Four examination methods: Questioning/history taking, inspection, auscultation (listening) & olfaction (smelling), and palpation.
The four methods have their unique clinical functions and cannot be replaced by one another. Sometimes, false manifestations of a disease occur which emphasize the importance of integrating all diagnostic methods.
The above methods are esential to determine the cause and origin of the problem from which an individual suffers. As has been discussed in this article, the symptoms experienced or felt on the outside of the body can often reflect a problem with the internal organs, yin yang balance or qi (vital energy) flow. Causes of the symptoms are often attributed to exogoneous evils that invade the body and disrupt its internal balance leading to illness, but illness can also arise on the inside of the body and express symptoms on the outside. A skilled TCM practitioner is usually able to distinguish where the origin of the problem comes from by using the examination techniques explained in this article.
1. Listening
Listening to the Voice
Speaking Voice: Generally, speaking in a loud and sonorous voice indicates syndromes of heat or shi type, while a feeble, low voice indicates syndromes of the cold or xu type.
Disordered Speaking: Speaking incoherently and loudly or deliriously indicates shi syndrome. Speaking verbosely, feebly, and intermittently indicates syndromes of the xu type. Muttering to oneself denotes qi deficiency of the heart. Stuttering speech suggests upward disturbance of wind-phlegm.
Listening to the Respiration
Feeble Breathing: Feeble breathing accompanied by shortness of breath usually indicates xu syndromes.
Coarse Breathing: Forceful breathing with a coarse voice belongs to the shi heat type syndromes. Asthma with feeble, short breathing is a category of xu type asthma.
Listening to the Cough
Course coughing usually indicates shi type syndromes. A low cough with weak breathing indicates xu syndromes.
2. Smelling
Foul breath is due to pathogenic heat in the stomach, indigestion, caries, and an unclean mouth. Sour breath indicates food accumulation in the stomach. The offensive smell of a secretion or excretion including stool, urine, sputum, pus, leukorrhea, etc., usually indicates heat syndromes of the shi type. A stinking smell usually indicates cold syndromes of the xu type.
3. Questioning
Questioning involves asking the patient or the patient’s companion about the disease condition to assist diagnosis. Because the chief complaint of the patient is of primary importance, the main information dealing with the problem must be carefully solicited. It is necessary to grasp the important clinical data as well as to get a general understanding of the patient’s disease condition. The main categories of concern are:
Chills and Fever Aversion to Cold and Fever:
At the beginning of a disease, aversion to cold and Fever occurs simultaneously. This indicates exterior syndromes due to invasion by exogenous pathogenic factors. The exterior syndromes due to invasion by exogenous pathogenic cold and wind are characterized by severe aversion to cold, mild fever accompanied by an absence of thirst, no sweat, headache, general pain, superficial and tense pulse, etc. The exterior syndromes due to invasion by exogenous pathogenic wind-heat are characterized by severe fever, mild aversion to cold accompanied by thirst, sweating, sore throat, superficial and rapid pulse, etc.
Alternating Chills and Fever:
This particular symptoms occurs when exogenous pathogenic factors are in between the exterior and interior of the body, accompanied by a bitter taste in the mouth, dry throat, fullness of the chest, hypochondrium, etc. If a high fever follows the first occurrence of chills and is complicated with a severe headache which subsides after the fever is gone, this indicates malaria.
Fever Occurring Without Chills High fever:
This is usually due to the transmission of exogenous pathogenic cold from the exterior to the interior, which then changes into heat; or the transmission of exogenous pathogenic heat from exterior to interior resulting in shi type interior-heat syndrome accompanied by profuse sweating, thirst, forceful pulse, etc.
Tidal fever:
This is one of the main characteristics of yin deficiency or shi heat syndrome of the Yangming channel. Tidal fever due to yin deficiency often occurs at noon or night, accompanied by a dry red tongue. Tidal fever usually appears at dusk associated with constipation, abdominal distension, penis pain, etc.
Perspiration:
Sweat is transformed from evaporated body fluid by the function of yang qi. So perspiration has a certain clinical significance in reflecting the status of yang qi and body fluid. On should first ask whether the patient has sweat or not. If the patient is sweating, further questioning should be concerned with the characteristics and accompanied symptoms of perspiration.
