Crafting a follow-up prescription: Two clinical cases

Well, the first days are the hardest days, don´t you worry anymore. 

Cause when life looks like East Street, there is danger at your door.

Think this through with me, let my know your mind.

Woah-oh, what I want to know is, are you kind?

These are the opening lines of Uncle John’s Band, a song by the Grateful Dead from the late 1960s, a time in the distant past that some of us still remember, when Chinese medicine in the West was just about to take off. Like many of Robert Hunter’s lyrics, the song’s verses invite us to explore their relevance to our own lives. Which is what I will do in this blog post with reference to the crafting of prescriptions in Chinese medicine.

In that context, the most difficult challenge—“the first and hardest days”—seems to be distilling a patient’s illness into a pattern that we can respond to with a prescription or acupuncture treatment. When the patient returns for their next visit and tells us they are feeling better, that is “life on Easy Street.” We obviously have cracked the problem, and all that remains is to see the job through. Yet, it is precisely this moment that presents the “danger at our door.” Any experienced practitioner knows that writing the follow-up prescription is often as challenging as composing the first one, and often more so. In fact, it is only when that follow-up prescription (or treatment) also works as expected that we can truly say we are on top of a particular case. In the rest of this blog, I outline four distinct scenarios we might encounter when writing that all-important second prescription, inviting you to “think this through with me.” As we shall see, such reflection requires honesty, self-awareness, and humility; qualities that can only be maintained by showing kindness to oneself.

Patterns versus disease

I want to begin with the claim that the crafting of the all-important second prescription is entirely dependent on pattern diagnosis. A pattern is a coherent assemblage of symptoms and signs that we expect to change together. It does not matter (to me at least) how one comes to assemble such patterns. It may be a TCM syndrome pattern, a formula pattern, the surface manifestation of a hidden disease dynamic, or something derived entirely from experience. What matters is that patterns represent a distinctive mode for observing how the “embodied self” (my translation of shen 身) responds to our intervention. Diagnosing a disease does not provide us with this tool. The disease is either present or absent. A pattern, on the other hand, can transform completely or only in part and that, in my experience, is crucial to how we craft our second formula.

Four possible scenarios

The diagram below outlines four possible scenarios for how patterns might change following an intervention—specifically, our initial prescription—and how I have learned to respond to them. Consider this diagram as a map. The purpose of this map is to help us navigate a complex and often challenging situation. It is not a direct reflection of reality, inasmuch as these scenarios are not rigidly bounded and can easily blend into each other.

In Scenario 1, all of the symptoms and signs that constitute the pattern we are addressing improve coherently, or even resolve completely. This is the most desirable outcome, but even this situation is not entirely free of danger, because we still need to decide what to do next. Fortunately, in this scenario, the answer is easy and straightforward.

As long as symptoms and signs persist, I recommend continuing the same prescription until the pattern is 80-90% resolved, regardless of how long it takes. Depending on one’s practice style, one might want to make small adjustments to the prescription, now that one has a better understanding of how symptoms and signs are interconnected. However, this is a personal choice. The figure of 80-90% is somewhat arbitrary and should not be taken literally; it could be 60% or 92%. The key is to avoid both under- and over-treating. Yin-yang logic teaches us that extremes become their opposites; therefore, aiming for 100% is a recipe for disaster. Instead, we should stop treatment as soon as the organism is able to complete the healing process on its own. [1]

It is common practice in China to follow the resolution of the main pattern with a formula that “harmonises” or “adjusts” (tiaohe 調和). This is often a tonifying formula, designed to provide the organism with resources for recovery and maintenance of health. From my experience as both a patient and a practitioner, I have strong reservations about this advice. I prefer prescribing based on what the embodied self tells us rather than following general rules. If the patient needs tonification, they will present with a distinctly new and different pattern. We are then in Scenario 2. We can, of course, support the self-healing process with dietary and lifestyle advice. But that —and here I agree with the famous Japanese physician Todo Yoshimasu—is the field of yangsheng, not medicine [2].

