DrEmTCM: October 7, 2020, 3:31am
This was one of my first cases post course (family member), so I don’t think I would have treated this way if I was
starting today… but we learn with each case.
Patient: LB
66 year old female
Primary complaint: Hot flashes throughout the day 8+ and night sweats for 15 years since perimenopause started.
flushed face, hot above cold below.
Recently since last tx: 1 month- Flushes and sweats whenever she shifts in bed 10+
Hands and feet cold 6+.
Body neutral temp. Aversion to wind
Secondary complaint:
Dryness. Dry skin and whole body feels parched. Can’t drink enough water. Feels like it just goes through her 10 +
Constipation for 20 years. Dry, hard to pass unless she is taking large doses of Magnesium 8+
Hemorrhoids (come and go, become painful and then burst) 8+
Tight muscles: back spasm easily. As do legs. painful spasms. Whole body tight. 8+
Other symptoms:
High energy, never bored 10+
Bright eyes 5+
Easily bloated 7+
Abdominal weight. Hard to loose weight 6+
Apple shaped body 6+
History of dizziness and fainting, though currently okay right now 2+
Sensitive to environment, textures of clothes, drafts 7+
Notices small details. dirt in a corner, dust on a shelf etc. 8+
Sleep: Snores 5+ Many dreams and disturbances at night + 4
My original diagnosis:
SJ excess – sup Lv ® – bright eyes, flushed face, cold hands/feet, hot above/cold below, sensitive to others and
environment. notices details.
LI excess- sup SP ® – Dryness, skin and dry constipation, never bored
KD excess- Sup SI ® – tight, spasm, blood stasis with hemorrhoids
Treatment: -Where I went wrong
First tx: Sup LV (RT)
I supplemented LV, which worked great and she had no night sweats that night and for 2 more nights.19/01/2024, 11:07Case study- Postmenopausal night sweats (where to go from here?) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-postmenopausal-night-sweats-where-to-go-from-here/1321/print2/6
Tx 2: Sup Lv (RT)(one month later)
I didn’t see her for a month because she lives out of town, so the next time I saw her I Supplemented LV again. She
still had hot flashes, no improvement.
Tx 3: Sup Lv (RT) (one day after Tx 2)
I supplemented LV a third time the following day. Still no relief.
Tx 4: Sup LV then switched to Sup Sp (RT) (one day after Tx 3)
Not learning my lesson, I started with Sup Lv again, then realized it was likely too much of the same, so I witched
to Supplementing Spleen for the dryness. She started getting flashes every time she moved in bed. Worse than
before.
It has now been a month, and I will see her again this weekend. I would like to do 2 treatments over a 3 day period,
but am struggling to figure out where to go from here.
I know I supplemented Liver too many times and should have gone to other options earlier. Call it a newbie
overzealous mistake trying to get the original reaction.
Now I don’t know which direction to go. Any help would be very much appreciated!
KristinWisgirda: October 7, 2020, 3:42pm
Thanks for the case @DrEmTCM. Such cases are awesome learning opportunities. Now you know not to repeat a
treatment that didn’t work.
Learning a new system we can get fixated on certain ideas. I had (and probably still have) plenty when starting out
with Saam. I suspect that certain fixations are preventing you from seeing your patient clearly.
How flushed is her face? A full flush or a patchy malar flush? A full flushed face is H excess and patchy flushing
can be SJ excess. I know face masks can make it a harder call but if her forehead is flushed, call it a H excess sign.
Did you palpate her midline to see if it is warm/cool soft/hard? Is her pulse rapid or slow? Where on her back does
she feel the spasms?
It seems to me that your patient is HOT and DRY internally and externally. She desperately needs ice cold water=
UB+.
The warm double damp Spleen didn’t work is an indication that cooling her off might be more important than the
moisture, though the moisture of SP is more yin than UB cold water.
I recommend reevaluating her K/SI balance. Does she have varicosities or other surface blood stasis signs? How
symmetrical and into her appearance is she? Does she have kids? Was she fertile or interested in fertility? How is
her medial heel? Does she have a history of lots of surgeries. How sturdy and consolidated is she?