Sweating of No Sweating:
Exterior syndromes without sweating are caused by exogenous pathogenic factors. Exterior syndromes with sweating are mostly exterior heat syndromes due to the invasion by exogenous pathogenic wind heat; or they may be exterior xu syndromes due to exogenous pathogenic wind.
Night Sweating:
Is usually the manifestation of yin deficiency, accompanied by tidal fever, flushed malar, red tongue proper with scanty coating, thready and rapid pulse.
Spontaneous Sweating:
This is a sign of qi or yang deficiency associated with fear of cold, lassitude, etc.
Profuse Sweating:
Excessive sweating together with high fever, thirst with desire for cold drinks, forceful pulse, etc. belong to interior shi heat syndrome. This is the outcome of excessive yang and heat compelling the outward flow of sweat. Dripping with sweat accompanied by lassitude, feckless breathing, cold extremities, and feeble pulse indicates the total prolapse of yang qi, also known as “sweating from exhaustion.”
Sweating of the Head:
Caused by heat in the upper jiao or damp heat in the middle jiao. It is caused by the heat in the upper jiao, it will be accompanied by irritability, thirst, yellow tongue coating, superficial and rapid pulse. if it is the result of damp heat accumulation, it will be associated with heaviness and tiredness of the body, dysuria, yellowish and sticky tongue coating, etc.
Food and Drink Appetite, and Taste No Appetite:
This is a symptom caused by the dysfunction of transformation and transportation of the spleen. Symptoms are emaciation due to chronic disease, poor appetite, loose stool, lassitude, and pale tongue proper with a thin white coating. If anorexia is associated with fullness of the chest, abdominal distension, thick and sticky tongue coating, then it is caused by the obstruction of pathogenic damp in the spleen.
Food Repulsion:
This is usually due to the accumulation of food in the stomach and intestines. It is often accompanied by distension and fullness of the epigastrium and abdomen, acid regurgitation, and a thick and sticky tongue coating.
Quick Hunger:
This is due to strong stomach fire and causes fast digestion.
Hunger and Anorexia Combined: This is due to injury of stomach yin and disturbance of xu heat.
Craving for Dirt Due to Intestinal Parasites:
This is common in children, and is a sign of parasitosis accompanied by emaciation, abdominal distension and pain, etc.
Thirst:
Whether the patient is thirsty or not often reflects the condition of body fluids. During the process of disease development, if there is no thirst, then the body fluid has not yet been damaged and it indicates a cold syndrome. If the patient is thirsty, it indicates a consumption or stagnation of the body fluid failing to nourish the upper body.
Generally, thirst with a desire for excessive drinking is commonly seen in heat syndromes. Severe thirst with a preference for hot drinks indicates a phlegm-humor obstruction which prevents the upward flow of body fluids. The upward flow of water usually causes vomiting after drinking due to thirst. If the patient is thirsty, but doesn’t want to drink, this indicates acute febrile diseases where the pathogenic factors have invaded the nutrient (ying) and blood (xue) systems of the body. If excessive drinking does not relieve the symptoms of thirst and then excessive urination follows, this suggests diabetes.
Taste:
Clinically, a bitter taste in the mouth is caused by pathogenic heat, especially the overflowing of heat from the liver and gall bladder. A sweet taste in the mouth is usually due to damp heat in the spleen and stomach. A sour taste is due to the accumulation of heat in the liver and stomach. A sour taste similar to spoiled food indicates injury by the accumulation of food. Tastelessness in the mouth is usually due to the dysfunction of transportation and transformation.
Defecation and Urination Shape of the Stool:
Dry stools shaped like sheep-dung are due to stagnation of heat or exhaustion of body fluid. A mucous stool is a sign of excessive damp caused by spleen deficiency. Loose bowels following dry stool are due to a dysfunction of the spleen and stomach, and an imbalance between dryness and dampness. Stools which are sometimes dry and sometimes loose are usually due to liver qi stagnation and spleen deficiency. Liquid stools with undigested food are due to the yang deficiency of the spleen and kidney. Diarrhea with yellow watery stool and burning of the anus is caused by damp heat in the stomach and intestines. Formed stools with undigested food and foul smell are the result of food accumulation.
The Color of the Stool:
Tarry stools are the symptoms of hemorrhaging in the spleen and stomach. Bloody and pussy stools are a sign of dysentery.