Scenario 2 occurs when, as a result of our initial prescription, the original pattern changes into a new one. In treating Covid-19 patients, for example, I observed that helping the body to expel pathogens located in the interior would often lead to visible signs of constraint in the exterior, such as headache or paraesthesia, sometimes accompanied by nausea and dizziness. I quickly learned to interpret the appearance of these new taiyang or mixed taiyang-shaoyang patterns as a positive development, indicating that with the right formula, the disease was about to resolve. Even in cases where a newly emerging pattern suggests a worsening of the condition or an adverse reaction to treatment, we face no hidden danger. The key to a successful resolution is to recognise the new pattern for what it is.

Scenario 4 is a variation of Scenario 2. Here, symptoms and signs have not responded to our initial formula. Maybe the dosage was too low, our diagnosis was wrong, or there was a mismatch between diagnosis and prescription. Perhaps this patient requires a different type of medicine or a different practitioner. Whatever the answer, there is no choice but to accept that we are not yet on Easy Street, and that the only way to get there is through a meticulous reassessment of the case.

Scenario 3 is perhaps the most common situation we encounter in clinical practice. Some symptoms and signs have improved. Our patient may be very pleased with these changes. However, if we are honest with ourselves, the pattern as a whole has not changed. This scenario also calls for a careful reassessment of the case, which may be even more challenging than in Scenario 4. Being completely wrong allows us to wipe the slate clean and begin anew. If some symptoms improve, but the pattern as a whole is not resolving, it indicates we have some insight but lack a clear understanding about how the different symptoms and signs that make up the pattern hang together. 

In my opinion, there is no single method that can provide us with a failsafe guide on how to proceed in these situations. Experience plays a significant role, transforming each case into a learning opportunity. In his work Notes on Implied Conceptions (Yuyicao 寓意草), the seventeenth-century physician Yu Chang 喻昌 posited that such learning necessitates the public disclosure of our deliberations on a case [3]. This does not mean we must publish our cases or openly discuss them—although Yu Chang did both and encouraged others to follow his lead. Rather, it entails documenting the thought processes that have informed our decision-making processes so that we can critically reflect on them, perhaps with the help of others. As Robert Hunter aptly put it, “to think this through with me, let me know your mind.” In that spirit, I would like to share two of my own cases and learning experiences (both telemedicine consultations and therefore lacking information about the pulse or abdomen).

Case 1 (Female ,48 years)

I have seen this patient on and off for almost 15 years. She initially consulted me for extreme fatigue and severe migraines against a background of psoriatic arthritis, which had caused her to give up the work she enjoyed. She has since returned to work, albeit not full-time. She only rarely gets migraines, and her autoimmune disorder is under control. She now consults me sporadically for colds and flus that don’t resolve. The last time was in August 2025, when she had been ill for about a month with the following symptoms:

Severe lack of energy and a feeling of being on the verge of developing flu, yet without her symptoms ever getting any worse; a constant sore throat with slightly swollen lymph glands in the neck; a dry chest with a slight non-productive cough; strong body aches characterised by heaviness in the muscles; restless sleep with frequent waking and vivid dreams; frequent urination; thirst; she felt neither hot nor cold, had no headaches, and her bowel movements were normal.

Her tongue was pale with a thin slightly sticky white coating and slight sublingual venous stasis. This was a video-based consultation, hence I have no information about the pulse.

I diagnosed her condition as a damp-warmth pestilential disorder (dampness predominant) at the wei level (following Ye Tianshi 葉天士) or the yangming/taiyin exterior (following Xue Shengbai 雪生白), for which I composed a prescription based on Sweet Dew Special Pill to Eliminate Toxin (gān lù xiāo dú dān) by Ye Tianshi, and Lifting and Directing Downward Powder (shēng jiáng san) by Yang Lishan 楊梨山.

