4.5 Inquiry II: Digestion, Excretion, Sleep, Senses, Gynecology, and History
Key Takeaways
Loose stools with undigested food point to Spleen Yang deficiency, 5 AM diarrhea to Kidney Yang deficiency, and alternating constipation and diarrhea with stress to Liver invading the Spleen.
Thirst for cold water indicates Full Heat, sipping or rinsing without swallowing suggests Damp-Heat or Blood stasis, and hunger without desire to eat indicates Stomach Yin deficiency.
Sudden loud tinnitus not relieved by pressure points to Liver Fire or Yang, while gradual faint cicada-like tinnitus softened by pressure points to Kidney deficiency.
Difficulty falling asleep suggests Heart and Spleen Blood deficiency, frequent waking with night sweats suggests Heart-Kidney Yin deficiency, and dream-disturbed agitation suggests Heat or Phlegm-Fire.
Cycle length, flow, color, clots, and timing of menstrual pain separate Heat, Cold, deficiency, and stasis patterns.
4.5 Inquiry II: Digestion, Excretion, Sleep, Senses, Gynecology, and History
Quick Answer: The second half of the Ten Questions covers stool and urine, food, taste, and thirst, chest and abdomen, hearing and vision, sleep, past history, and, for women, menstruation and pregnancy. Each answer narrows the pattern: undigested food in the stool points to Spleen Yang deficiency; thirst for cold water to Full Heat; hunger without appetite to Stomach Yin deficiency; difficulty falling asleep to Blood deficiency; dark clotted menses to Blood stasis. Good inquiry also means asking the right follow-up questions and identifying the cause of illness (internal, external, or miscellaneous).
The 2026 FOM outline gives Inquiry 10% of the exam, more than any other examination method. Its task statements include identifying the presenting complaint, formulating additional questions from the patient's answers, conducting a review of systems with the Ten Questions, identifying etiological factors, and assessing personal and family health history. Section 4.4 covered chills and fever, sweating, and head and body pain. This section covers the rest.
Asking Follow-Up Questions
Every answer should generate a question that separates two patterns. For example:
| Patient says | Follow-up question | What it separates |
|---|---|---|
| "I have diarrhea." | "What time of day, and is there undigested food?" | 5 AM diarrhea (Kidney Yang) vs. undigested food after meals (Spleen Yang) vs. urgent burning stools (Damp-Heat) |
| "I'm always thirsty." | "Do you want cold drinks or warm, and do you drink much?" | Full Heat (gulps cold water) vs. Yin deficiency (sips) vs. Damp-Heat or stasis (wants to rinse, not swallow) |
| "I can't sleep." | "Is it falling asleep or staying asleep?" | Blood deficiency (falling asleep) vs. Yin deficiency (waking with heat and sweats) |
| "My periods are painful." | "Before, during, or after the flow, and does pressure help?" | Stagnation or stasis (before or during, worse with pressure) vs. deficiency (after, better with pressure) |
Question 4: Stool and Urine (Bian)
Stool Dynamics
- Loose Stools with Undigested Food Particles (Wan Gu Bu Hua): Indicates Spleen Yang Deficiency failing to transform grain essence.
- Cockcrow Diarrhea (Wu Geng Xie): Watery diarrhea occurring at dawn (5:00 AM) preceded by abdominal rumbling and pain, relieved immediately by defecation. Pathognomonic for Kidney Yang Deficiency failing to warm Spleen Earth.
- Alternating Constipation and Diarrhea: Emotional stress provokes diarrhea or stool irregularity. Indicates Liver Qi Invading the Spleen (Gan Pi Bu He).
- Dry, Hard, Pebble-Like Pellets (Sheep Dung Stools): Indicates Intestinal Dryness due to Blood or Yin deficiency, or Stomach Heat.
- Watery Diarrhea with Burning Anus and Foul Stench: Indicates Damp-Heat in the Large Intestine.
- Dysentery with Blood, Pus, and Tenesmus (Li Ji Hou Zhong): Painful urgency with difficult, incomplete evacuation. Indicates Toxic Damp-Heat in the Large Intestine.
