Chief Complaint: palpitations, insomnia, irregular erratic heartbeat
Western Diagnosis: arrhythmia, Post Traumatic Stress Disorder
Medical History: Pt. is 37 yr. old male with history of extreme sports career (cycling) with exposure to extreme heat and cold while racing. Childhood history of multiple traumatic events. For the past 20 years Pt. has noticed gradually worsening irregular heartbeat. Has been hospitalized 2 times for acute attacks. Pt. cannot sleep well. Very difficult falling asleep, dream-disturbances, night sweats, some low back pain. Still exercises but only light to moderate because of heart condition. Endurance and stamina, energy level throughout the day very low. Risk of arrhythmia acting up.
Questioning exam: Pt. experiences tinnitus of high pitch when tired. Head rush when stands too quickly. Hx of low Bp. Also sees tunnel vision when tired.
Pulse exam: Pulse is weak and thready on left, more deep on right.
Patient seems unable to focus, very tired but can’t sleep, pulse is becoming more irregular.
Tongue exam: Tongue is pale, large, dry, with light yellow coat on the back.
Face is pale with dark purple circles under the eyes, lips are slightly bluish.
OM Diagnosis: Erratic heartbeat palpitations, insomnia, fear from PTSD, all contribute to a restless spirit and Heart Yin and blood def. Exposure to extreme temperatures while cycling/racing has injured both Yin and Yang of heart and kidneys, and Kidney Qi in general.
Treatment Principle: Calm spirit, nourish Heart, tonify kidneys
Point Prescription: Ear shenmen, Shenmen – to induce sleep
Yintang – calm mind
Guanyuan, Zhaohai – nourish Yin, Kidney Yin
Zusanli – nourish Qi and Blood
yinxi – nightsweats
Taixi -tonify Kidney
Herbal Formula: Pt. is very sensitive to any drugs. is already on depacote for mood stabilizing, zoloft as antidepressant, and synthroid to counter effects of depacote.
I prescribed low dose 1 tab/TID of Shen Gem from Health Concerns for palpitations, calming shen with good results. Later tried Nine Flavor tea to nourish Yin but Pt. felt palpitations increased correlating with herbs and discontinued use.
Lifestyle Prescription: Recommended Yin-type exercises, Qi-gong, hiking, meditation. Eat root veggies, all cooked.
Results: Results were great! Pt. slept during treatment and heartbeat regulated. Pt. was able to leave with clear mind. Pt. continued treatment weekly and energy level and stamina have improved as well as sleep. Night sweats have completely gone away.
Synopsis: Patient needs long term care but is responding well to acupuncture alone.
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