Patient: Male, 19 years old
Date : 7th April 2024 first visit
Main issue: Reflux & Heart Burnt for a year plus

18 years old patient was accompanied by his father to enter the diagnosis room.

Caught with a glimpse, the outlook of the patient was tall and slim. He looked shy when entering the room.

“Hi! May I know what is your problem?”
“Hi TCM Practitioner, I have a reflux and heart burnt. I have bloated stomach too.”
“How long had it been there?”
“A year plus.”
“I see. When did it happen?”
“Almost daily early in the morning after I woke up, the reflux started. My mouth is bitterness. When I brushed my teeth, I have an urge to vomit.”

“Do you take your meal regularly?”
“Yes.”
“Do you see any other symptoms?”
“Recently, I encountered stress due to my studies. I was lying on the bed at 10pm, somehow I kept tossing and turning on the bed for 2 hours plus then only managed to fall asleep. Later, about 2-3 hours later, I woke up again. Sometimes I had nightmare.”

14th April 2024 second visit:

The patient revisit a week later.

“Hi, how are you boy?”

“Hi, TCM Practitioner, I feel good. For past one week, the reflux and heart burn sensation rarely appear. But my mouth could still feel bitterness. Sometimes if reflux happened, i could still sense the bitterness and urge of vomiting. My appetite improved much.”

“How is your sleep now?”
“The time duration to fall asleep reduced. The mid night woke up reduced as well.”
“Great! Don’t give up ya!”

28th April 2024 third visit :

During the third visit, the patient has felt his symptoms alleviated much. He has better appetite and could eat in a speedy manner compare to last time. His emotional feeling also changed, he felt better compare to last time. We emphasized to the patient to maintain a good diet habit, with no cold or iced drink. Besides, we also asked him to cut down spicy and fried food.

Through an in depth conversation, we found that the patient was humble and felt unconfident about his own weight. He dare not see the result when he stood on the weighing tool because always hinted himself as an underweight person. We highly recommended him to do some exercises.

26th May 2024fourth visit:

The patient’s symptoms improved and he has continued the medication remedy. We planned to monitor the outcome in the upcoming time frame.

30th June 2024 fifth visit:

The patient’s symptoms improved and he has continued the medication remedy. We planned to monitor the outcome in the upcoming time frame.

4th August 2024 sixth visit:

After few months’ treatments, the problem of reflux and heart burnt has almost recovered. His appetite improved much. His bloated stomach only occurred when he was affected by emotion feeling or he felt tensed.

The patient’s lifestyle has changed and become self-disciplined. He has been doing the push up exercise 20 times per day, and 15 push up counts per time. His character changed to be more confident and pleasant nowadays.

4th January 2025 seventh visit:

After 5 months of self-disciplined training habits, the patient’s outlook changed pretty much. He has become more confident and the body strengthened and become muscular. He entered the room with a pleasant face.

“Hi TCM Practitioner, how are you? ”
“Hi boy! You gained weight ya!”
“Do you still do the push up exercises persistently? ”
“Yup!!”
“Great! Do you still feel cold?”
“No more cold. Now I feel hot easily compare to last visit. Last time, my body was sensitive to both cold and hot temperature.”
“When I touch your hand and feet, I feel your body cold ya!”
“Cold as usual, TCM Practitioner.”
“How was your sleep?”
“Compare to last time, my sleep quality improved. Sometimes i still encountered nightmare.”

The patient’s weight has risen from 52.3kg to 53.9kg. He is on a good direction to maintain the health and his confident gained as well.

Case study analysis:

The patient’s main issue was reflux and heart burnt for a year plus when he turned up at the first visit on 07.04.2024. Almost daily early in the morning after woke up, the reflux started. His mouth is bitterness. When he brushed his teeth, he kept vomiting. This indicated the heatiness of liver. Even though he has a regular diet time, due to stress of the studies, he could hardly sleep well. He got up to bed at 10pm, and take 2 hours to toss and turn before fall asleep. Then some time later, he would wake up at about 2-3am. Luckily, he could fall asleep quickly. Sometimes, he has nightmare. He did sweat if performed exercises. He felt dry mouth and always has urge to drink water. After each meal, he could stand for shorter hours and get hungry easily. He felt bloated stomach before sleep. We advised him to cut down spicy and fried food.

After the oral prescription for a week, he found that his problem improved when he turned up for the second visit. But he could still feel reflux cum bitterness mouth as well as urge of vomiting. Due to the obvious improvement, he has become more confident to get well with the herbal medicine remedy.

At the third visit, the patient felt his major improvement. He got better appetite. He could eat in a speedy time frame compare to last time. His emotion changed and become merrier than last time. We emphasized to maintain a good diet habit, with no cold or iced drink. Besides, he was asked to cut down spicy and fried food too. Through an in depth conversation, we found that the patient was humble and felt unconfident about his own weight. He dare not see the result when he stood on the weighing tool because always thinking himself an underweight person. We highly recommended him to do exercise.

Few months later after the treatments, we observed that the patient’s digestive system has changed a lot obviously. The patient’s lifestyle has become more self-disciplined. He used to perform a regular push up exercises. His character changed to become more pleasant too.

After 5 months later, he turned up again in Jan of 2025 with a confident and pleasant outlook. He has become muscular and managed to gain weight from 52.3kg to 53.9kg.

Tips for daily care:

1. Healthy Dietary maintenance.

We emphasized to maintain a good diet habit, with no cold food or iced drink. Any cold food from fridge such as salad, iced-cream, chilled fruits are inhibited. Due to the coldness will affect and slowing down the process of digestive system. Besides, he was asked also to cut down spicy and fried food.

2. Emotional tuning

Advised patients to approach nature explore or other activities such as listening to music, reading book and some activities to calm down the mind-set.