The Smell of the Stool:
Sour stinking stools are due to the accumulation of heat. A rotten egg stink is due to food accumulation.
The Sensation of Defecation:
A burning sensation in the anus during defecation is due to pathogenic heat in the rectum. Mild prolapse of the anus during bowel movements is the outcome of chronic diarrhea due to the sinking of qi and spleen deficiency. Tenesmus is a sign of dysentery due to qi stagnation in the intestines. Fragmentary defection is a manifestation of the liver failing to cause a free condition for qi. Diarrhea occurring soon after abdominal pain, and pain relieved after bowel movements, are signs of food accumulation. Pain not relieved after bowel movements is a sign of spleen deficiency and liver preponderance resulting in “liver-wood subjugating the spleen-earth.”
The Color of Urine:
Deep yellow urine indicates heat, while clear and profuse urine indicates cold. Turbid urine or a mixture of urine with sperm denotes the downward flowing of damp heat. Brownish urine indicates that pathogenic heat has injured the blood vessels.
The Amount of Urine:
An increased amount of urine indicates kidney qi deficiency. A decreased volume of urine is caused by the consumption of body fluid or by dysfunction of qi activities causing failure to transform body fluids into urine. Dribbling of urine or retention of urine indicates the exhaustion of kidney qi or the downward flowing of damp heat.
The Sensation of Urination:
A stabbing pain during urination, accompanied by an urgent and burning feeling, is caused by damp heat. Pain after urination mostly indicates the declining of kidney qi. Dribbling urination is due to the non-consolidation of kidney qi. Nocturnal enuresis is caused by the deficiency of kidney qi. Unconsciousness accompanied by incontinence of urine indicates that the heart has failed to control the mind and the urinary bladder has lost its restrictive capacity.
Pain
Headache:
Occipital headache, referring to the nape and the upper back, is a disease of the Taiyang channel. Frontal headache, referring to the supraorbital ridge, indicates a disease of the Yangming channel. Headaches of the temporal region are diseases of the Shaoyang channel. Vertex headache is a pain of the Jueyin channel. headache related to the teeth is a pain of the Shaoyin channel due to invasion by cold.
Pain of the Chest:
This is mostly due to the obstruction of phlegm or blood stasis, leading to qi stagnation.
Pain in the Hypochondriac Region:
Is caused by obstruction in the liver and gall bladder channel, or by malnutrition of these channels.
Epigastric Pain:
Is caused by disorders of the stomach.
Abdominal Pain:
Lower lateral abdominal pain is caused by qi stagnation of the liver, obstruction of the liver channel, or appendicitis or hernia. Pain around the umbilicus is seen in parasitosis, food accumulation, constipation, etc. Lower abdominal pain and distension is caused by dysuria and/or retention of urine. If there are no complicated urination symptoms, the usual cause is retention of blood in the lower jiao.
Low Back Pain:
Is mostly due to a deficiency of the kidney, invasion by cold damp, or blood stagnation in the channels.
Pain of the Limbs:
Pain may appear in joints, muscles, or channels and collaterals due to the invasion of exogenous pathogenic factors.
The Nature of Pain:
A wandering pain associated with numbness or itching is due to invasion by pathogenic wind. Pain associated with heaviness and soreness is most often caused by pathogenic damp. Severe pain with a cold feeling or fear of cold is caused by pathogenic cold. Pain accompanied by redness, swelling, and heat or fear of heat is due to pathogenic fire (heat). Distending pain or referred pain is caused by qi stagnation. Pain which is aggravated by pressure relates to the shi type of symptoms complex. Pain which is alleviated by pressure is related to the xu type of symptom complex.
Sleep
Insomnia associated with palpitation, dreams and nervousness is usually caused by the insufficiency of blood nourishing the heart. Insomnia accompanied by restlessness in the mind and difficulty in falling asleep indicates yin deficiency leading to preponderance of fire. Insomnia complicated by bitter taste, vomiting saliva, palpitation, irritability, and an inability to fall asleep indicates the internal disturbance of phlegm-fire. Insomnia due to the disharmony of the stomach indicates a derangement of stomach qi leading to restlessness in the mind during sleep.
