Patient Details

Name: Gao | Age: 35 | Race: Chinese | Sex: Female | Initial Consultation: February 1, 2009

History

Chief complaint: Diarrhoea for two years. Two years ago, due to improper diet causing her to suffer from acute gastro-enteritis. She was then treated with antibiotic of which she recovered. Afterwards she again presented with diarrhoea and she took Huang Lian Su and Gatiflo (Gatifloxacin) for her intestinal infection. The effect was not satisfactory. She moved her bowel 3~4 times daily, with sloppy movement accompanied by slight abdominal pain and distention with a subjective feeling of coldness in the abdomen, no desire for drinks, no cold drinks or cold food, aversion to cold and preference for warmth, no vomiting.

Symptoms

Pale complexion, thin, white tongue coat with pale red tongue body and a moderate pulse.

Abdominal Coldness: Symptom such as abdominal coldness is a cold pattern while lower limbs coldness can be a reversal heat jue.
Heat jue is due to constrained yang qi.
Function of Rou Dou Kou:
Rou Dou Kou is the seed of nutmeg after drying.
It warms the middle and move qi; astringe the intestine and stop diarrhoea. It is indicated for spleen and stomach deficient cold characterised by chronic diarrhoea, distended and painful epigastrium and abdomen; no appetite and vomiting.
Si Shen Wan: Bu Gu Zhi, Rou Dou Kou, Wu Ju Yu, Wu Wei Zi, Jiang and Da Zao.

Diagnosis

Spleen and stomach yang deficiency with damp-cold obstruction in the middle.

Prescription

Warm the middle and tonify the spleen, dissipate coldness and eliminate damp. Li Zhong Tang modified. Gan Jiang 25g; Dang Shen 25g; Zhi Gan Cao 20g; Chao Bai Zhu 20g; Rou Dou Kou 15g; Da Zao 30g. Seven packs. Decoct in water and take one pack per day three times.

Follow Up

After ingesting the medication, there was a subjective feeling of heat and warm and comfortable sensation. The next day , her diarrhoea and abdominal pain was substantially reduced.
Stick with the original formula and add Wu Ju Yu 5g; Gui Zhi 10g to increase the warming effect of the middle and dispersing cold. 7 packs.
After the seven packs of medication, her diarrhoea and abdominal pain further improved with occasional recurrence. In the past she had no desire to drink but after two weeks of medication the lack of desire to drink vanished. Stick with Li Zhong Tang and add Yi Zhi Ren 10g. 7 packs.
Altogether she took a total of 21 packs and she recovered.
She was instructed to refrain from cold food and drinks.

About Professor Fu Yan Ling

Professor Fu Yan Ling was awarded his PhD in Shang Han Lun by the Beijing University of Chinese Medicine, where he studied under the supervision of the renowned Shang Han specialist Professor Liu Du Zhou. In 1991, he was nominated by the Chinese govern… Read more