(Disclaimer: This article is for general use only. To protect patient privacy, the information in the following content has been processed.) Abstract: The patient presented with a heavy and weak body, frequent diarrhea, thin stools, poor energy, fear of cold and fear of cold, and was diagnosed with possible cold-damp trapped spleen evidence, which is closely related to the usual poor living habits and poor dietary habits injuring the spleen and stomach. After giving medication, the patient’s body heaviness was greatly reduced, stools were formed, and gastrointestinal discomfort was significantly improved. The patient’s symptoms became more and more pronounced. When the weather changed, he was unable to add or remove clothes in time. Over time, he developed a heavy body, dizziness, memory loss, drowsiness and fatigue, eating discomfort, and loose stools. The patient had been examined by gastroscopy in the hospital, which showed superficial gastritis, and was given oral treatment with gastric pellets and omeprazole enteric capsules, but there was no change in the symptoms after taking the drugs for about one month, so he came to our clinic. According to the information collected from the four consultations, the patient had a light tongue with thin coating, a sunken pulse, a slightly sticky feeling in the mouth, loose and unformed stools, long and clear urine, frequent urination, depressed mood, fear of wind and cold, frequent stomach pain, chest tightness and shortness of breath, poor appetite, self-conscious sleepiness, easy to wake up in the middle of sleep, and fatigue and weakness. The initial treatment was to strengthen the spleen, resolve dampness, warm yang and disperse cold, and to give Rizhong Pill with reduction for oral treatment. After taking the medicine for 1 week, the patient felt that her body heaviness improved, her dizziness and drowsiness were relieved, and her stomach discomfort improved. The second consultation was based on the original formula to warm Yang and strengthen the spleen to resolve dampness, such as fried coix seeds, cardamom and sand seeds. At the third consultation, the patient’s general condition was acceptable, fear of coldness improved significantly, the body was warm, and the stool was occasionally loose, which was significantly better than the original. The patient’s general condition improved significantly from the initial consultation to the end of the treatment for 3 weeks, and the patient was given Rizhong Pill plus and minus medication through Chinese medicine identification. After the treatment, the patient’s energy status was greatly improved, and the dizziness and drowsiness were significantly improved. During the individualized treatment with Chinese medicine identification, the patient’s symptoms at the initial consultation were all improved. IV. Precautions We are glad that after the treatment, the patient’s symptoms have been reduced. However, it is recommended that the patient should also pay attention to the following points: 1. It is recommended that the patient should actively control smoking during the treatment process and gradually reduce or quit smoking; 2. Irregular eating habits, overeating or habits that deplete the spleen and stomach yang such as raw and cold seafood, fatty and oily foods, and cold drinks will gradually form cold and dampness trapped in the spleen, so good eating habits and diet structure will be of great help in the treatment; 3. With the overlapping of the seasons and temperature With the change of seasons and temperature, we should add and subtract clothes to avoid wind and rain to prevent the invasion of external evil, which may cause cold and dampness to be trapped in the middle jiao; 4. Five, personal insight Cold and dampness trapped in the spleen this kind of constitution is particularly large, take this patient, the internal and external factors have, eventually leading to damage to the spleen Yang, cold and dampness within the stop. First of all, from the internal causes, irregular eating habits and frequent late nights can cause Yang energy depletion, Spleen Yang damage, Qi and blood biochemical irregularities, and Wei Qi, so it is easy to be attacked by external cold and dampness, resulting in the physical state of cold and dampness trapped in the spleen. Therefore, in addition to medication, patients need to actively change their lifestyle habits.