Covid-19 Case Report — SIEAM

The patient, a 32 year old Caucasian male, presented to the clinic on April 24, 2020 with suspected Covid-19.

Initial Consultation • April 24, 2020

The patient had an exposure to a Covid-19 positive co-worker two weeks prior to presenting to the clinic. One week prior to presenting to the clinic, his toddler had a cough and fever, and his wife had severe fatigue and a sore throat for one day. In response to this, the patient had been self-isolating.

Five days ago, the patient developed a sore throat. Initially the sore throat was minor and the patient was not a concerned. The sore throat persisted and he began to experience a low-level headache, and upper back and neck tension.

One day ago, his headache started to intensify and he began to experience fever as high as 101.5°F, and chills that were described as “going to the bone”. In addition, he was experiencing severe body aches and joint pain. The patient took acetaminophen (Tylenol) and rested. When taking his temperature afterwards, he noted that it was reduced. He also had very low energy. That night he had significant sweating, which he described as “sweating out of every pore of his body”.

Due to his symptoms and his confirmed exposure, the patient received a Covid-19 test on April 24, 2020.

At the time of consultation, the patient was still experiencing fever and chills that were described as alternating. His temperature was above 99°F (self reported). The patient felt subjectively hot and also reported being sweaty. His body aches and joint pain had reduced, but were still present. The patient reported no coughing, but felt “tight through the ribs” when taking deep breaths. He was still experiencing a sore throat that was intermittent and not very severe. The soreness was localized to the middle of the throat and was more pronounced when swallowing. He reported that there was no phlegm. He was experiencing significant thirst and reported a “nasty” taste in his mouth. His headache was still present and was primarily in the frontal region and behind the eyes extending to the temporal region. His energy was slightly improved compared to the day before, but was still very low. His appetite was low with little desire for food, and he had not had a bowel movement in the last two days. His tongue was pale pink, with a thin white, moist coat, and teeth marks along the sides.

The patient was diagnosed with a shao yang (Lesser Yang) disorder complicated by invasion of a damp pathogen.

Diagnosis

shao ​yang pathogenic influence with dampness

Prescription

He was prescribed granules for the first 24 hours consisting of Xiao chai hu tang (Minor Bupleurum Decoction) 20g, and Huo xiang zheng qi san (Patchouli/Agastache Powder to Rectify the Qi) 10g. He was instructed to take 5g, three times per day. He was also prescribed 3 bags of loose herbs based on the same formulas, to be taken after the first 24 hours.

Loose Herb Formula - Xiao chai hu tang + Huo xiang zheng qi san