Urine Dynamics
- Clear, Profuse Urination with Nocturia: Indicates Kidney Yang Deficiency or Interior Cold.
- Scanty, Dark Yellow, Turbid Urine with Burning Pain: Indicates Bladder Damp-Heat.
- Dribbling, Hesitancy, Weak Urinary Stream: Indicates Kidney Qi Deficiency or Kidney Jing depletion.
Question 5: Food, Taste, and Thirst (Yin Shi)
Thirst Patterns
- Absence of Thirst: Indicates Cold patterns or absence of internal heat.
- Thirst with Desire for Copious Cold Water: Indicates Full Heat in the interior (Stomach Fire or Yangming Heat).
- Thirst with Desire to Sip Warm Liquids, or Wetting Mouth Without Swallowing (Ke Bu Yu Yan): Indicates Blood Stasis or Damp-Heat (heat creates thirst, but dampness/stasis prevents fluid ingestion).
- Unquenchable Thirst with Voracious Hunger and Profuse Urination: Indicates Wasting-Thirst (Xiao Ke).
Appetite and Taste
- Canine Hunger with Rapid Digestion and Emaciation (Xiao Gu Shan Ji): Patient eats voraciously but loses weight. Indicates Stomach Fire.
- Hunger with No Desire to Eat (Ji Bu Yu Shi): Patient feels hungry but cannot tolerate more than a few bites. Indicates Stomach Yin Deficiency.
- Poor Appetite with Postprandial Abdominal Fullness: Indicates Spleen Qi Deficiency.
- Taste Sensations: Bitter = Liver/Gallbladder Fire; Sweet/Sticky = Spleen Dampness; Sour = Food Stagnation; Salty = Kidney Disharmony; Bland = Spleen-Stomach Cold/Deficiency.
Question 6: Chest, Abdomen, and Flanks (Xiong Fu)
- Chest Oppression and Discomfort: Qi stagnation, Phlegm obstruction, or Heart Blood stasis.
- Hypochondriac Distension and Fullness: Liver Qi stagnation, Liver Fire, or Gallbladder Damp-Heat.
- Response to Pressure:
- Pain Relieved by Pressure (An Zhi Tong Jian): Indicates a Deficiency Pattern (Xu).
- Pain Aggravated by Pressure (An Zhi Tong Shen): Indicates an Excess Pattern (Shi) (Blood stasis, food retention, or phlegm).
Question 7: Hearing and Vision (Er Mu)
Tinnitus Differentiation
- Sudden Onset, Loud, Roaring Tinnitus (Ocean Waves or Machinery): Aggravated by emotional outbursts, not relieved or worsened by pressing the ears. Indicates an Excess Pattern: Liver Fire Blazing, Liver Yang Rising, or Gallbladder Heat.
- Gradual Onset, Faint, Thin Tinnitus Like Cicadas or Running Water: Low in volume, intermittent, worse when fatigued, and softened by pressing on the ears. Indicates a Deficiency Pattern: Kidney Jing Deficiency or Kidney Yin deficiency.
Vision
- Blurred Vision, Floaters, Dry Eyes, Night Blindness: Indicates Liver Blood Deficiency or Liver Yin deficiency.
- Red, Swollen, Bloodshot, Painful Eyes: Indicates Liver Fire Blazing or external Wind-Heat.
Question 8: Sleep Architecture (Shui Mian)
- Difficulty Falling Asleep (Sleep-Onset Insomnia): The patient tosses and turns for hours. Indicates Heart Blood Deficiency or Spleen Blood Deficiency failing to house the Shen.
- Waking Frequently Throughout the Night with Agitation and Night Sweats: Indicates Heart and Kidney Yin Deficiency with Empty Heat.
- Early Morning Waking (3:00 AM – 5:00 AM) with Inability to Return to Sleep: Indicates Gallbladder Qi deficiency or Liver Blood deficiency.
