Hombre 54 años
Reason for consultation
Insomnia
Clinical history
For one year the patient has been suffering from insomnia. He usually wakes up between 3 and 4 a.m. and has difficulty falling back asleep. Sometimes he remembers his dreams. The patient complains of decreased mental energy during the day, drowsiness, poor memory and dizziness. His appetite is poor and he experiences abdominal bloating after eating. He has asthenia and lassitude. He is indifferent to cold and heat. He has no thirst. Urination and stool are normal.
Pale tongue with soft whitish coating Fine pulse
Diagnosis
If there is insomnia I think of the heart first.
- insomnia, easily startled, loss of memory, dizziness, pale face without luster, discolored lips, pale tongue, weak fine pulse.
- Heart-Blood deficiency
There are also symptoms that are not from the heart:
- The rough or fine pulse, slight post-prandial abdominal distension, fatigue, lassitude
- Spleen-Blood deficiency
concomitant deficiency of Spleen-Heart Qi-Blood
Therapeutic principles
- Tonify Qi and Blood
- Nourish the Heart
- Calm the Shen