jedwardian: May 18, 2020, 10:05pm
M is a divorced mother of two in her forties, with a slight build and high sensitivity. She’s boundary-diffuse–very
open to energetically–which may be constitutional but is also almost certainly worse following many years of
multiple drug addiction. She’s been clean for many years. Herbally, for what it’s worth, I think of her as a
cinnamon twig patient, very chilly and deficient with that wide-open-to-the-world quality.
Chief complaint: persistent low-grade fever, comes on in the evening and leaves her exhausted. She had been
quite sick with possible Covid a few weeks ago and responded well to herbs (Chaihu Guizhi Tang modifications
among other things). However the fever recurred on multiple occasions after we thought she was through it, and
now it’s settled into the current nightly low-grade fever pattern with severe fatigue.
Secondary complaint: Headaches most days recently, temporal, one-sided. She also suffers from migraines every
few weeks.
Body temp: runs very chilly in general.
Demeanor: a little wide-eyed, deer-in-the-headlights quality, often overwhelmed. Nerves easily jangled. When
feeling comfortable she’s down-to-earth, with a ready sense of humor. Voice is quiet. There’s an overall sense of qi
deficiency. She struggles financially.
Digestion: delicate / easily perturbed, prone to bloating, bowels on the sluggish side except around her cycle
Abdomen: thin/tense abdominal wall, pulsations palpable along ren mai, tightness findings on both sides of the
costal margin, very lax/deficient below navel with hardness palpable at depth
Eyes: sparkly
Grossest things in the room: the deficient abdomen, a feeling of nervous system tension on top of deep
deficiency. her constant struggle for resources.
1st and only Sa’am tx: LU+. The needling was very intense for her, not surprisingly, and I wasn’t sure whether she
would settle, but she did. Felt more grounded after the treatment and had more energy for a few hours. Then that
evening her fever came on again, this time higher, up to 101, which it hadn’t done in a week or two. Confounding
things, perhaps, I also gave her Bu Zhong Yi Qi Tang to cook. She felt better again the next day, then back to low-
grade fever that night, and by the second day after treatment was back to feeling exhausted.
My first curiosity is whether this response should be interpreted as positive or negative. On the one hand, a higher
fever could be a positive sign in a sense–she had enough qi to mount a more vigorous response? And she did feel
better after the treatment and the following day. On the other hand, the chief complaint remains basically
unchanged.
And then the question of where to go from here. She could use KD+ but I’m noting another thread in which
Kristin, I believe it was, shared that Toby prefers not to go to KD+ off the bat. Plus, my own (personal) experience
with KD+ has been that draining SP 3 takes qi away from the middle jiao which can be a challenge for those of us23/01/2024, 12:13Chronic low-grade fever case – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-low-grade-fever-case/1051/print2/4
with weak spleen qi in the first place. Basically I don’t feel ready to go for the deep, KD layer with her yet. But
maybe I’m being biased by my herbal training (save fuzi formulas for later in treatment, after other layers are
cleared up, that type of thinking).
She’s slight of build, fine-boned and pretty, so that could also point to SI+, yes?
It seems clear that she can use LR+, especially as I write this up and put two and two together regarding her
extreme openness–she really does need shielding. LR is not the first channel I’d think of for a febrile condition, but
maybe that’s not the way to think about this case. UB+ feels intuitively wrong–she’s so cold. HT+ is a distinct
possibility but could be rather extreme for her, as she’s so sensitive. Since SJ+ is out, would SI+ or KD+ be
reasonable ways to test her response to some fire?
SP+ also feels like a distinct possibility for her, as she’s thin and dry. No shortage of ideas…and wanting to make
the right moves in a timely way for this one, she’s struggling badly.
Also curious about folks’ experience with very sensitive patients using this system. I caught that Toby said he
won’t tonify the same channel twice in a row with sensitive patients, that was helpful to hear. Any other tips most
welcome.
Thanks all,
KristinWisgirda: May 18, 2020, 11:48pm
Thanks for your first case @jedwardian. Though your presentation was good, but please refer to this post for
some refinements that will help you and the readers see your patient better:
Case Study Format
Here is a proposal for case a case study format for our forum. I welcome any and all feedback. The goals are to
help you sharpen your Saam diagnostic skills, help your readers see your patient and stimulate conversation
that will helps us grow as Saam practitioners. When presented with the idea of a case study format/intake sheet,
this was Toby’s response: Great idea, basically the Saam diagnosis is interested in everything. I think the Shen
Kuo quote from the lecture is a good starting framew…
The case study writing process as outlined in this post is a really great way to review Saam theory and apply it to
your patients. I know it is lots of work but it will pay off. It is also important to make clear and give stronger
weight to what the patient is experience now. If you rewrite you case, then I will feel more comfortable making
treatment suggestions. Here are some ideas to start.
jedwardian:
Toby prefers not to go to KD+ off the bat.
Absolutely. My memory says that he had a hard time recalling when he used K+ as a first treatment. It is best to
clean up other departments before you bring in strongly consolidating K.23/01/2024, 12:13Chronic low-grade fever case – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-low-grade-fever-case/1051/print3/4
jedwardian:
She’s slight of build, fine-boned and pretty, so that could also point to SI+, yes?
The pretty for sure is K excess. Toby’s teacher said small boned +thin+ dizzy suggest a SI+ treatment.
jedwardian:
LR is not the first channel I’d think of for a febrile condition,
Liver+ is high on the list for febrile conditions. Liver+ is the second most cooling treatment after UB+. But she is
also very chilly. SJ excess often has a mixed hot and cold presentation- heat above and cold below. From the info
you have shared, Liver+ looks like a treatment to consider.
jedwardian:
My first curiosity is whether this response should be interpreted as positive or negative.
Even though her chief complaint didn’t change the positives I see are that she settled during the treatment and felt
improvements in other areas. Even though you didn’t didn’t get a home run, Lung+ was a base hit that will benefit
the game.
jedwardian:
No shortage of ideas…and wanting to make the right moves in a timely way for this one, she’s struggling
badly.
Delicate patients really need us to Saam Responsibly. As for not lacking ideas, she sounds deficient enough that she
will likely benefit from a wide variety of treatments overtime.
jedwardian:
HT+ is a distinct possibility but could be rather extreme for her, as she’s so sensitive.
Yes, you do want to be careful with the “double” quality treatments: double cold UB, double hot Heart, double dry
LI, double damp SP. But you have written that she is also “very chilly”.
jedwardian:
Plus, my own (personal) experience with KD+ has been that draining SP 3 takes qi away from the middle jiao
which can be a challenge for those of us with weak spleen qi in the first place.
Not being sure what your experience was, it is important to reconsider this line of thinking. Plenty of Spleen xu
patients have benefited from K+ treatment with no detriment to Spleen function. The 4 point Saam treatments are23/01/2024, 12:13Chronic low-grade fever case – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/chronic-low-grade-fever-case/1051/print4/4
greater than the sum of their parts. If you had a negative reaction to K+, it was because K+ was wrong for you, not
because draining Sp 3 was wrong for you. Consider that in K+, you are draining the source point of the Kidney!
Please consider a rewrite but less us know how treatment goes either way.