bxiong89: December 6, 2019, 1:29am
Hi SAAMers
My name is Bree and I’m a practitioner in Sydney Australia practicing SAAM (Thanks Toby!)
I just wanted some insight into a 16yo patient that I am currently seeing
I’ve seen this patient twice now and about to see him again today.
Primary Reasons for Seeking Care:
16yo Male, Underdeveloped Emaciation and malnourished, 40kg weight, 175cm Height +9 and Increased Fatigue
(worse with activity) +7, Energy levels better in the evening and worse in the mornings +7
Secondary Reasons: constant global myalgia and bilateral knee pain +7- More SP channel, Muscular weakness
+8, Photosensitivity (needs to stay in dark room- bedroom always has shutters drawn) +8, Brain fog is quite
debilitating; frustrating- has high expectations- wants to do school work well but English is the hardest +8 and
decreased appetite +4
Subjective: Poor concentration and focus- difficulty reading +5
Appearance and demeanor : Average face symmetry, neat dress, seems slightly shielded and concave (Body has
poor posture and is bent over) +7
Non-animated talker, keeps to self a lot unless correcting mother (who is slightly overbearing and protective) +7,
Pale Face +8, nothing notable Re: politeness
Slow movements +5, Stubborn, wont back down when correcting mother +7
Lifestyle: Currently homeschooled (started in May 2019), decreased physical activity due to exacerbation of
fatigue +8, always doing something even though tired +6, self critical +5, Anxious and not too many friends
currently – missing out on teenage years +8
Body morphology and flesh quality: Emaciated thin, long limbs, poor posture +9, sunken muscle atrophy +8,
Slightly sunken LU-10 Thenar Eminence
Skin Quality: dry. Nil sweating. Nil acne
Body Temp: runs hot, enjoys winter +6, cold toes +8
NIL Sudden changes to temperature, NIL chills, fever
GI: stools: fluffy, loose stools – 2-3 times per day +7,
No urgency to go bathroom for evacuation; will come out easy +4
Thirsty +5, NIL bloating, nausea +5, Craves savory not sweet +5
Halitosis in last couple of days but no bitter taste in the mouth +6
Respiratory: Shortness of breathe- only when drinking water (will get puffed afterwards but nil throughout
day).No History of Asthma +524/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print2/11
Sleep: Sleep: 10.30pm-11pm and wakes up at 7am- Wakes up at 8am typically +7, will sleep through the night +6
Emotions: Anxiety, sensing slight anger underneath but presenting as apathetic +6
Urination: Urinating alot- urgency and slight incontinence +6, No Nocturia +6
Other Body: Few varicosities, abdomen is concave and slightly hard +7
Tongue: pale, teethmarks, quiver, red tip,
pale thick TC
Pulse: thready and rapid
Excess Presentations:
HT: Rapid pulse
BL: Urinating alot- urgency and slight incontinence +6, No Nocturia +6
GB: Anxiety, sensing slight anger underneath but presenting as apathetic +6
PC: Slow movements +5, Concave and inward +8
SJ: Photosensitivity (needs to stay in dark room- bedroom always has shutters drawn) +8, : runs hot, enjoys winter
+6, cold toes +8
LV: Brain fog is quite debilitating; frustrating- has high expectations- wants to do school work well but English is
the hardest +8, seems slightly shielded and concave (Body has poor posture and is bent over) +7
LU: Shortness of breathe- only when drinking water (will get puffed afterwards but nil throughout day).No History
of Asthma +5
ST: Slightly sunken LU-10 Thenar Eminence +9, Poor physical resources +9
LI: dry. Nil sweating. Nil acne, 16yo Male, Underdeveloped Emaciation and malnourished, 40kg weight, 175cm
Height +9, Emaciated thin, long limbs, poor posture +9, sunken muscle atrophy +8, Stubborn, wont back down
when correcting mother +7
SP: constant global myalgia and bilateral knee pain +7- More SP channel,
SI: Sharp Knee Pain- Warm and cold feet
KD: mixed warm and cool, pain
I supplemented the Spleen on the LHS for him and accidentally tonified SP-1 which made him have a reaction. He
ended up shaking and as soon as I took the needle out and readjusted the direction to drain, everything settled
down. The shakes stopped but I am yet to see him again and see how he went.