Pogostemonis/Agastaches Herba (huò xiāng) 5g, Menthae haplocalycis Herba (bò hé) 5g, Fritillariae Bulbus (bèi mǔ) 6g, Forsythiae Fructus (lián qiào) 6g, Cicadae Periostracum (chán tuì) 6g, Bombyx batryticatus (bái jiāng cán) 6g, Curcumae longae Rhizoma (jiāng huáng) 4g, Talcum (huá shí) 6g, Scutellariae Radix (huáng qín) 6g, Glycyrrhizae Radix (gān cǎo) 3g, Paeoniae Radix alba (bái sháo) 9g, Artemisiae scopariae Herba (yīn chén) 5g

After 5 days of taking this prescription, the patient reported that the sore throat had improved, the muscle aches were significantly better, the cough had gone, and the lymph nodes were no longer swollen. However, she had had a severe migraine for one day and was left with a heavy head indicating that she might have another migraine any day. The fatigue had not changed much. It did not improve by lying down. Instead, she felt better by moving and being out in the fresh air. She was also still thirsty and urinated frequently.

I interpreted this as indicating that the pathogen was on the way of being resolved, but that the clear yang failing to ascend led to turbidity above. To treat this, I prescribed a variation of Tonify the Middle to Augment the Qi Decoction (bǔ zhōng yì qì tāng), adding herbs such as Chuanxiong Rhizoma (chuān xiōng) and Nelumbinis Folium (hé yè).

The response to this formula was not good. The sore throat returned; she started to feel slightly feverish but did not sweat, and she also had muscle aches again. Neither the tiredness, nor the thirst and frequent urination had improved.

I had made several mistakes. I had based the switch to a tonifying formula on previous positive experience in helping this particular patient in a similar situation, when Tonify the Middle to Augment the Qi Decoction (bǔ zhōng yì qì tāng) had been key to resolving the case. This time, however, the fact that her fatigue did not improve by lying down should have alerted me to a different presentation. I also had ignored/misinterpreted the symptoms of thirst and frequent urination, which, with hindsight, did not fit a damp-warmth pattern. According to my own road map, I believed to be in Scenario 2 when, in fact, I was in Scenario 3.

Upon further consideration, I therefore decided to treat this as a Five-Ingredient Powder with Poria (wǔ líng sǎn) pattern, in which fluid accumulation was hindering the qi dynamic and the resolution of the epidemic toxin, for which I added Lifting and Directing Downward Decoction (shēng jiáng tāng).

Poria (fú líng) 6g, Alismatis Rhizoma (zé xiè) 9g, Polyporus (zhū líng) 3g, Atractylodis macrocephalae Rhizoma (bái zhú) 6g, Cinnamomi Ramulus (guì zhī) 4g, Forsythiae Fructus (lián qiào) 6g, Cicadae Periostracum (chán tuì) 6g, Bombyx batryticatus (bái jiāng cán) 6g, Curcumae longae Rhizoma (jiāng huáng) 4g, Fritillariae Bulbus (bèi mǔ) 6g

This prescription quickly resolved all of the symptoms.

Case 2 (Male ,28 years)

This young man consulted me in August for help with what he thought might be long-Covid. He had fallen ill in January with an acute sore throat and cough, but had not carried out a Covid test. Four weeks later, he still felt tired with brain fog, body aches, and recurrent sore throats. This had not since resolved. Previously, he had been a triathlete, but he now felt his symptoms were aggravated by excessive physical exercise. He found it difficult to get going in the mornings. His ability to concentrate had also decreased, in response to which he had increased his coffee intake. He had occasional neck stiffness and mild tinnitus. Overall, he felt quite hot; he preferred the fresh air and having the windows open, but sometimes he would also feel chilly.

Various biomedical tests had proven inconclusive. He had put himself on a gluten-free diet, which had resulted in some improvement in the muscle aches. His bowels were regular, as was his urination, but he drank a lot of water, up to 3-4 l/day. He consumed alcohol in moderation, suffering from bad hangovers if he drank too much.

Upon further questioning, he informed me that he had suffered from night sweats for a long time. It was something that ran in his family and that he accepted as part of who he was. He would sweat particularly from his lower back. He regularly would wake up once or twice a night, sometimes with sleep paralysis and terrifying dreams. This had been something he had experienced since childhood, but which he could not link to any life event or trauma.

His appetite was not as good as it used to be, and he felt bad after oily and greasy foods.

His tongue was mauve in colour, elongated, with a thin greasy yellow coating. There was a notable depression in the Lung area of his tongue.

