Ryan_Gallagher: October 14, 2019, 6:45pm
56 year old woman; I’ve been seeing her every other week; I’ve been doing Sa’am treatments recently.
Chief complaint: Menstrual irregularity with headaches, scapular pain, shortness of breath
Perimenopausal; was having regular periods about every 7 weeks; but this week, she started a period after 3
weeks; it was preceded by clear discharge; this period has featured light flow, no clots, no cramping…the only
issue was a hot flash.
Periods are typically associated with headaches, R scapular pain, and occasionally shortness of breath (none of
which occurred during this period, but all of which occurred during previous period). She has a history of
pneumothorax (2008) requiring surgery of R lung; this was likely a “catemenial pneumothorax,” meaning it was
related to her menstrual cycle. Since the pneumothorax, she experiences sporadic episodes of SOB along with R
scapular pain, corresponding with menses (typically the respiratory episodes will occur around day 3 or 4 of
cycle).
History of fibroids, cysts, polyps, and menorrhagia; iron deficiency; myomectomy. Currently, fibroid on right
side is stable (neither growing nor shrinking). Uterine thickness (likely due to scar tissue from ablation) has
been shrinking over time (a good trend).
Upon palpation, she is very tender at the R ribside, and the tissue here is very dense, extending downward from
the ribside toward the R lower abdomen. She’s been told she has benign Liver cysts.
History of 2 vaginal births and 1 miscarriage.
Second complaint: Hypertension (this has been fine lately)
Appearance and demeanor: Average facial symmetry; nose is slanted to the left side; wears sweats and an old tee
shirt to appointment; wears a short, no-fuss haircut; not very into her looks; reserved, serious demeanor +5; does
not over-communicate, but is not shy; moves slowly and deliberately +7; average eye brightness +4
Lifestyle: Works as an elementary school principal; she recently returned to elementary school (which she finds
fulfilling) after a time as a university administrator (which she disliked). Lives with husband; has two grown
children who live out of state. Work is very stressful, but she’s made great strides in establishing boundaries around
her work so that she can take care of herself. Enjoys exercising (biking especially). Enjoys watching baseball
games.
Body morphology and flesh quality: Tall; average frame; upright posture; angular face; average-to-thin limbs,
with mild excess fat around the belly +3.
Medial heel: plump, healthy +8
Varicosities around ST37/R +5
Skin Quality: On the damp side +3; clammy, pale; ruddy facial complexion (esp nose) +3; recently had skin
biopsy around R scap (no results yet).
Body Temp: Runs neutral to warm; occasional hot flash +2; occasional night sweats
GI: fine currently25/01/2024, 11:39Case: Menstrual irregularity – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-menstrual-irregularity/684/print2/5
Respiratory: prone to nasal congestion +4
Sleep: can be fitful during periods of high stress +3
Emotions: very even-tempered; some anxiety, grief and fear this week as she navigates a difficult staff issue
Urination: no complaints
Other: prone to thirst +3; prone to breast cysts; history of partial thyroidectomy
Tongue: short, scalloped, cracks, reddish tip; sublingual veins +6
Excess Presentations:
Heart: subjective warmth +2; thirst +3
UB:
GB: ribside congestion (GB channel) +7
P: reserved, rational demeanor +7; ribside congestion (GB channel) +7
SJ: subjective warmth +2; thirst +3
Liver:
Lung: R rib-side tenderness and hypertonicity +7; has resources +7; thryoidectomy (ST channel)
Stomach: R rib-side tenderness and hypertonicity +7; thryoidectomy (ST channel); damp skin +3
LI: perhaps interior and exterior dampness?
Spleen:
SI: disinterest in looks; misaligned nose
K: cysts, fibroids, varicosities, SLV, plump medial heel
The Grossest Thing(s) in the Room: Consolidation (cysts, fibroids, varicosities)
Main treatment ideas: +SI/L
Other treatment ideas: +LU/L
Last 3 treatments:
Last treatment (Saturday): +SI/L
2 weeks before that: +LU/L; the week after this treatment, experienced clear discharge and then the onset of an
early period (but had no respiratory symptoms, no headache—period was uncharacteristically smooth).
2 weeks before that: +SI/L; 4 days afterward, she started period; it lasted 7 days, low to medium flow, first day had
severe h/a; on day 3 of period, she experienced LU constriction.25/01/2024, 11:39Case: Menstrual irregularity – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-menstrual-irregularity/684/print3/5
Questions
Should I be incorporating +KD in order to discourage menstrual flow? Perhaps alternating +KD with +SI?