Has anyone treatment anything similar, regarding weight gain? Could anyone suggest what i could have done
differently or to improve? Any questions I should be asking him? Any help would be so so appreciated! Thanks!
KristinWisgirda: December 6, 2019, 4:15pm
Hi Bree,24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print3/11
Thanks for the case. This poor fellow certainly needs some serious help. Clarifying your diagnosis will be a good
start.
Thanks for grading symptoms and going through all of the channels. Let’s fine tune it and see what stands out.
First, take all normal parts of the presentation, such as no nocturia, no acne, no sweating. You want to see which
heavily weighted parts of the presentation line up behind which channel excesses. Including normal parts of
presentation aren’t an excessive of any channel and just clutter the picture.
I encourage you to revisit Toby’s powerpoint and compare the excesses with your patient’s symptoms.
This may seem like lots of work the first time you do it but it will really help you understand and apply the system
better. It will get easier and faster with each case.
Here is some feedback. It isn’t exhaustive but it is a start.
Running hot and liking winter (if it is because he prefers cold weather) is a Heart excess sign. The mix of running
hot and cold toes can be a SJ, SI or K excess as you have mentioned.
Shortness of breath is a classic GB excess presentation. As is Red tipped tongue when it is clearly a different color
than the rest of the tongue.
Brain fog isn’t a definitive sign of Liver excess though it could be included there. Using the search tool on the
forum will lead you to a number of discussions of brain fog where other possible channel excesses are mentioned
including Spleen excess, SJ excess. Asking what helps/aggravates the brain fog might help you differentiate.
Varicosities in a 16 year old is a for sure K excess sign.
bxiong89:
has high expectations- wants to do school work well
This sounds more like a self critical SJ excess. Not sure.
Concave body posture is not Liver excess. It is P excess. Liver excess morphology is dense.
Myalgia is not a Spleen excess sign. If it had a heavy nature or was worse in damp you could assign it to Spleen
excess. Pain by itself is a K excess. Worse with movement (the fatigue) is a SI excess.
The insistence on correcting his mother sounds like more SJ excess control as well as LI excess stubborness. If it
feels aggressive then you have GB excess.
bxiong89:
sensing slight anger underneath but presenting as apathetic +6
Apathy is Spleen excess or Liver excess. What feels true to you about this patient in his behavior?
When did this fellow’s health start to unravel? Proximate cause is an important consideration.
bxiong89:
always doing something even though tired +6,
This kind of restlessness activity could be LI excess, Gb excess.
This patient is in tough shape, is soo deficient and has so many heavily weighted symptoms. With each treatment24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print4/11
ask yourself which channel quality would best benefit him on the day of the treatment. Definitely only do 1
channel each treatment. This guy needs clarity and patience. Likely his path will be the slow miracle.
Keep us updated.
bxiong89: December 6, 2019, 10:52pm
Hi Kristin! Thanks so much for your time and reply! This is AWESOME! I’m just going to go back and clear
everything up so the clinical picture becomes a bit more obvious. But thanks so much…
I want to ask why Brain Fog would be a San Jiao Excess? I was thinking more opposite being the LV excess as
they are more clouded over?
Excess Presentations:
HT: Rapid pulse, Running hot and liking winter
BL: Urinating alot- urgency and slight incontinence +6, No Nocturia +6
GB: Anxiety, sensing slight anger underneath but presenting as apathetic +6, Shortness of breathe from drinking
+5, Red tip tongue +4, always doing something even though tired +6?
PC: Slow movements +5, Concave and inward +8, seems slightly shielded and concave (Body has poor posture
and is bent over) +7
SJ: Photosensitivity (needs to stay in dark room- bedroom always has shutters drawn) +8, : runs hot, enjoys winter
+6, cold toes +8, (Brain Fog?), Brain fog is quite debilitating; frustrating- has high expectations- wants to do
school work well but English is the hardest +8,
LV: sensing slight anger underneath but presenting as apathetic +6
LU: Shortness of breathe- only when drinking water (will get puffed afterwards but nil throughout day).No History
of Asthma +5
ST: Slightly sunken LU-10 Thenar Eminence +9, Poor physical resources +9
LI: dry skin. always doing something even though tired +6?
