This is a great example of why it's so important to make sure we have as many pieces of the puzzle as possible. This is a telemedicine patient so I only have the TCM Hub intake and the tongue photos.

The patient's main complaint is being cold. You can see in her comments that it takes a lot to warm her up and when her feet get cold for an extended period of time she invariably winds up with an external contraction of Wind with Cold signs/symptoms.

The basic breakdown from the intake:

The Patterns:

The LV/SP disharmony is very clear from the first 2 sets of questions. There are also signs and symptoms of Blood Vacuity, KD Qi/Yang Vacuity, and some Blood stasis.

At 39 years old and as a mother of 3 children, all the KD signs plus the main complaint of being cold, one might think KD Yang vacuity as the main culprit. And you wouldn't be totally wrong. But it's not the whole picture...

Look at the tongue pics and look at the bowel section on the intake: sticky bowels, has to wipe more than 3-4 times along with little desire to drink. These all indicate dampness and particularly dampness in the Lower Jiao.

We must also look at the heat signs such as easily flushed cheeks along with easily blushing/red when upset or angry.

• here you may be thinking, true cold, false heat and that is possible but we won't know until we take care of the Damp Heat visible on the tongue.

This is a classic case of Dampness Blocking (Obstructing) Kidney Yang.

The Pathomechanisms

Long-standing Liver Depression Qi Stagnation and Spleen Qi Vacuity lead to enduring Dampness and Heat. Dampness pours downward and obstructs the lower jiao (i.e. Kidney Yang) leading to Cold signs, especially below, along with other KD Yang vacuity S/S. The heat floats up and leads to flushing cheeks and is made worse when the Liver is obstructed by emotional upset (or Damp).

Further, since Wei Qi issues from the lower jiao (and middle) vis a vis KD Yang and Spleen creating Ying and Wei, when the KD Yang is obstructed by damp and the patient compounds the problem by being in a cold environment, leading to very cold feet, there is insufficient Wei Qi produced and circulated to warm and secure the exterior against external invasion of Wind evils thus leading to external contraction of Wind Cold whenever her feet are cold for an extended period of time.

The Kidney and Spleen both play critical roles in the transformation and transportation of fluids, but in this case going after the Kidney first or alone would not likely produce a desirable outcome. The Dampness has to be transformed first.

Dampness as a sticky, heavy Yin evil, obstructs the free flow of Qi leading to Liver Depression and the engendering of Heat, Obstructs the Free Flow of Blood leading to signs of Blood vacuity (or inability to engender new Blood), leads to Blood Stasis, leads to little desire for fluids to drink, and finally can tax the Spleen to the point it begins to draw from the Kidney leading to KD Yang vacuity signs and symptoms. So the Damp has to go.

The Treatment:

My first job is to transform dampness and clear heat (evidenced in the thick, yellow coating) so I prescribed San Ren Tang for 1 week. I have little doubt that very soon her tongue will clear up and if her symptoms don't improve with just SRT we will likely need to add Jing Gui Shen Qi Wan and likely XYS to help protect the middle jiao from engendering more dampness and further complicating the problem.