Hi Fellow Sa’amsters!
I haven’t participated in the forum for a while, but I’m looking for suggestions on this case. I feel like I’ve thrown the kitchen sink at it without much progress. Thanks in advance for any comments. I’ve been using Sa’am since Toby’s Seattle seminar in January 2019 but haven’t used it exclusively so I could use guidance (and most likely a refresher webinar sometimes soon); I think I’ve missed some more advanced signs & symptom education (like pointy index finger for GB)!?! Please also give me feedback on formatting if it is not correct.
Case: 32 year old slender & timid male with pale to normal complexion (is a red head and can get rosy when flushed).
Chief Complaint: extreme chronic (several years) muscle tension & spasms on the L side of the body (all channels affected); muscle weakness on the R side of the body that feels like muscles aren’t engaging; and extreme bilateral hip, low back, & jaw tightness
Secondary Complaints: clear copious phlegm in the sinuses that drains when his muscle tension improves, L sided throat obstruction (that may or may not be phlegm related), one big loud sneeze a day with a funny smell & subsequent salivation, tinnitus worse when muscles relax (when meditating)
Appearance: thin tight body (+8), small frame, wears all black clothing, quiet, shy & reserved (+8) but can be friendly & engaging with nervous laughter, very intelligent (+9)
Lifestyle: IT guy with plenty of financial resources, plays guitar in a heavy metal band but has recently discovered meditation, qi gong, spiritual awakening, etc.
Body & flesh: underweight (+3), moist skin (+5), minimal red pustular acne on face & back, sweaty hands & feet, flat spinal curves esp. in neck (+5), jumpy spastic muscles (+10) – some areas are too painful to palpate & he has even come in with multiple bruises on his calf muscles where his calves went into spasm & burst blood vessels
Body Temp: warm body (comes underdressed in winter) with cold feet
GI/Urinary: no complaints, regular BMs, some lack of appetite (+1) that manifests as general ambivalence towards food, eats the same thing daily, some thirst (+3), urination normal
Respiratory: lungs are clear, all phlegm issues are in the sinuses (+7) & throat (see above)
Emotions: seems somewhat repressed emotionally (+8) but not depressed or lacking energy
Tongue: pale body, puffy front with slight toothmarks, purple dip in center, white coat – thicker in back, red tip, distended sublingual veins
Excesses (not sure I’m doing this part right):
SJ: polite & hyperaware
PC: quite & intelligent
ST: thin body, moist skin, acne
Grossest Thing in the Room: muscle pain & phlegm in sinuses
I’ve tried tonifying LR, GB, SI, & LU at different times without much change. So far the most profound treatment has been to needle all acupuncture points on the L side that affect the vagus nerve. Stimulating these points at the neck area seem to cause a domino effect in his body & his muscles relax & open up temporarily.
His muscles are so taut and his body is thin but he has all this phlegm in his head with a big puffy tongue. I’m not sure where to go from here…
Thanks for your help!