16yo Male, Underdeveloped Emaciation and malnourished, 40kg weight, 175cm Height +9, Emaciated thin, long
limbs, poor posture +9, sunken muscle atrophy +8, Stubborn, wont back down when correcting mother +7
SP: , (Brain Fog?)
SI: Sharp Knee Pain- Warm and cold feet, Worse with movement +8, constant global myalgia and bilateral knee
pain +7- More SP channel
KD: mixed warm and cool, pain
UPDATE 06/12/2019
So I went with Supplementing the Spleen again yesterday on the LHS (Male). He is so deficient that he gets the24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print5/11
shakes on the table as soon as all the needles go in. (I think this is Internal Wind from Blood Def)- This is despite
the needles being all in the right direction and tonfied and reduced accordingly.
This one is quite tricky. Although the good news since the last treatment was that he had put on 0.8kg since last
week’s treatment. This also included a 30% increase to food, slightly uncomfortable from the amount but nothing
he can’t handle. No bloating or distension after the food
Stools are slightly more formed and less soft than before, less urinary incontinence and frequency.
Would you recommend doing the SP more than 3 times. I know that Toby has said not to hit the channel more than
3 times (as a flex rule?) but I actually think it might be needed in this case.
I can’t do herbs as I am working with an Integrative GP, on this case…he is given alot of supplements and only
eats organic foods. His mother is lovely but can be slightly overbearing. She’s also trying to cope…
Really appreciate the help Kristin.
KristinWisgirda: December 8, 2019, 5:03pm
bxiong89:
I want to ask why Brain Fog would be a San Jiao Excess?
Words can be misleading. We have to be so careful to probe the into the patient’s actual experience whenever
possible. Some patients may not be so helpful describing but we can try. There are cases on the forum and in my
own practice of brain fog being caused by light exposure or too much brightness. Imagine being blinded by the
light.
bxiong89:
Would you recommend doing the SP more than 3 times. I know that Toby has said not to hit the channel more
than 3 times (as a flex rule?) but I actually think it might be needed in this case.
Toby’s recommendation is that you don’t repeat a treatment more than twice, only repeating a treatment a third
time in extreme situations. However, very deficient patients most often do better with changing the treatment each
and every time. With these folks, the same treatment that gave great results last week often tanks if you repeat it
the next week. Saam treatments are shoves in a particular direction. Imagine shoving a weak patient twice in the
same direction. The first shove might make them more upright, the second shove will knock them over because
they just aren’t stable enough. Sturdier patients can handle twice in a row. Only the very strong patients can handle
3 times.
As well, treatment response with SP+ wasn’t that great. True, given his state he might be a slow responder. But if
he was sturdier and had this response to SP+, I wouldn’t repeat that treatment.
What really stands out to you with him? There is some mix of SJ/Liver excess but the photosensitivity to the point
of needing to stay in a dark room sounds extreme and is a strong counter to being only “slightly shielded”. Have
you considered a Liver+ treatment?24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print6/11
The case study is really a way of practicing and checking your Saam thinking so I’m going to be nit-picky about
how precise you are with your write up.
You put “slightly shielded” under P excess. This should go under Liver excess. The shield is an archetypal image
for Liver.
Under Sj you put
bxiong89:
runs hot, enjoys winter +6, cold toes +8,
It would be better put to say, “heat above, cold below” since this matches the SJ excess presentation. I like how you
wrote “mixed hot and cold” under Kidney excess. It helps to match the pointer phrases used in Toby’s powerpoint
to your patient’s presentation whenever it is possible and a true reflection of the patient.
Under Liver, you put “slight anger”. Anger is GB excess.
Under GB, you put “anxiety”. This is possible but not totally correct. There are lots and lots of discussions of
anxiety on the forum. Reactivity for sure is Gb excess. Anxiety can be so, so many other things. Anxiety can be the
results of an excess of any of the 12 channels, though Toby says that he most often thinks of treating a yin channel
for anxiety.
Poor posture is not a sign of LI excess.
Sp channel knee pain should be listed under LI and SP excess since it could be a manifestation of either.
Pain by itself is a Kidney excess. Worse with movement is SI excess.
Visit Toby’s powerpoint again and revisit the way you characterize your impressions of him. Then ask yourself
what is really true about this patient.
