Bevin Clare, MS, LDN, RH Associate Professor Herbal Medicine Department Maryland University of Integrative Health Laurel, MD

Transcription

1 A Teaching Case Study Bevin Clare, MS, LDN, RH Associate Professor Herbal Medicine Department Maryland University of Integrative Health Laurel, MD

2 Client s reason for coming: Nonspecific autoimmune condition 41 year-old Caucasian female Occupation: Mother, part-time medical assistant Passions: Family, puzzles, knitting Home Situation: Married to a man, two young children, ages 3 and 6, 2 cats, 1 dog

3 Client s reason for coming: Five years ago client suddenly presented with acute high fever and severe pain leading to hospitalization and severe intervention of high dose steroids. After almost 3 weeks in the hospital and investigation of various diseases she was diagnosed with a non-specific autoimmune condition. She remained on high dose steroids for almost two years, each time she lowered her dose the inflammation increased and she was hospitalized.

4 Clients reason for coming: After almost two years, she became pregnant at which time she ceased the steroids and had no recurrence of the autoimmune disease while pregnant and 6 months later. After 6 months, she recently had a full recurrence with hospitalization and life threatening inflammation and fever. Sleeps poorly, 4-5 hours per night and then can t sleep anymore. Can only sleep with the TV on. Bloodwork reveals elevated liver enzymes and elevated ANA levels. Also concerned about cold hands and feet even when in warm places.

5 Observations Body Type: Client is observed as fairly deficient woman of average height and weight with typical steroid side effects in her appearance. She appears pale and fatigued, with dark circles under her eyes. Tongue: pale, glistening with little coat, puffy with scallops. Exercise: no formal exercise, has 2 small children CV: Hypertension as a medication side effect.

6 Observations Skin/joints Joints are painful and stiff at times. Digestion Client reports limited digestive tolerance for foods. Reports raw foods, lots of vegetables and most fruits cause her to have gas, distension, bloating and loose stools. Cannot tolerate fried or oily foods. Urinary and Respiratory Nothing urinary. Frequent respiratory infectious each winter and any mild URI s transition quickly to severe respiratory infections with log recover times.

7 Objective Psych / Social Supportive family and colleagues. She is frustrated with her health and lack of medical care to support her condition. Medications methotrexate 2.5mg prednisone 40mg / day beta-blocker (? Dosage) Herbs and Supplements none

8 Diet Breakfast toaster pastry, breakfast bar or donuts w/ coffee and orange juice Lunch Lean cuisine frozen meal, subway cold cuts or mcdonalds chicken sandwich. Snack Doritos, chips, funyuns Dinner pizza, pasta, lasagna or fish sticks always with Texas toast Beverages diet coke or pepsi 48-64oz / day

9 Health Narrative Client is frustrated with her current health state. Despite getting the best care she can find because of her location and connections within the medical community, she has never gotten better. Life looks grim and she can t imagine how long she can live this way.

10 Assessment What is going well? Inputs / processes Lifestyle Diet What areas are challenging her health? Inputs / processes Lifestyle Diet

11 Goals Short term goals: 1. To feel she has the ability to change her health. 2. To have her diet detract less from her health. 3. To help mitigate damage from corticosteroids and reduce the dose Long term goals: 1. To have fewer auto-immune acute episodes of less severity and shorter duration. 2. To have health practices which support her wellbeing and have the confidence and knowledge to implement them.

12 Plan: First Visit 1. Substitute diet sodas with fruit juices and sparkling water. 2. Improve sleep hygiene and take capsules of Valeriana officinalis (2g) and Humulus lupulus (2g) 60 minutes before bedtime. 3. Licorice root tea: 3g Glycyrrhiza glabra c/s root decocted in 2 cups of water with 4 dried apricots for 20 minutes. Drink in the morning.

13 Second Visit Goals Short term goals: 1. To feel she has the ability to change her health. 2. To have her diet detract less from her health. 3. To mitigate immunopathological harm. 4. To support her immune system.

14 Plan: Second Visit Add in extract daily dose: Astragalus membranaceus 2mL Ganoderma lucidum 2mL Schisandra Chinensis 1mL Panax quinquefolius 1mL Turnera diffusa 1mL TOTAL 7mL / day Add in 1 cup frozen blueberries / day. Add in 1 serving of greens / day Create a daily mantra

15 Third Visit Goals Short term goals: 1. To feel she has the ability to change her health. 2. To have her diet detract less from her health. 3. To mitigate immunopathological harm. 4. To support her immune system.

16 Plan: Third Visit Increase Glycyrrhiza tea to 5g / day. Incorporate a bitter tincture before meals TID: Angelica archangelica 0.25mL Citrus sinensis 0.25mL Artemisia vulgaris 0.25mL Take one dropperful before meals Eat a daily egg for breakfast

17 Fourth Visit Goals Short term goals: 1. To have her diet detract less from her health. Daily fruit compote with aromatics Daily probiotic Greens twice / day

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