seonah hong 06010102
RECORD OF FIRST VISIT
NAME OF STUDENT CLINICIAN: SEONAH HONG NAME OF SUUPERVISOR: MAI
DATE:
CHIEF COMPLAINTS: INSOMNIA for 1MONTH
DESCRIPTION ( 4 DIAGNOSTIC METHODS):
ASKING: The patient has suffered from insomnia for 1 month. 1 month ago, she had lots of stress from her school exam. She feels very tired but, she cannot easily fall in sleep. During sleep, she doesn’t wake but has dream a lot. The dream is like busy. She sleeps for 3~4 hours. Sometimes she has headache. No medication or treatment.
Present symptoms: insomnia, sometimes headache, slightly fever, appetite is ok, normal urination, little bit hard defecation, sometimes bitter taste in the mouth, chest depression, tired, cold water drinking, thirst, no palpitation, no swollen, normal sweating
Past history: NAD
LIFESTYLE:, Drinking 2 per month(1 cup of wine)
MENSTRUATION: 15 6/30 Single with no child,
She had menses last month. 6th~11th red color with little clots
FAMILY HISTORY: NAD
INSPECTION:
General: 9/10 vitality, free movement, little bit reddish complexion, normal posture
Tongue: Red tongue with thin white little yellowish coating
Auscultation/Olfaction:
Sound: speak clearly and breathing is ok
Odors: NAD
PALPATION:
Body areas: NAD
Pulse: rapid and taut
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case summary
Definition:
insomnia is a condition that makes the patient unable to have normal hours of sleep. it has different patterns: difficulty in falling asleep after retiring, early awakening, inability to sleep again after awakening, intermittent waking through the period of attempted sleep and even inability to sleep all the night.
WMS:
Insomnia is a condition in which people have trouble falling or staying asleep. Some people with insomnia may fall asleep easily but wake up too soon. Other people may have the opposite problem, or they have trouble with both falling asleep and staying asleep. The end result is poor-quality sleep that doesn’t leave people feeling refreshed when people wake up.
Insomnia is a common health problem. It can cause excessive daytime sleepiness and a lack of energy. Long-term insomnia can cause you to feel depressed or irritable; have trouble paying attention, learning, and remembering; and not do your best on the job or at school. Insomnia also can limit the energy you have to spend with friends or family.
Insomnia can be mild to severe depending on how often it occurs and for how long. Chronic insomnia means having symptoms at least 3 nights per week for more than a month. Insomnia that lasts for less time is known as short-term or acute insomnia.
Secondary insomnia often resolves or improves without treatment if you can eliminate its cause. This is especially true if the problem can be corrected soon after it starts. Better sleep habits and lifestyle changes often help relieve insomnia. You may need to see a doctor or sleep specialist to get the best relief for insomnia that is persistent or for which the cause of the sleep problem is unclear.
Seonah 06010102
TCM etiology and pathogenesis:
1. Deficiency of Both the heart and spleen qi: anxiety and overwork dmage the heart and spleen. blood is exhausted, the deficient heart can not hold the mind while qi and blood production becomes poor in case of deficiency of the spleen qi. blood deficiency is unable to nourish the heart, leading to insomnia. Difficulty in falling asleep, dreamy, palpitation, poor memory, lassitude, anorexia, sallow complexion, pale tongue with thin coating, thready, weak pulse.
2.Disharmony between the heart and kidney: congenital deficiency, indulgent sexual intercourse, or a chronic illness damages the kidney yin. the kidney water fails to ascend to the heart to check the heart fire. A violent emotional fit can induce flaring of the heart fire which fails to descend to the kidney to control the kidney water, then the heart yang is hyperactive and excess of the heart fire injures the mind and hence insomnia results.-restlessness, poor sleep, dizziness, tinnitus, dry mouth with little saliva, burning sensation of the chest, palms and soles, red tongue, thready, rapid pulse, or nocturnal emission, poor memory, palpitation, lumber pain
3.Upward disturbance of the liver-fire: emotional depression causes the stagnation of qi in the liver. The stagnation qi of long duration is transformed into fire, which flares up and disturbs the mind, and then insomnia occurs.-irritability due to insomnia, dreamy sleep, headache, bitter taste in the mouth, distension in the costal region, string-taut pulse.
4.Dysfunction of the stomach: irregualr food intake damages the spleen and stomach. The accumulated undigested food causes dysfunction of the stomach and insomnia as stated in Internal classics that sleep is disturbed if the function of the stomach is in disharmony-insomnia, suffocating feeling and distending pain in the epigastric region, poor appetite, difficult defecation, sticky tongue coating, rolling pulse.
TCM diagnosis: Insomnia
Syndrome differentiation: Upward disturbance of the liver-fire
Seonah 06010102
Explanation:
Lots of stress from school exam causes the stagnation of liver qi and disturbing the mind and dreamy sleep so that insomnia occurs. Due to the patient cannot sleep enough, she always feels tired. Liver qi stagnation came from his emotional problem and it transformed to heat. So he has heat symptoms such as red tongue body, reddish complexion, rapid pulse, prefer cold drink. Causes of the liver qi stagnation, the meridian blockage occurs, so that the headache, chest depression present.
Treatment principle:
Regulate the liver qi stagnation and calm the mind
Points and therapy: taichong, shenmen, sishencong, sanyinjiao, anmian, xingjian
sanyinjiao: nourish the liver, pacify the mind
anmian: soothe the mind
Taichong: circulate qi and regulate the liver qi
Shenmen: nourish the mind
Sishencong: calm the mind
Xingjian:calms liver fire and mind
Lifestyle:
l Exercise helps promote good health, and good health allows us to combat common disorders including insomnia. Even light exercise is better than no exercise when it comes to improving your sleep. The best time to exercise is in the morning or afternoon, when people will get a burst of energy from people’s activity and avoid exercising 3 to 4 hours before bedtime, because this can reduce the quality of sleep or promote insomnia. Stretching is a great way to ease into an exercise routine.
l Diet-
A healthy diet can also encourage sleep filled nights. should try eliminating the following foods from diet. They can all contribute to insomnia.
· Coffee
· Tea
· Soda
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· Spicy Food
· Chocolate
· Alcohol
· Have some hobby to get rid of the stress. Don’t think about the school exam
· Foods With Heavy Sauces
take some time to evaluate people diet. Rich foods can slow digestion and leave people feeling uncomfortable at night. Coffee and other stimulants can cause people to wake during the night or experience trouble falling asleep. Processed foods including those filled with refined sugar can cause dramatic fluctuations in blood sugar levels. This can also lead to insomnia.
Conclusion
I had one patient who had insomnia before. His insomnia was because of the Deficiency of Both the heart and spleen qi. Now he is ok with sleep. He said my lifestyle advice was a good information so I was happy to tell the lifestyle advise to this patient as well. She had just one treatment and I will see her again. When I meet her again, the time will be her school exam finished. So I think she will get better soon. Because I think her insomnia is from the stress of school exam. So when the exam finished, I expect that her insomnia also get better. And plus my treatment.
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