1 Like24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print7/11
bxiong89: December 9, 2019, 11:26pm
Hi Kristin,
Just so you know, the first treatment I did for him for LV, and he was adamant that there was no change to his
perception of light after the treatment. I wanted to go with that approach first as it seemed the most gentle…I
thought I added that in, but I guess I went straight to the second treatment (as that was the one with the reaction)
and forgot to mention the initial one.
Thanks for the tips regarding shoving in direction, I won’t repeat SP+,
Can I ask why worse with movement is SI+ as SI+ generally doesnt present with much pain and tonifying the SI is
a way to move Qi and Blood?
I’ll query him a bit more regarding the brain fog…and keep you updated.
KristinWisgirda: December 10, 2019, 12:40am
bxiong89:
Can I ask why worse with movement is SI+ as SI+ generally doesnt present with much pain and tonifying the
SI is a way to move Qi and Blood?
SI+ is used to add more movement of qi and blood when there is stasis. Yes it is true that SI excess doesn’t present
with pain. So pain worse with movement is a bit of a paradox. I originally saw “worse with movement” here
bxiong89:
Increased Fatigue (worse with activity) +7, Energy levels better in the evening and worse in the mornings +7
So that is a bit of a paradox too. Usually “worse with activity” symptoms are better after resting overnight. Paradox
invites more exploration of what is really going on for this guy. Everything he says might be true or he might not
be a great reporter or you might have to ask for more details.
Toby warns against believing patients words unless you find they absolutely resonate with what your ears, eyes and
heart tell you about that patient. If someone says they loved their kayaking trip, can you imagine them loving their
kayaking trip? Patients expressions and actions are much ore reliable information than their self reporting, in
general.
It is curious that Liv+ didn’t improve his significant photosensitivity in any way. This is a symptom that patients
consistently get relief from with Liv+ in my practice. Was your needling meticulous, using adequate gauge and
length needles to stimulate all points properly? Did you needle the points on the right hand side?
1 Like24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print8/11
bxiong89: December 10, 2019, 1:08am
Blockquote
SI+ is used to add more movement of qi and blood when there is stasis. Yes it is true that SI excess doesn’t
present with pain. So pain worse with movement is a bit of a paradox. I originally saw “worse with movement”
here
So just to clarify would SI+ present with pain which is worse with movement and if so, why would that be the
case?
Blockquote
So that is a bit of a paradox too. Usually “worse with activity” symptoms are better after resting overnight.
Paradox invites more exploration of what is really going on for this guy. Everything he says might be true or he
might not be a great reporter or you might have to ask for more details.
Toby warns against believing patients words unless you find they absolutely resonate with what your ears, eyes
and heart tell you about that patient. If someone says they loved their kayaking trip, can you imagine them
loving their kayaking trip? Patients expressions and actions are much ore reliable information than their self
reporting, in general.
It is curious that Liv+ didn’t improve his significant photosensitivity in any way. This is a symptom that patients
consistently get relief from with Liv+ in my practice. Was your needling meticulous, using adequate gauge and
length needles to stimulate all points properly? Did you needle the points on the right hand side?
Yes I needled LV on the RHS, Needling could have been much stronger but as a first treatment, I did go more
gentle as I needed to test the waters so I didn’t send him too far down the track.
I used 0.30x30mm and stimulated the points until there was De Qi Sensation…but not to the point of facial
contortion XD
KristinWisgirda: December 10, 2019, 4:43pm
bxiong89:
So just to clarify would SI+ present with pain which is worse with movement and if so, why would that be the
case?
Pain by itself can be Kidney excess. Worse with movement is SI excess. They are separate entities.
[quote=“bxiong89, post:7, topic:776”]
Needling could have been much stronger but as a first treatment, I did go more gentle as I needed to test the waters
so I didn’t send him too far down the track.24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print9/11
This is not the right way to approach Saam treatments. By not giving adequate, clear stimulation by using needles
that are too small, you are muddying the waters rather than testing the water. Helping a patient in this amount of
chaos requires that you get clear feedback from your treatments. Saam technique requires that you thread an 1.5
inch needle on both Liv8 and K10. 1 inch needles are just too short for these points. 30mm needles might or might
not be giving adequate stimulation. By using smaller needles you are never going to be sure if the treatment was
correct or not. In my early days of learning Saam, several experiences showed me that adequate stimulation with
big enough needles was critical for treatment outcome.
