Case notes: insomnia

johns

Case notes:   insomnia
First visit 30th Sep. 2004
Gender: Male                         Age: 38
Main complaint: Insomnia, stress, fatigue,
Pulse: Wiry
Tongue: Red with medium greasy yellow coat toward the back
Interview:
Low energy, tired for lack of sleep, red eyes
He had insomnia since this July. He feels stressed and anxious about having a new family. His partner carried two children with her. He is a single child in his family and left parents after his teenage, and had been kept alone until this August. At night, he had difficulty to get into sleep. He did not visit his GP because he worried about side-effect of biomedical therapies such as antidepressants and sleeping tablets.
His appetite is low. He is eating, but does not really enjoy food (taste not good). His abdominal felt bloating, distention pain in the hypochondriac region. He also has dry and bitter taste in mouth, especially in the morning when he woke up. His urine is yellow.
Diagnosis: Stagnation of Liver Qi, Liver Qi Transformed Into Fire
Treatment:
Acupuncture: PC 6 nei guan, LR 2 tai chong, ST 36 zhu shan li,
            ST 37 shang ju qu
Herbal treatment: Shu Gan Wan (Tablets)

Second visit 6th Oct. 2004
Pulse: Wiry
Tongue: Red with thin white coat
Changes since last treatment:
His sleeping got better after last treatment and took herbal tablets. Less bloating feeling and distention pain around hypochondriac region. Also, mouth is not bitter any more. He is still distracted by thinking about small things he need to do, feels anxious and nervous about the new family, although two children are nice.
Diagnosis: Stagnation of Liver Q
Treatment:
Acupuncture: HT7 shen men, SP6 san yin jiao, ST 36 zhu shan li,
            ST 37 shang ju qu
Herbal treatment: Shu Gan Wan (Tablets)

Third visit 13th Oct. 2004
Pulse: Wiry
Tongue: Red with slight white coat at rear
Changes since last treatment:
He can fall into sleep after 10 minutes on bed, does not feel restless. His dry mouth is gone, no bitter taste in mouth. No fullness feeling and pain in the hypochondriac region. Still worrying his new life, however can cope more easily. His urine sometimes looks yellow.
Diagnosis: Stagnation of Liver Qi
Treatment:
Acupuncture: PC 6 nei guan, KI 6 zhao hai, ST 36 zhu shan li,
            ST 37 shang ju qu
Herbal treatment: Shu Gan Wan (Tablets) comment

Comment:
This is a typical case of Liver Qi be stagnated.
This patient’s new living environment stimulated him to do some reactions, which causes his Liver Qi be constrained. His Liver function (TCM) was effected: Qi could not be dispersing and discharging properly. Shao yang Channels were stagnated by Qi, which could cause distention pain in the hypochondriac region. The transforming and transporting effect of the spleen was affected by Liver Qi, which could be found in his abdominal bloating and his greasy coat. His blood and body fluid could not flow smoothly. Upside, his mouth could not got enough body fluid, he felt dry mouth. Qi was stagnated for a while could transfer into fire, his month became bite, his tongue changed to red, his coat changed to yellow colour, downside his urine changed to yellow colour. His spleen and heart could not keep harmony, sleepless caused. Three months insomnia is enough let him fatigue.   
His treatment was focus on disperses Liver Qi. LR 2 (tai chong) is Stream Point of Liver Channel, is good at getting ride of Liver fire. ST 36 (zhu shan li) and ST 37 (shang ju qu) can build Qi very well. I tried use PC 6 (nei guan) to nourish his heart energy. I chose Shu Gan Wan to disperse his stagnated Liver Qi. One week later, I found his Qi in Shao yang began smoothly, less pain in hypochondriac region. His spleen got transforming and transporting effect back. Fire caused by stagnation of Qi reduced, he did not feel bite in his month. His sleep got better. However he still got muddled thinking. Second time, I changed PC 6 (nei guan) to HT 7 (shen men), which was called Sprit Gate. I carried on using ST 36 (zhu shan li), ST 37 (shang ju qu) and SP 6 (san yin jiao) to build his Qi and Yin; Shu Gan Wan carried on be used to disperse his Liver Qi. Another week later, his sleeping problem is fine. His body fluid could support his mouth, not feel dry mouth any more. His energy also was built well. As his pulse still was wiry, I thought his Liver Qi wasn’t totally dispersed. I suggested him to carry on with Shu Gan Wan, and chose PC 6 nei guan and KI 6 zhao hai to keep his heart and kidney energy harmony. One week later, he called me he was fine and wished to finish his treatment.

兰心

good case! is he your patient?