Any P/GB excess signs?
It can be helpful to write out all the channels when considering a case and go through the basic excess signs
presented in the intro Powerpoint.
Feel free to ask questions. Please let us know what happens.
1 Like19/01/2024, 11:07Case study- Postmenopausal night sweats (where to go from here?) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-postmenopausal-night-sweats-where-to-go-from-here/1321/print3/6
DrEmTCM: October 7, 2020, 6:20pm
Hi Kristin. Thank you for your response.
She does not get red in the face. The flush is more felt than seen, I didn’t explain that well. She is a case I have
struggled with in the past with herbs because though she gets hot flashes, she gets cold right before the hot flash.
Sweats on the neck, needs to undress, but once the flash is gone, needs to put sweater back on.
Here is the SAAM breakdown:
It looks to me like:
LI excess
BL excess
KD excess
SJ excess
It just feels counter intuitive to sup HT when they are complaining of hot flashes.
Lu: plenty of qi and external resources 4+
Very rare acid reflux 2+
ST: slightly deflated Lu 10 area 2+
SP: none
LI: Both inside and outside are dry 10+
Teeth, bones, and gums are strong 7+
Never bored or lazy 8+
Tends to be stubborn 7+
Constantly moving on to a new project 7+
Dry constipation 8+
HT:
Hot flashes 10+
(no fevers ever, even with illness)
BL:
Whole back pain for women 7+
Scared of needles/fear 3+
Pulse is slow + low blood pressure (55-57 beats per minute) 5+
Cool and hard abdomen (bloat by end of day that is hard) 7+
Pain and spasm along BL line -especially lower back and hamstrings 8+
Feels cold, whole body before having a hot flash (?)
She hates ice water to drink, but will swim in the cold ocean. (?)
KD
Pathogenic wind (itchiness with food sensitivity 6+, dizziness with fright 6+)
Strong sexual drive and high fertility (though now postmenopausal) 6+
Flesh, firm not dry or cracked medial heel 7+
Stiffness and pain in muscles 8+19/01/2024, 11:07Case study- Postmenopausal night sweats (where to go from here?) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-postmenopausal-night-sweats-where-to-go-from-here/1321/print4/6
Blood stasis (large hemorrhoids that are visible and burst causing fresh red blood hemorrhage…not sure if this is
blood stasis or unconsolidated blood once it bursts)
SI: Little to no signs of blood stasis aside from hemorrhoids. no spider veins 3+
Sublingual veins: pale, with slight distension
PC:
Intellectually snobbish 5+
GB:
History of sciatica. But usually more just low back spam. 1+
LV: None
SJ:
Notices every little change (new hair cut), intensely focused on details 8+
Very sensitive person (to environment) 5+
Wants to have control over everything 5+
hot above and cold below 5+
Inability to regulate body temperature -hot flashes, swinging between hot and cold 9+
Anger directed at self 4+
Cold hands and feet only 6+
OCD behavior- notices everything when it comes to cleanliness of a house 9+
KristinWisgirda: October 7, 2020, 6:54pm
Thanks for a much more complete picture! She is still very hot and very dry so UB+ can be kept on the table but
may not be my first choice.
DrEmTCM:
It just feels counter intuitive to sup HT when they are complaining of hot flashes.
I wasn’t suggesting H+ for this case as you first presented it but now I see you have good reason to consider it
down the road but there are many other options that are more likely to help. BTW: I recently had a case of
recalcitrant hot flashes where H+ was an important part of the treatment.
A couple of points in your symptom analysis that might be helpful.
DrEmTCM:
Whole back pain for women 7+
Whole back pain and being a woman are 2 separate things. UB channel involvement can be either UB or Heart
excess. Yes, women tend more toward UB excess but I give that tendency much less clinical weight than the19/01/2024, 11:07Case study- Postmenopausal night sweats (where to go from here?) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-postmenopausal-night-sweats-where-to-go-from-here/1321/print5/6
symptoms I see before me. I have treated UB+ on lots of woman with back pain and so many other symptoms.
Don’t get hung up on it.