Watching the patient’s response on the table will be a good indication of how appropriate the treatment is, if you
have given the body a clear directive. If the treatment is going south on the table, this too is valuable information.
Take the needles out and put in the counterbalancing treatment.
bxiong89:
I used 0.30x30mm and stimulated the points until there was De Qi Sensation…but not to the point of facial
contortion XD
Great that you are getting de qi. Bigger needles don’t have to be more painful. The more comfortable you are using
larger needles, the more comfortable your needling technique will be.
bxiong89: December 13, 2019, 5:07am
[quote=“KristinWisgirda, post:8, topic:776”]
bxiong89:
Needling could have been much stronger but as a first treatment, I did go more gentle as I needed to test the
waters so I didn’t send him too far down the track.
This is not the right way to approach Saam treatments. By not giving adequate, clear stimulation by using
needles that are too small, you are muddying the waters rather than testing the water. Helping a patient in this
amount of chaos requires that you get clear feedback from your treatments. Saam technique requires that you
thread an 1.5 inch needle on both Liv8 and K10. 1 inch needles are just too short for these points. 30mm
needles might or might not be giving adequate stimulation. By using smaller needles you are never going to be
sure if the treatment was correct or not. In my early days of learning Saam, several experiences showed me that
adequate stimulation with big enough needles was critical for treatment outcome.
Watching the patient’s response on the table will be a good indication of how appropriate the treatment is, if
you have given the body a clear directive. If the treatment is going south on the table, this too is valuable
information. Take the needles out and put in the counterbalancing treatment.
Hi Kristin, thanks for your reply. Yes, I think I might have understimulated for the first treatment.
I will attempt it again.
His stools are getting more formed and his appetite has been improving with the 2x SP+ treatment.24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print10/11
Joint pain has not been touched.
Will keep you update ;PP
KristinWisgirda: December 13, 2019, 1:26pm
bxiong89:
His stools are getting more formed and his appetite has been improving with the 2x SP+ treatment.
Great news that he has been improving. Changing up the treatment next time will help address another facet of his
difficulty receiving nourishment and building structure.
With such emaciation, I can understand having an instinct to want to treat his system gently. Saam isn’t the system
for that, since it is such a powerful all-in way of practicing.
Steep yourself in Saam notes, evaluate this patient with fresh eyes every time and watch him closely on the table.
This is the best recipe for helping him get his life back.
Please keep us updated.
bxiong89: January 15, 2020, 1:51am
Update @KristinWisgirda
He has now put on 3kg since treatment… treatment strategy changed to supplementation of Lungs as weak knees
and lack of resources…
Didn’t seem like tonification or SP did as much as tonification of Lungs.
This change has had a more profound effect. Went away and could stomach more food…Red meats now also.
Stools are formed with no undigested foods presenting. Exciting update!
KristinWisgirda: January 15, 2020, 4:23pm
Thanks so much for the update!
Sounds like Lung+ is helping him absorb nutrients on the interior as evidenced by the weight gain and stool
changes.24/01/2024, 12:0016 yo Male patient- LI+, SJ+ Case – Need help SAAMers! – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/16-yo-male-patient-li-sj-case-need-help-saamers/776/print11/11
Do be careful to keep reevaluating and changing up the treatment, not to be seduced by good results with Lung+.
As well, sometimes strategies that didn’t work in the past become more effective once certain resources are there.
bxiong89: January 15, 2020, 9:13pm
Interesting thing was that I did the Lung Supplementation once before the holidays with those results which
weren’t achieved with SP supplementation…even though it appeared that he was grossly thin- so the initial thought
would be to supplement SP…
Thanks! I didn’t know that LU+ would have that function, but makes sense!
I went ahead and did KD supp on him this week to consolidate, as his weight had since started fluctuating a little…
I will see how he goes and update.
I did this as you had mentioned that SI+ presented with pain worse on movement…which is what he was
presenting
Can I ask what bone or joint pain would be attributed to? Would the thinking be along the lines of KD–>bone?
weakness–> Consolidate- KD Supp?
Thanks so much for all your help @KristinWisgirda