TCM Case Study: Modular Formula Construction

PATIENT CLINICAL INTAKE FILE

Demographics

Chief Complaint (Biao)

Secondary Symptoms

Objective Physical Diagnostic Markers

Tongue Evaluation

Pulse Diagnostics

Module Reference Quick-Sheet

Phase 1 of 5

Diagnostic Assessment

Phase 2 of 5

Formulating the Treatment Strategy

Map each patient presentation to its corresponding treatment principle.

Presentation A

Dry mouth, red dry tongue, rapid pulse, and a constant feeling of heat.

Target Strategy:

Presentation B

Chronic, lifelong constipation (Biao) requiring gentle lubrication.

Target Strategy:

Presentation C

Disruptive night sweats accompanied by insomnia.

Target Strategy:

Phase 3 of 5

Herb Cabinet: Module Selection

1. Nourish Kidney & Liver Yin, Subdue Yang, Clear Heat Required

Strongest Yin Tonic & Yang Subduer: Sheng Di Huang, Gui Ban, Zhi Mu, Huang Bai Mild Constitutional Kidney Nourisher: Shu Di Huang, Shan Yao, Shan Zhu Yu, Mu Dan Pi

2. Moisten Intestines (Lubricate chronic constipation & regulate peristalsis) Required

Yin Def. Lubricator with Qi & Blood Movement: Huo Ma Ren, Tao Ren, Dang Gui, Zhi Ke Cold Bitter Downward Purgative (Acute Excess): Da Huang, Mang Xiao, Zhi Shi, Hou Po

3. Relieve Night Sweats & Calm the Shen (Insomnia) Required

Heavy Anchor Astringents + Shen Calmer: Duan Long Gu, Duan Mu Li, Wu Wei Zi Wei Qi Exterior Def. Antiperspirant: Huang Qi, Fang Feng, Bai Zhu

Phase 4 of 5

Dosing Decisions & Customizations

Dosing is where clinical theory meets the actual patient. Determine the target dosing weight ranges based on TCM principles, and decide if you want to optimize for fluid production.

Module 1 (Yin Def)

Addresses the long term, constitutional Liver/Kidney Yin deficiency.

Target Dosage Range:

Module 2 (Constipation)

Addresses the chief complaint (lifelong, bothersome constipation).

Target Dosage Range:

Module 3 (Night Sweats)

Addresses the distressing acute presentation of night sweats & insomnia.

Target Dosage Range:

Optimize for Dryness (Fluid-Promoting Herbs Modification)

Check this option to clinically boost the specific herbs within your selected modules that have the direct secondary function of promoting fluids and relieving intense dryness.

Phase 5 of 5

Final Formula Prescription & Clinical Summary

Below is the complete compound herbal prescription compiled from your modular choices. Review the final dosage adjustments and clinical rationale.

Composite Prescription (Decoction) 1 Bag Daily (Divided Doses)

Module 1: Nourish Liver & Kidney Yin / Clear Heat

Sheng Di Huang (Rx. Rehmanniae):

Gui Ban (Plastrum Testudinis): 18g

Zhi Mu (Rx. Anemarrhenae):

Huang Bai (Cx. Phellodendri): 6g

Module 2: Moisten Intestines (Chief Complaint Priority)

Huo Ma Ren (Sm. Cannabis):

Tao Ren (Sm. Persicae): 9g

Dang Gui (Rx. Angelicae Sinensis): 9g

Zhi Ke (Fr. Aurantii): 9g

Module 3: Astringe Night Sweats & Calm the Shen

Duan Long Gu (Os Draconis): 20g

Duan Mu Li (Concha Ostreae): 20g

Wu Wei Zi (Fr. Schisandrae):

Clinical Takeaway:

Modularity: Traditional formulas can be parsed, stacked, and adjusted according to symptoms.
Dosage Balance: The chief complaint (Constipation) is dosed at the higher end of the ranges, while the constitutional chronic base (Yin Def) is treated slowly with low-to-mid range dosages.
Targeted Fluid Promotion: Active fluid-promoting herbs (Sheng Di, Zhi Mu, Huo Ma Ren, Wu Wei Zi) can be elevated individually inside their modules when profound dryness manifests.