Chief Complaint: Allergy and Insomnia
Western diagnosis: Allergy and Insomnia
Medical History: Dizziness, fatigue, frontal headache, insomnia, asthma, nausea, earache, hay fever, sinus problems. back, legs, neck and shoulders pain, Lumps in groins.
Allergic to passion fruit, chamomel, some fruits, cats, horses, goats, deers, some herbs.
Questioning exam: Allergy and asthma since pt was born and has been tested and confirmed by specialist. Symptoms included daily sneezing, itchy throat, running nose, stuffy ears, frontal headache, and frequent skin rush.
Sleep: difficult fall to sleep for about 20 years. Pt usually fell to sleep at 4 to 5am and woke up by 6am. Felt tired by 3pm. Dreamed about running away and avoiding a lot.
Occasionaly has palpitation and worried a lot daily.
Fingers and toes always cold.
Bowel movement regular, Urine normal, No abnormal thirst or sweats. Taste normal.
Pulse exam: Right: Wiry, deep at cun
Left: Weak, deep at cun
Tongue exam: Tongue body:Pale, red tip and red prickles on the upper jiao, swollen and teethmark.
Tongue coating: thick white.
OM Diagnosis: Lung qi deficiency and heart blood deficiency associate with liver qi stagnation.
Treatment Principle: Calm the shen tonify middle jiao and strengthen Lung Qi.
Point Prescription: After evaluate pt's symptoms and medical history, I found out that insomnia was the root problem and chronic insomnia affected the middlejiao and weaken lung qi. Food allergy and respiratory tract symptoms were the manifetations of Lung and middle jiao deficiency.
The Points I chosed were: St36, Ht7, Lv3, Ren12, Yin Tang, Sp6, Auricular-allergy and shenmen. Also Ear seeds on shenmen and alllergy.
Herbal Formula: I did not give Pt herbal formula until 3rd treatment (a week later after pt has reported allergy symptoms free between the treatments, because Pt was allergic to herbs)
Tian Wang Bu Xin Dan 2tab/3tid
Lifestyle prescription: No icy cold drink or cold food. Add ginger in the food daily. Keep emotional calmness and learn how to approach daily life with less worries and less stress.
Results: The results was very good. The Pt. was able to sleep whole night since the 1st treatment and as long as Pt has good sleep during the night, there was no allergy symptoms during the day. After 5 treatments (3 weeks duration), Pt was insomnia free and almost allergy symptoms free. Pt can enjoy outdoor activities with her family now.
Synopsis: I also treat pt's shoulder pain and hernia and those symptoms went away after 2 treatments. The Coldness of fingers and toes improved.