Clinical Case #3

History and Symptoms

The patient was diagnosed with hyperthyroidism at a hospital of Western medicine. She came to the clinic later with palpitations, excessive perspiration, jumpiness, fear of heat, hot sensations in hands and feet, increased appetite, fatigue, low fever, dry mouth, poor sleep and feeling as if some objects were in her throat.

Diagnosis

To make a diagnosis of hyperthyroidism as the chief complaint, a total of six syndromes should be taken into account (link to hyperthyroidism).

The symptoms in boldface are the symptoms to be checked against those listed under the six syndromes.

1. Hot stomach syndrome (2)

• Getting hungry easily (1)
• Thirst (1)

2. Liver energy congestion syndrome (5)

• Insomnia (1)
• Psychological tension (jumpiness) (2)
• Subjective sensations of objects in the throat (2)

3. Sputum-fire syndrome (14)

• Dislike of heat (3)
• Eat a lot (2)
• Emotionally disturbed easily (3)
• Excessive perspiration (2)
• Palpitations (3)
• Sleeplessness (1)

4. Liver-kidneys yin deficiency syndrome (5)

• Fatigue (3)
• Palms of hands and soles of feet are both hot (1)
• Sleeplessness with forgetfulness (1)

5. Deficiency fire syndrome (9)

• Becoming angry easily (2)
• Excessive perspiration (2)
• Dry sensations in the mouth (1)
• Hot sensations in hands and feet (2)
• Low fever (1)
• Sleeplessness (1)

6. Simultaneous deficiency of yin and energy syndrome (8)

• Excessive perspiration (1)
• Fatigue (3)
• Hot sensations in hands and feet (1)
• Palpitations (2)
• "Tidal" fever in the afternoon (1)

Conclusion

Thus, the diagnosis is 3. Sputum-fire syndrome, with the highest score of 14.