- Dream-Disturbed Sleep with Violent Nightmares and Sudden Waking: Indicates Heart Fire, Gallbladder Fire, or Phlegm-Fire Harassing the Heart.
- Somnolence (Excessive Daytime Sleepiness): Indicates Spleen Qi Deficiency with Dampness or Kidney Yang deficiency.
Questions 9 & 10: Past Medical History and Gynecological Inquiry
Past Medical History and Medications
- Chronic health conditions, previous surgical procedures, lifestyle stressors, and Western pharmaceuticals (e.g., diuretics causing dry peeled tongue; beta-blockers creating slow pulse; broad-spectrum antibiotics generating thick greasy tongue coating).
Gynecological Inquiry
- Cycle Duration:
- Shortened / Advanced Cycle (<21 days): Indicates Blood Heat forcing blood extravasation, or Qi Deficiency failing to hold blood.
- Lengthened / Delayed Cycle (>35 days): Indicates Blood Deficiency, Interior Cold contracting vessels, or Blood Stasis obstructing flow.
- Irregular Cycle: Indicates Liver Qi Stagnation or Kidney deficiency.
- Flow Volume, Color, and Consistency:
- Profuse, Bright Red Flow: Blood Heat.
- Scanty, Pale Pink Flow: Blood Deficiency.
- Dark Purplish Flow with Clots: Blood Stasis or Cold Stasis.
- Dysmenorrhea Timing:
- Severe Cramping Before or During Menses Relieved by Passing Clots: Qi and Blood Stasis (Excess).
- Pain During Menses Relieved by Heat and Warm Compresses: Cold Stasis (Excess/Cold).
- Dull, Lingering Ache After Menses Relieved by Rest and Pressure: Qi and Blood Deficiency (Deficiency).
Identifying Etiological Factors and Personal and Family History
The 2026 outline lists the causes of disease as separate inquiry targets. Ask about each group:
- Internal (emotional) factors: prolonged anger or frustration (Liver), worry and overthinking (Spleen), grief (Lung), fear or shock (Kidney, Heart), and recent major life stress.
- External (environmental) factors: exposure to wind, cold, damp, heat, or dryness before onset; living or working conditions (damp basements, outdoor work in cold weather, air-conditioned offices); contact with contagious illness.
- Miscellaneous factors: diet (raw and cold food, greasy or spicy food, alcohol, irregular meals), overwork and lack of rest, sedentary habits, sexual activity, trauma or surgery, medications, and occupation.
Personal history includes past illnesses, surgeries, current diagnoses, and concurrent treatments, including prescription drugs and supplements that may mask or mimic signs. Family history identifies constitutional tendencies and hereditary risks. In the Ten Questions, these are questions nine (past diseases) and ten (causes). They link the pattern to its root and shape advice on diet and lifestyle (see Sections 5.7 and 5.8).
A 64-year-old male reports waking up abruptly at 5:00 AM every morning with severe abdominal cramping, borborygmi, and chilliness. He must rush immediately to the toilet to pass loose, watery stool, after which his abdominal pain completely subsides. He also complains of chronic coldness in his lower back and knees and frequent night urination. Which diagnosis is indicated by this classic cockcrow diarrhea?
Damp-Heat in the Large Intestine
Kidney Yang Deficiency failing to warm Spleen Earth
Food Stagnation in the Stomach and Intestines
Liver Qi Invading the Spleen
A patient says she has felt hungry for weeks but can only eat a few bites, with a dry mouth, dry stools, and a red tongue peeled in the center. Which pattern does this inquiry finding point to?
Stomach Fire Blazing
Spleen Qi Deficiency
Stomach Yin Deficiency
Food Stagnation
A patient reports waking frequently through the night feeling hot and sweaty, with five-palm heat and a sore lower back. Which follow-up finding would best confirm Heart-Kidney Yin deficiency rather than Heart Blood deficiency?
A pale, thin tongue with a thin white coat
A red tongue with little coating and a thready, rapid pulse
Difficulty falling asleep with a pale complexion
Poor appetite with loose stools
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