FMU s Functional Diagnostic Medicine Case Review February Information Gathered from the Initial Patient Intake Questionnaire and N.A.Q.

Transcription

1 FMU s Functional Diagnostic Medicine Case Review February 2009 Objectives of the clinical case review: 1. To use the FDM Thinking Process and the Categorization Matrix to analyze a case and come up with a diagnostic hypothesis. 2. To use the FDM Categorization Matrix to further refine the case and get a clearer sense of what is going on with the patient from an FDM perspective. 3. To use the FDM Categorization Matrix to triage a diagnostic assessment utilizing primary and advanced FDM tests 4. To outline potential therapeutic interventions based on the results of the diagnostic assessment Chief Complaint Information Gathered from the Initial Patient Intake Questionnaire and N.A.Q. 46 year old female presents with a chief complaint of Inflammatory Bowel Disease (IBD) History of Present Illness Initial health problems seemed to have started in 1999, while on a backpacking trip. She returned from the trip with flu-like symptoms and fatigue and was hospitalized for 1-2 days. She returned to work, but continued to feel fatigued with intermittent and non-specific gastrointestinal complaints. She was subsequently diagnosed with depression and placed on Prozac. This did not seem to help. Her general symptoms continued and she was then diagnosed with Epstein-Barr (EBV). However, nutritional and botanical therapy did little to improve her fatigue and intermittent GI symptoms. In 2003, with continuing fatigue and digestive problems, a colonoscopy was performed and she was diagnosed with IBD. She was placed on Asacop and later sulfasaliazine. However. she did not feel her symptoms of fatigue nor intermittent GI symptoms showed much improvement and she eventually discontinued. Digestive symptoms worsened and in 2006 further follow-up testing resulted in a diagnosis of microscopic colitis. Again, she was treated with Asacol with no improvement after 8 weeks. On her own she tried Pepto Bismol and noted significant improvement and normal stools. When she went off Pepto Bismol the symptoms returned. Currently, she has symptoms of diarrhea, 5-6x/day with no formed stool at all; undigested food in her stool but no blood noted; little bloating or gas

2 Past Medical and Surgical History Diagnosed as hypothyroid and is on replacement therapy. Has a history of depression which she reports is now controlled on medication. Unilateral oophorectomy in 1989 and then again in 1993; hemorrhoidectomy in Family History Her mother died of a heart attack at age 66; father of colon cancer at age 64; brother died of colon cancer at age 45. She also reports an older sister with intestinal problems that appear more related to heartburn and gastritis. Medications and/or Supplements Prescriptive; Levoxyl, Zoloft. Non-Prescriptive: a nutritional supplement used for menopausal symptoms; a multiple vitamin; calcium; lactobacillus supplement and a saccharomyces boulardii supplement. Pertinent Review of Symptoms She reports cold hands and feet and poor libido, long term Nutrition and Lifestyle She reports worsening with spicy foods and caffeine and has had some improvement in the recent past with a gluten-free diet. She is currently seeing a nutritionist and is on a dairy, wheat, corn, gluten, coffee- free program with lowered intake of raw vegetables and soy, which has resulted in a modest improvement of her symptoms Social History Married. No kids currently considering adoption. Works full time as an administrator in the State Department of Motor Vehicles Environmental Influences New carpets and drapes put into the house 2 years ago. Objective Findings Weight: 127 pounds. Height 63 inches. BP: 97/62. Caucasian female in no significant distress. Essentially normal PE with light pain and irritation in the left lower quadrant. Functional PE: Tender upper GI and liver reflexes, positive Murphy s sign and tenderness on deeper palpation in RLQ and LLQ with similar findings on

3 palpation of ITBs. Pupils pulsed and became larger after 7 seconds on the Pupillary Response test and 10 point systolic drop with Raglan s test. Evaluating the Case: Concepts and Ideas When evaluating this case consider the following: 1. What underlying etiologies and factors could be affecting this patient s physiology? 2. What are the underlying Predisposing Factors, Triggers and Mediators from the patient s story? Evaluating the case using the FDM Categorization Matrix Read through the information presented above and take the blank categorization matrix (at the bottom of this case) and fill out the Predisposing Factors, the Triggers and the Mediators from the case above. Start thinking about all of the information presented in the case above and consider which of the 8 Functional Systems would be affected by any piece of information i.e. Patient had Giardia in 1996 could be written in the GI, the Immune System and the Inflammatory system sections of the FDM Categorization Matrix or in the space below: Digestion, Absorption, Mucosal Integrity Immune System Energy Production, Oxidative Stress & Mitochondria Inflammation

4 Detoxification Neuroendocrine Regulation Psychological, Emotional, & Spiritual Balance Structural Integrity Now, consider the following: 1. What's your diagnostic hypothesis or initial evaluation? 2. What's going on with this patient? 3. What Functional Systems are involved?

5 4. How will you objectify your suspicions? 5. What primary FDM tests would you consider? 6. What advanced FDM tests would you consider? 7. What functional system is the priority? Summarize in your own words a conversation you would have with the patient to pull all of this information together:

6 NOTES:

7 Functional Diagnostic Medicine Categorization Matrix Information from Patient s Initial History is placed in this matrix Predisposing Factors Triggers Mediators Digestion, Absorption, Mucosal Integrity Immune System Inflammation Energy Production, Oxidative Stress & Mitochondria Detoxification Neuroendocrine Regulation Psychological, Emotional, & Spiritual Balance Structural Integrity

8 Using the FDM Filtering Matrix to process all patients When processing a new patient, the above two questions must be on the forefront of your thinking process. To aid in the thinking process, the filtering matrix needs to take into account the following three areas of clinical evaluation: 1: Predisposing factors: these are factors that PRECEDE the onset of the symptoms and may make your patient more susceptible to an illness. Predisposing factors include both genetic and acquired factors. Examples include: Genetic factors: Family history of a common detoxification enzyme defect. Acquired: Maternal-placental transfer of xenobiotics Abusive spousal relationship History of antibiotics leading to a compromised GI health Hysterectomy leading an estrogen and progesterone deficiency 2: Triggers are physical, emotional, psychological and/or chemical/environmental factors which exert influences upon organ systems, cells, organelles, or molecules which, in turn, alter homeodynamic balance and lead to the release of substances which in turn damage or further disrupt the homeodynamic balance. Triggers exert more or less influence depending upon the predisposing factors which have left their biological mark upon the organism. Examples: Excess bombardment of immunoglobulins penetrating the mucosal lining entering the circulatory system causing a chronic antigen-antibody reaction == auto-immune disease. Chronic emotional crisis leading to a depressed cortisol output stressing the body s ability to produce adequate amounts of cortisone == fibromyalgia H.pylori affecting the stomach lining leading to ulcers. It can even be thought that the introduction of proton pump inhibitor which causes a reduction of gastric acid production (hypochlohydria) may be a trigger of a trigger 3: Mediators are the final common pathway for disruption in homeodynamic balance or damage to organ systems, cells, organelles, or molecules. Pharmaceutical intervention is the primary treatment and many times the only treatment for this final disruption in homeodynamic balance. For example: The patient suffering from GERD is commonly prescribed a proton pump inhibitor to stop or at least minimize the spilling of acid into the esophageal tissue. On the same note, a health professional focused on a natural symptomatic approach to GERD may prescribe Orange Peel. Both of these approaches are treating the common mediator of your patient s illness. Statin medications are HMG-CoA reductase inhibitors stopping the natural production of cholesterol. On the other hand, Red Yeast Rice also is an inhibitor of HMG-CoA Reductase.