Insomnia for 5 years

Record of first visit

Date : 29/10/08 Name : ***

Gender : m DOB : 27/12/1989

CHIEF COMPLAINT : Insomnia for 5 years

Description :

A) Asking

Present illness complaints : patient has Insomnia for 5years,he can not fall sleep easily and also wake up easily, when he wake up still feel tired, no nightmare, he thinking to much, sometimes he go to bed and can not sleep untill morning.

Poor appitite, no headache, normal urination and defication, no taste in mouth, he does not do exercise, no chill and fever, no sweating, sore throat, prefer to eat spicy food, no abdominal pain, always feel tired, no tinitus,

past illness history : NAD

lifestyle : no drinking, no smoking, go to bed very late(playing game)

B) Inspection

General : Red cheek

Others : NAD

C) Auscultation/Olfaction

Sound : NAD

Odours : NAD

D) Plapation

Body areas : NAD Pulse : rapid, floating

Case summary

Diagnosis : insomnia

TCM type/pattern : both def of Heart and Spleen

Explanation : He plays game to much at night every day, so do not go to bed early. Too long time doing this makes him insomnia. And also too much thinking damage to heart, so that make it worse.

He can not have enough sleeping time so always tired, it mean qi deficiency. Irregular meal time damaged his spleen and no exercise make him weak.

Treatment principle : nourish the heart and spleen

Treatment method : acupuncture

1. Needling

Prescription : shenmen, neiguan, zusanli, baihui.

Explanation : shenmen : nourish the heart

Neiguan : nourish the heart

Zusanli : tonify spleen

Baihui : calm the mind

2. Moxibustion

Prescription

Explanation

3. Cupping

Prescription

Explanation

4. Electro acupuncture

Prescription

Explanation

5. Microsystems

Prescription

Explanation

6. Lifestyle advice : do not play the game to much especially at night, go to bed early and wake up early. Do some simple exercise.

Case conclusion

I treated this patient with needle. His symptom was improved but I could not treat after that. So now he has insomnia again. And he afraid needle so difficult treat him again. So I asked him to do some exercise, go to bed early and do not play game a lot.