Hypersomnia is commonly seen in febrile diseases caused by exogenous pathogenic factors; in qi deficiency caused by chronic diseases; in failure of the spleen yang to ascend due to the obstruction of damp; or in the condition of yang deficiency leading to excessive yin.
Menses and Leukorrhea
Antedated Menstruation:
Red color and an excessive amount indicates heat syndrome. Light color, post-menstrual pain in the lower abdomen is most often due to a deficiency of both qi and blood.
Postdated Menstruation:
Dark purple menstrual flow with clots, and premenstrual abdominal pain, most often indicates cold syndromes or blood stasis. Postdate menstruation with a scanty light-coloured flow indicates blood deficiency.
Indefinite Menstruation:
If it is associated with dysmenorrhea or distension of the breasts before menstruation, it is caused by the stagnation of liver qi.
Amenorrhea:
Many factors may cause amenorrhea, such as pregnancy, blood stasis, blood exhaustion, consumptive diseases, qi stagnation in the liver, etc.
Incessant Menstrual Flow:
If it is dark purple color with clots and abdominal pain, this indicates deficiency of the chong and ren channels, or failure of blood control by the spleen due to the sinking qi of the middle jiao.
Leukorrhea: Thin and whitish leukorrhea with little odor indicates deficiency of the spleen and kidney. Excessive yellowish and thick leukorrhea with offensive smell indicates the downward flow of damp heat.
4. Palpation
Palpation is a method of diagnosis using the hand to touch, feel, and press certain areas of the body to ascertain the patient’s disease condition. Generally there are two types: pulse feeling and body palpation.
Pulse Feeling
In traditional Chinese medicine the pulse is considered as having three divisions: cun, guan, and chi. A normal pulse is neither superficial nor deep, neither quick no slow, and it beats in medium frequency, i.e., 4-5 beats per breath, with a regular rhythm.
To feel the pulse correctly, place the patients hand comfortably on a cushion with the palm facing upward. First, the practitioner should put their middle finger on the guan division, then the index and ring fingers should naturally fall on the cun and chi divisions. Finger force should at first be light, then moderate and finally heavy to get a general picture of the depth, rhythm, strength, and form of the pulse. An even force should be applied on the three regions. Through comparisons of the three regions, the practitioner can gain a correct impression of the pulse as a whole. A normal pulse is of moderate frequency, i.e., 4-5 beats per breath, regular rhythm, even and forceful.
The following are abnormal pulses commonly seen in the clinic:
Floating Pulse (fumai): When the pulse is pressed lightly it appears under the finger, and when pressed heavily it becomes weak. It often occurs in the early stages of diseases caused by exogenous pathogenic wind cold and heat, i.e., exterior syndromes. If it is seen in patients who are suffering from prolonged chronic diseases, it indicates a dangerous site where the yang qi of the body flows outward.
Deep Pulse (chimai): No clear pulse is felt by superficial pressure, only by heavy pressure. This indicates an interior syndrome.
Rapid Pulse (sumai): The pulse beats rapidly at a rate higher than the normal 5 beats per breath (i.e., more than 90 times per minute). This indicates a heat syndrome.
Xu Type Pulse (xumai): If the pulses of the three regions are weak and forceless, this indicates xu type syndromes. These are mostly caused by both qi and blood deficiencies and are seen during the process of chronic diseases.
Shi Type Pulse (shimai): If the pulses of the three regions are forceful with both light and heavy pressure, shi type syndromes are present.
Slippery pulse (huamai): If the pulse is smooth and flowing, like a pearl rolling on a plate, this indicates excessive phlegm, retention of food, or shi heat type syndromes.
Rough Pulse (semai): This pulse is uneven and has a roughness similar to scraping bamboo with a knife. It indicates a deficiency of blood and essence, qi stagnation, and blood stasis.
Fine Pulse (ximai): This pulse is as fine as a silk thread, and indicates exhaustion of qi and blood.
Full Pulse (hongmai): This pulse beats like a dashing wave, with one rising wave following another. It indicates excessive heat.
Wiry Pulse (xuanmai): This pulse is straight and long, like a tremulous music string, seen usually in diseases of liver, gall bladder, pain, or phlegm-humor.
Tense Pulse (jinmai): The pulse is taut and forceful, like a tightly stretched cord, and occurs in diseases caused by cold, pain, or retention of food.
