Male, 20 years
Reason for consultation
Palpitations, shortness of breath for 10 days
Clinical history
Palpitations, sensations of chest oppression (worsened after playing 3 basketball games in three days where he had sweated a lot), anxiety, insomnia, dizziness, physical asthenia (unable to walk more than 20 meters continuously), dry mouth and throat, loss of appetite, scanty dark urine, normal stools.
Tongue: red with little coating. Pulse: fine rough.
Diagnosis
Rough -> lack of body fluids
- Heart-Yin deficiency
- Heart-Qi deficiency, significant fluid escape, chest oppression and tongue.
The weakened Heart starts to affect Spleen-Qi.
Therapeutic principles
- Restore fluid
- Calm shortness of breath and palpitations
- Tonify Heart-Yin and Qi
Treatment
- BL-15; BL-43.
- ST-36 raise energy.
- SP-6: strengthen Yin and calm the Shen.
- Heart yuan and luo: HT-7 + HT-5 -> tonify the Heart; also HT-3 (water point)
- KI-6(Yin Qiao Mai, sleep) + LU-7: dryness.
- PC-7 and PC-6: Ghost Point; (-> better NOT because it would extinguish too much, they are too potent)
- SP-4 carries Qi to the whole body