DrEmTCM:
Cool and hard abdomen (bloat by end of day that is hard) 7+
As you are learning the indications it helps to differentiate the whole abdomen and the midline between Ren8-15
which is the H/UB area in Saam. The whole abdomen can be cool and hard but the midline might soft and warm.
I would also put abdominal bloating under Lung excess, especially with dry skin.
Back to her being hot and dry. My top 3 treatment choices for her are UB+, SI+ and K+.
I am interested in her K/SI balance and would still like to know how pretty and into her appearance she is. Water
and Fire. If the strong sex drive is current then list it separately for clarity. It is significant that she has little to no
signs of surface blood stasis given her age. I put less weight on the hemorrhoids as straight up blood stasis and
consider it as a prolapse because she has been constipated for so long and is likely straining.
DrEmTCM:
she gets cold right before the hot flash.
What stands out to me more is how hot she gets and how disruptive the heat is and how dry she is.
Let me know how pretty she is and if her strong sex drive is historical or current.
DrEmTCM: October 7, 2020, 9:58pm
Thank you for the help. This is a great learning experience.
She has medium sex drive currently, so I guess this falls into a past issue.
Fertility was very high. Got pregnant very easily 3 times. Easy pregnancies, easy births.
She is not traditionally beautiful, but is very concerned about her looks (as in always thinking she looks bad in
photos, very self deprecating, always felt like the ugly duckling)
Pain in back is mostly lower back. With tight muscles in legs that will spasm if you push on them. (does that still
fall under a KID excess?)
Abdomen: I am not sure about the midline. I can confirm this weekend, but I don’t think the midline (ren 8-15) was
hard. Thank you for clarifying that diagnosis for me!
Thank you!19/01/2024, 11:07Case study- Postmenopausal night sweats (where to go from here?) – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/case-study-postmenopausal-night-sweats-where-to-go-from-here/1321/print6/6
KristinWisgirda: October 8, 2020, 12:20pm
There are lots of pieces to put together jumping from intro course to clinic. Following Toby in clinic really helped
give me a 3D view of the channel excesses especially Kidney. With Kidney excess you are looking at symmetry
and bone structure but also how much love and attention the patient is giving to her appearance. Many students are
hesitant to rate patient beauty but for our purposes you have to put euphemisms aside and say she is x out of 10.
So your patient is very concerned about her looks but you want to note how perfect her hair is, whether or not she
gets her nails done, wears makeup, takes care with her clothes and shoe selection. The more energy she pours into
her appearance the more K excess she is. It can be tricky sometimes because there often can be K excess but the
patient will be self deprecating too which can be SJ excess or even some SI excess. People are complicated.
With K excess you also have to consider the cycles of 7 and 8 and age appropriateness. That she is 66 yo and has a
medium sex drive gives some points to K excess.
DrEmTCM:
Pain in back is mostly lower back.
Try to pin point the back shu levels that are the most painful to her or the most painful when palpated. Correlate
those to the channel and counterbalancer.
DrEmTCM:
With tight muscles in legs that will spasm if you push on them. (does that still fall under a KID excess?)
Not all pain is K excess/blood stasis of course. You consider the channel(s). Spasms are windy so you think SI+,
Liv+. But her intense dryness has to be considered too.
From the info you have given me, UB+ and SI+ are neck and neck as top choices. SI+ wins out. Even though I am
still not clear about what she looks like, she has enough K excess signs and few enough SI excess to tell me that
SI+ is safe. The mixed heat and cold picture helps too. The intensity of her heat and dryness totally call for UB+,
my only concern is the slow pulse (low blood pressure is not a UB excess finding BTW) and the possible cold/hard
abdomen that you have to check. Kidney is a way distance third unless she is grossly asymmetrical and unkempt.
Look at her with fresh eyes at the next visit. Please let us know what happens. Thanks!
I can tell you are a good observer and are getting a hang of the system based on your symptom analysis, even
though it had a few glitches. Reviewing notes and reading lots of cases on the forum will help you clarify your
knowledge. The search bar on the forum is your friend. It can really help to retake the intro class too- Michael
has an on demand option on the website.