I diagnosed this case as a heat pathogen that had failed to be resolved because of constraint in the shaoyang exterior, with damp-heat at the ying aspect, for which I prescribed a combination of modified Minor Bupleurum Decoction (xiǎo chái hú tāng) and Coptis and Ass-Hide Gelatin Decoction (huáng lián ē jiāo tāng) as follows.

Bupleuri Radix (chái hú) 9g, Scutellariae Radix (huáng qín) 9g, Coptidis Rhizoma (huáng lián) 6g, Trichosanthis Radix (tiān huā fěn) 9g, Salviae miltiorrhizae Radix (dān shēn) 6g, Paeoniae Radix alba (bái sháo) 12g, Glycyrrhizae Radix (gān cǎo) 6g, Jujubae Fructus (dà zǎo) 6g, Polygoni multiflori Caulis (yè jiāo téng) 12g

After a week, the patient reported a distinctive improvement. His energy levels were up by about 30%, he had more mental stamina and less brain fog, and he no longer had any sensations of cold. His appetite had also improved. However, his night sweats continued unabated, to the point that he had to change his T-shirt every night. He did not sweat much in the daytime, and only was bothered by the heat if the weather was hot.

Reviewing his reaction to my prescription, I classified it as Scenario 3 above. Some symptoms had improved, but the pattern as a whole had not shifted. This implied that I had failed to correctly interpret all the symptoms, and most likely ignored some important signs. One of these signs was the dip in the Lung area of his tongue, which to me indicated deficiency of the gathering qi. This would also account for the signs of blood stasis in his tongue. Qi deficiency in the exterior manifested with the inability to contain sweating. However, the fact that he only sweated at night meant the sweating itself was not caused by this deficiency but by heat and stasis at the ying and blood aspects. This heat and stasis also explained the night terrors. I therefore prescribed the following formula, which is based on my readings of Zhang Xichun 張錫純. However, even without being familiar with his work, readers should be able to see that the formula tonifies qi, unblocks blood stasis, secures the exterior, clears and drains heat, as well as continuing to unblock the shaoyang.

Codonopsis Radix (dǎng shēn) 12g, Astragali Radix (huáng qí) 12g, Scutellariae Radix (huáng qín) 12g, Scrophulariae Radix (xuán shēn) 12g, Fossilia Ossis Mastodi (lóng gǔ) 12g, Ostreae Concha (mǔ lì) 12g, Salviae miltiorrhizae Radix (dān shēn) 6g, Sparganii Rhizoma (sān léng) 4.5g, Curcumae Rhizoma (é zhú) 4.5g, Paeoniae Radix alba (bái sháo) 12g, Bupleuri Radix (chái hú) 5g, Glycyrrhizae Radix praeparata (zhì gān cǎo) 6g

The patient took the formula for 10 days, after which he reported significant improvement in all his symptoms. His energy was back to normal; he had had no more night sweats or night-time terrors, and he slept much better overall. All the external symptoms (tinnitus, neck stiffness, sore throat) had also resolved, with no relapse since then.

Conclusions

My aim in presenting these cases was to clarify the four scenarios outlined earlier within the context of real-life clinical situations. The precise clinical reasoning that led me to specific prescriptions is idiosyncratic and therefore not pertinent to this meta-level discussion.

When we constellate symptoms and signs into patterns, on the other hand, it is precisely our clinical reasoning that gets us there, right or wrong. That is why self-critical evaluation of a patient’s response to our treatment must begin and end with deliberating how our attempts at discerning what is and what is not important in a given case, what hangs together and why, led us astray.

Notes

1. I learned about discontinuing treatment at the right moment by reading Ye Tianshi's Treatise on Warmth and Heat (Wenre lun 溫熱論).

2. In his Organon of Medicine (Idan 醫斷) Todo Yoshimasu makes an important distinction between medicine, as being concerned with the treatment of disease, and yangsheng as the, in his eyes, problematic attempt to prolong life, especially when attempted with the help of medicinals that are, by their very nature, unbalanced (pian 偏).

3. Yu Chang 喻昌. "Deliberating disease before employing remedies" (Xian yibing hou yongyao 先議病後用藥) in Notes on Implied Conceptions (Yuyicao 寓意草).