Hollow Pulse (koumai): This pulse is floating, large, and empty inside, feeling like a scallion stalk. It indicates a massive loss of blood and essence.
Hesitant Pulse (cumai): This pulse is rapid with irregular intermittent beats. It indicates excessive yang and shi heat, qi stagnation, pathogenic phlegm mixture with cold, blood stasis, etc.
Knotted Pulse (jiemai): This pulse is slow and uneven with irregular intervals. It indicates excessive yin, qi stagnation, pathogenic phlegm mixture with cold, blood stasis, etc.
Intermittent Pulse (daimai): This pulse is slow with regular intervals. it indicates qi exhaustion of the zang organs, or syndromes of wind and pain caused by emotional pathogenic fright and fear.
Body Palpation
This is a diagnostic method to ascertain abnormal changes in the body and to determine the location and nature of the disease through palpation and finger pressure.
Palpating the Skin and Muscle: Generally, if there is excessive pathogenic heat in the body, the patient will usually have heat on the body surface. Yang qi deficiency has a cold body surface on palpation. If the surface feels hot on first palpation becoming slightly hotter when you palpate longer, this indicates that the pathogenic heat has proceeded from the exterior to the interior of the body. Body palpation showing moist and smooth skin demonstrates that the body fluid is not yet damaged. If the skin and nails are very dry, this indicates consumption of the body fluids. If body palpation shows swelling and further pressure makes a depression, this indicates edema. If a depression appears on pressure and disappears after taking the hand away, this indicates qi distension. Palpating the skin can also indicate the patient’s sweat condition.
Palpating Hands and Feet: Coldness of the four extremities is mostly due to yang deficiency and excessive pathogenic cold. An overheating of the four extremities indicates excessive heat. Coldness of the four extremities with heat in the chest and abdomen is due to the retention of internal heat preventing the flow of yang qi outward. Heat in the dorsum of the hand is a sign of disease caused by exogenous pathogenic factors.
Palpating the Epigastrium and Abdomen: If the patient has fullness and distention of the hypochondrium, palpation may demonstrate hardness and pain in this region. This is known as an accumulation of excessive pathogenic factors in the chest of the xu type. If the hardness extends over a large area in the chest, it is due to phlegm-humor. Palpation of the abdomen showing abdominal distention with a tympanitic note on percussion, but with normal urination, indicates qi tympanites. Abdominal distension with a splashing sound like water, and accompanying dysuria indicates was tympanites or ascites. If hand pressure relieves the abdominal pain, it is considered to be a xu type; if the pain is made worse by pressure, it is a shi type. Immovable hard masses in the abdomen with pain fixed in a certain area are due to blood stasis. However, if the patient feels that lumps sometimes appear and disappear with unfixed pain, and palpation of the abdomen shows they do not exist, then this is due to qi stagnation.
Palpating Channels and Points: Clinical practice proves that in some diseases there may occur tenderness or abnormal reactions along the courses of the affected channels or at certain points. These signs have significance in diagnosis by palpation, especially in acupuncture treatment. For example, there may be tenderness at Pt. Zhongfu (Lu. 1) or Pt. Shufu (K. 27), which are closely related to the disorders of the lung and trachea. In diseases of the heart and stomach, tenderness may occur at Pt. Jugue (Ren 14), Pt. Zhongwan (Ren 12), Pt. Burong (St. 19), or Pt. Liangmen (St.21). In disorders of the liver and gall bladder, tenderness may be at Pt. Qimen (Liv. 14) and Pt. Riye (G.B. 24). In diseases of the spleen, tenderness may occur at Pt. Zhangmen (Liv. 13) and Pt. Huangmen (U.B. 51). In disorders of the kidney, Pt. Jingmen (G.B. 25) and Pt. Zhishi (U.B. 52) may have tenderness. Tenderness at Pt. Tianshu (St.25). Pt. Daji (St.27) and Pt. Fujie (Sp. 14) may be closely related to disorders of the intestines. Tenderness at Pt. Guanyan (Ren 4), Pt. Qihai (Ren 6) and Pt. Zhongji (Ren 3) may have a close relation with disorders of the urinogenital system. When there are abnormal reactions appearing at the above points, they may reflect pathological changes of the related zang or fu organs.
