RECORD OF FIRST VISIT
Date of First Visit: 12 Aug 2008 Name: XXX
Date of Birth: 54yrs Gender: male
CHIEF COMPLAINT: Insomnia for 2months
DESCRIPTIONS (4 Diagnostic methods)
A) Asking
Present illness history: The patient has suffered from Insomnia for 2 months. It would be waken from sleep about 1-2am. After waken going to toilet. Also patient has had night sweating. Recently, he has suffered from blurry eyes and flow out tear from eyes as well. No S.O.B, No Back pain, No knee pain, No palpitation, Normal digestion
He feel easy to thirsty(bitter taste),
Past illness history: he has got a Diabetes but now is gone
Life style: busy school life, no smoke, no drink. Regular coffee drinker
Family history: NAD
Menstruation, martial & obstetrical history: married with one son,
B) Inspection
General: medium height and figure, vitality 7/10, Red colour face, very hard(Neck, Shoulder, Back area)
Tongue: Red tongue body, white coating
Sound: normal
Odours: NAD
D) Palpitation
Pulse: Irregular pulses(cun mai), taut
Body areas: NAD
CASE SUMMARY
DEFINITION
Insomnia is a symptom of a sleeping disorder characterized by persistent difficulty falling asleep or staying asleep despite the opportunity. It is typically followed by functional impairment while awake. Insomniacs have been known to complain about being unable to close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and non-organic insomnia constitute a sleep disorder.
WMS
Although there are several different degrees of insomnia, about three types of insomnia have been clearly identified: transient, acute, and chronic.
- Transient insomnia lasts from days to weeks. It can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, severe depression, or by stress. Its consequences - sleepiness and impaired psychomotor performance - are similar to those of sleep deprivation
- Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months.
- Chronic insomnia lasts for years at a time. It can be caused by another disorder, or it can be a primary disorder. Its effects can vary according to its causes. They might include sleepiness, muscular fatigue, hallucinations, and/or mental fatigue; but people with chronic insomnia often show increased alertness. Some people that live with this disorder see things as though they were happening in slow motion, whereas moving objects seem to blend together.[
TCM ETIOLOGY and PATHOGENESIS
Insomnia is often caused by emotional or psychic disturbances. Anxiety and anger make the Liver depressed, and the depressed Liver qi may be transformed into fire, which interferes with the normal functions of the Heart. Excessive anxiety may also impair the Heart (mind) and the Spleen, and insomnia occurs due to inadequate supply of nutrients and blood to the Heart.
In the aged and the patients suffering from chronic diseases, qi and blood are insufficient to nourish the Heart, thus leading to palpitations and insomnia. Qi deficiency may also involve the Heart and the Gallbladder, impairing one's sleep and making one vulnerable to fright. Consumption of Kidney essence may break down the normal balance between the Heart and the Kidneys, and incoordination between the Heart and the Kidneys may also be manifested as insomnia.
Syndrome Differentiation
According t the pathogenesis, insomnia can be classified into the following syndrome patterns:
1. Depressed Liver with exuberant fire: Insomnia accompanied by irritability, irascibility, thirst, yellow coating, and stringy, rapid pulse.
2. Incoordination of the Heart and the Kidneys: Insomnia accompanied by dizziness, tinnitus, dryness in the mouth, heat sensation in the palms and soles, palpitations, forgetfulness, lumbar aching, reddened tongue, and thready, rapid pulse.
3. Deficiency both the Heart and the spleen: Dreamful sleep with early waking, palpitations, forgetfulness, dizziness, lassitude, lack of strength, anorexia, pallid complexion, and thready, weak pulse.
4. Deficiency of the Heart ad the Gallbladder: Dreamful sleep with wakefulness, susceptibility to fright, and stringy, thready pulse.
TCM DIAGNOSIS
A) Diagnosis: Insomnia
B) Syndrome Differentiation : Qi and Blood Stagnation & Liver Qi stagnation
C) Explanation: The patient shows liver Qi stagnation type Insomnia symptom such as Insomnia accompanied by irritability, irascibility, thirst, yellow coating, and stringy, rapid pulse . Another Symptom from Qi and Blood stagnation is typically caused by A vesanic condition by stagnation of qi and blood obstructing channels and collaterals and further resulting in the disconnection between the brain –qi and qi of zang and fu organ TREATMENT or temples
Treatment principles :
Open Pacify the Liver, eliminate stagnation, calm the Mind
B) Points and Therapies
An mian, Tai chong, Shen men, San yin jiao, YinTang, Shen ting
C) Explanation
An mian : Calms the spirit and pacifies the Liver
Taichong (Liv3) : pacifies the Liver and eliminates stagnation.
Shen men: Calms the spirit
Regulates and tonifies the Heart
San yin jiao : Tonifies the Spleen and Stomach,Resolves dampness, Harmonises the Liver and tonifies the Kidneys, Regulates menstruation and induces labour, Harmonises the lower jiao, Regulates urination and benefits the genitals, Calms the spirit, Invigorates blood, Activates the channel and alleviates pain
.Shenting( Du24) : In combination with Taing and Yanglingquan relieve stagnation of Liver-Qi stagnation
Taiyang and yintang are for relieve headache
LIFESTYLE ADVICE
l relieve stress and gain more qi
l suitable execise
l avoid spicy and greasy food
CASE CONCLUSION
I finished this case with 1 treatment. The patient said the Insomnia is a perfect cured after treatment, And the Blurry eyes has gone after cured, flow out tear as well. So I recommend to visit again when a same symptom reoccur.
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