Does it make sense to y’all to be using +LU/L for R-side ribside congestion plus R lung issues?
Can anyone remind me why +LU is used for R ribside issues?
Any other recommendations for treating this patient???
KristinWisgirda: October 15, 2019, 12:14am
Thanks for sharing this interesting case.
Ryan_Gallagher:
Should I be incorporating +KD in order to discourage menstrual flow? Perhaps alternating +KD with +SI?
Her significant K+ signs and all the other stuff going on makes me hesitate to suggest K+ at this point. I am curious
what will happen after this last SI+ treatment. I am also curious about the status of her right rib side tenderness and
hypertonicity.
A few notes/questions on your Excess Presentation analysis. Some of it may sound like nit picking, but it might
help clarify what is a complex case.
Paleness could be put under SJ excess as it is a blood xu sign.
I wonder about the ruddy nose. Is her face blotchy or does she have a malar flush as well- another possible SJ
excess sign? I have lots of heavy bleeding patients with the palor and malar flush including the nose. If it is just the
nose, could it possibly be considering St channel?
Thirst is about dryness, the mouth (internal/external?) or stomach (internal) wanting fluids. I wouldn’t put it thirst
under Heart or SJ excess for that reason.
Ryan_Gallagher:
mild excess fat around the belly +3.
This is internal dampness.
The scap pain and sob, the varicosities being located on the stomach channel, among other symptoms could put
into channel categories.
Ryan_Gallagher:
Can anyone remind me why +LU is used for R ribside issues?
A number of traditions say that the Liver (wood) rises on the left and the Lung (metal) descends on the right.
Ryan_Gallagher:
Does it make sense to y’all to be using +LU/L for R-side ribside congestion plus R lung issues?25/01/2024, 11:39Case: Menstrual irregularity – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-menstrual-irregularity/684/print4/5
That is classic. If needed at some point, you could St+ on the left for the right ribside congestion.
Ryan_Gallagher: October 15, 2019, 2:41am
Thanks for the feedback, Kristin. Helpful insights!
I’d say her face seems more globally ruddy than a malar flush presentation, but I’ll take a closer look the next time.
I’ll also keep track of the state of the ribside tenderness over the course of the treatment. And I’m realizing I forgot
to check the thenar, so I’ll gather that info, too.
Are you suggesting that I might supplement ST to see if it’s actually the ST that’s deficient and not the Lung (based
on how she responds)…or are you saying that BOTH the Lung and Stomach might be deficient, so I might need to
alternate supplementing each? I’m now wondering if the shortened menstrual cycle (and discharge) should be
considered a negative response to the +LU treatment…
Jason: October 15, 2019, 1:34pm
Are you suggesting that I might supplement ST to see if it’s actually the ST that’s deficient and not the Lung
(based on how she responds)…
I’m confused on this too. The class notes say LU organ excess manifests on the right; but under Clinical
Practicalities, it says, “R hypochondriac region stuck and tight (consider supplementing LU channel).”
KristinWisgirda: October 15, 2019, 3:07pm
Ryan_Gallagher:
pale; ruddy facial complexion (esp nose)
This patient is such a mix. I am trying to see her better and rule out a stronger SJ excess picture than you have
painted.
Ryan_Gallagher:
I’m now wondering if the shortened menstrual cycle (and discharge) should be considered a negative response
to the +LU treatment…
If it is correct to say that the first time she had a shortened cycle was after the Lung+ treatment, then the treatment
was a mixed bag with some obvious benefits.25/01/2024, 11:39Case: Menstrual irregularity – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-menstrual-irregularity/684/print5/5
Ryan_Gallagher:
are you saying that BOTH the Lung and Stomach might be deficient, so I might need to alternate
supplementing each?
All of the signs and symptoms suggest that dual Lung/St excess is possible.
The discharge could be internal damp or a lack of consolidation.
Jason:
The class notes say LU organ excess manifests on the right; but under Clinical Practicalities, it says, “R
hypochondriac region stuck and tight (consider supplementing LU channel).”
Correct. Both Lung excess and Stomach excess can manifest with the right hypochondriac stuck and tight.
Jason: October 15, 2019, 4:58pm
Thank you!