause is found through colonoscopy, the patient may be diagnosed with "irritable bowel syndrome."

The medical community has not fully understood the cause of IBS, but it is generally believed to be related to individual dietary habits, stress, sleep disorders, emotional changes, etc., leading to factors such as rapid or slow intestinal motility, increased sensitivity to pain, and disruption of brain processing of intestinal messages. Symptoms may include abdominal pain, bloating, diarrhea, constipation, feeling of incomplete evacuation, hard or watery stools, or mucus during bowel movements.

In terms of Traditional Chinese Medicine (TCM) etiology and classification, the external and internal factors are distinguished: diarrhea can be caused by external factors such as wind, cold, dampness, and summer heat, or internal factors such as disharmony between organs, spleen deficiency, or kidney yang deficiency. Diarrhea caused by external factors is mostly a syndrome of excess, with a short course and easier recovery. Diarrhea caused by internal factors is mostly a syndrome of deficiency, sometimes with a combination of deficiency and excess, and generally has a longer course. Of course, internal and external factors can also combine to cause complex and protracted conditions.

Reflections
During the initial consultation, based on the examination of the tongue, pulse, spirit, tone, body shape, and dry mouth bitterness, the diagnosis was spleen deficiency and liver hyperactivity, with the liver overacting on the spleen. The prescription aimed to suppress the liver and tonify the spleen, with Da Cheng Qi Tang as the base formula, supplemented with Bu Zhong Yi Qi Tang to tonify the middle and boost qi. Additionally, Wu Zhu Yu was added to assist yang and stop diarrhea, and Qian Shi was included to consolidate and astringe. After three doses of medication, there was no significant improvement in symptoms, and it was not due to insufficient dosage. Since the medication did not match the symptoms, the liver overacting on the spleen diagnosis was abandoned in the second consultation. After re-examining the symptoms, the approach shifted towards addressing cold and dampness stagnating the spleen, and the prescription was changed to Li Zhong Wan as the base formula with adjustments, and dried ginger was heavily used, resulting in slight signs of internal heat. Therefore, in the fourth consultation, the focus was shifted to slightly weaker warming of the middle, primarily tonifying kidney yang with Si Shen Wan, combined with Xiao Jian Zhong Tang to soothe deficiency and urgency. By warming the spleen, the spleen and kidney are both warmed, similar to heating the pot and the fire below it. In the fifth consultation, in addition to the improvement in the main symptoms, the patient also reported feeling more energetic and increased appetite, indicating signs of the spleen and stomach functioning well and dispelling cold and dampness. Therefore, the treatment method was not changed, and the previous prescription was continued. Additionally, throughout the changes in the base formula, Ge Gen and Qian Shi were consistently used to stop diarrhea and consolidate, ensuring simultaneous treatment of both symptoms and the root cause.

In treating this diarrhea syndrome, the diagnostic methods and prescriptions used do not necessarily have to be the most appropriate—especially evident since the correct diagnosis was not made during the initial consultation! However, overall, the treatment followed the principles of "raising what has fallen," "warming what is cold," and "tonifying what is deficient," primarily focusing on the spleen and kidney with medication. Another profound point is the situation faced when symptoms do not improve after medication during the initial consultation—was the diagnosis incorrect? Was the dosage insufficient? Was the medication mismatched with the symptoms? Or was the duration of medication inadequate? Which aspect went wrong? While writing this case study, I remembered a teacher telling me, "As a physician, one must always be prepared to accept the possibility of making mistakes! When you're wrong, you must know to step back, perhaps even take multiple steps back, and carefully consider where the mistake occurred... Wanting to progress means understanding how to admit mistakes." Perhaps this is the insight I most wanted to share through this case study.