Chief Complaint: Fatigue, nausea and loss of appetite.
Western Diagnosis: HIV Positive
Medical History: Male, 33 years of age, 5’10″, 175 lbs., full time student/part time bartender. Diagnosed HIV positive in 1989 remaining healthy with no complications. Currently (2002) and since 1996 patient on triple drug therapy of Indinovir, 3TC and AZT due to high viral load. Current viral load measures 200,000 copies per milliliter. Most notable side effects are chief complaint of fatigue, nausea and loss of appetite. Irregularly exercises, meditates and practices Qi Gong daily. Eight hours of sleep consistently but restless with dreams most nights, Excellent organic non vegetarian diet, mealtimes at regular hours 3x daily. Exposure to smoke daily.
Questioning exam: Extremely low energy, Patient tends to feel warm flashes and sweats easily. Feels a desire to vomit before and during meals, Little or no appetite, no taste, abdominal distention and borborygmus constantly, fatigue accompanied by dull headache, feels sleepy frequently and needs to nap in middle of the day, bowel movements twice daily soft but formed and foul smelling diarrhea two to three times week.
Pulse exam: Wiry and a little slippery. Both Kidney Yin and Yang seem weak and empty. 60bpm.
Tongue exam: Slightly dark body (light purple), slightly swollen and moist with teeth marks and thick white coat in lower jiao.
OM Diagnosis: Spleen and Stomach Qi Deficiency; fatigue, sleepiness, easily sweats with no exertion, no appetite, loose stool, abdominal distention, weak/empty pulse. Stomach Qi Stagnation; nausea, loss of appetite, decreased taste, loose stool, borborygmus. Dampness; looses stool, nausea, no appetite, moist tongue; Heat; tendency to feel warm, chronic dry lips, darrk tongue body. Kidney Deficiency; aversion to cold weather, lassitude, apathy, poor appetite, loose stool, decreased sex drive, weak Kidney Yang pulse.
Treatment Principle: Tonify Spleen and Stomach Qi, Clear Damp Heat, Support Kidney Yin and Kidney Yang.
Point Prescription: LI4; tonify wei qi, eliminate heat in LI.
ST25 – regulate intestinal function, clears heat. Ren6 – Sea of Qi, tonifies Qi and Yang.
SP6 – strengthen SP and transform Damp.
PC6 -nausea.
ST40 – calms mind, essential for Phlegm and Damp. LI11 harmonizes ST, cools heat, relaxes patient.
Ren8 -Salt Moxa to tonify KD Yang. Yintang – calms patient.
Herbal Formula: Patient prefers patents due to time restraints and is more compliant with patent. Prescribed Health Concerns formulas Source Qi to address fatigue, nausea and loss of appetite, Marrow Plus which counteracts AZT side effects of supporting bone marrow, Clear Heat which is equivalent to an antiviral and treats the epidemic toxic heat of the virus.
Lifestyle Prescription: Less smoke exposure would be very helpful. Adequate iron supplementation such as Floradix liquid iron. Stop coffee and soft drinks.
Results: Patient has reported an increase in energy and a lowered viral load since protocol began a year ago. Appetite had increased and the constant warm feeling has evened out.
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