Case Studies. Aimee C. Duffy, M.D. Carolina Integrative Medicine
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1 Case Studies Aimee C. Duffy, M.D. Carolina Integrative Medicine
2 Claudia, 67 yo F History/Symptoms S/P hysterectomy for fibroids at 48 Currently using natural hormones Phyto B 3-4 pellets in am and 3-4 pellets in pm. Has tried to wean down but complains of continued hot flashes day and night, difficulty sleeping Sister diagnosed with DCIS at age 52
3 Claudia, 67 yo F Test Results
4 Claudia, 67 yo F Treatment Topical BHRT Rx E2 0.5mg/g E3 3mg/g Prog 30mg/g use ½ gram daily Begin to wean down Phyto B Adrenal Support Supplement
5 Claudia, 67 yo F Follow-up Using cream but can only get down to 2-3 Phyto B twice a day as hot flashes continue Taking Tylenol PM at night
6 Claudia, 67 yo F F/U Test Results
7 Claudia, 67 yo F Adjustment Add Vivelle patch 0.5mg weekly After 3-4 weeks she was able to get down to 1 pellet Phyto B twice a day
8 Claudia, 67 yo F Follow-up Symptoms significantly improved Likes the patch and wants to continue Adjust BHRT to E3 3mg/g Prog 40mg/g Added DHEA 5mg daily
9 Claudia, 67 yo F
10 Claudia Thermography
11 Anne, 74 yo F History/Symptoms Currently on Estrogen and Testosterone Implant Pellets (last implant 3 months ago) and SL Progesterone troches Continued complaints of vaginal dryness, decreased libido, fatigue, thinning hair New diagnosis of asthma 2 years ago, arthritis in hands Strict gluten-free diet for the last 10 years Recent abnormal thermography, recommends breast US
12 Anne, 74 yo F
13 Anne, 74 yo F Results Low E2, Low EQ, Adequate Pg/E2 ratio Adequate Test however pellets 3 months prior Low DHEA
14 Anne, 74 yo F Treatment E3 1.5mg/g Prog 50mg/g topical cream ½ gram nightly DHEA 5mg capsule Vaginal Estriol 1mg cream
15 Anne, 74 yo F Follow-up Night sweats improved Fatigue was 3-4, now 5-6 Sleep is improved Vaginal dryness improved
16 Anne, 74 yo F
17 Anne, 74 yo F Asthma and Arthritis Very strict Gluten-free, low sugar diet due to IBS symptoms several years ago Symptoms improved with diet but now new onset asthma
18 Anne, 74 yo F Stool/Saliva Testing
19
20 Anne, 74 yo F Treatment Anti-inflammatory diet Anti-fungal herbs Anti-parasitic herbs Probiotics Digestive Enzymes
21 Anne thermography
22 It s all in the Family Janet 52-year-old mother Lee 17-year-old daughter Elizabeth 15 year-old daughter
23 Elizabeth, 15 yo F History/Symptoms Anxiety 8/10 - worse with school stress Depression on lexapro, started with 10 mg then increased to 20 mg recently. Has had some improvement in symptoms but not dramatic. Mother is concerned with now too much apathy. Severe constipation (with impaction at times) Stress triggers GI issues, abd pain, decreased appetite
24 Elizabeth, 15 yo F Work-up Blood tests TSH 3.459, FT3 3.7, FT B ( ) Vit D 49 (30-100)
25 Elizabeth, 15 yo F Neurotransmitter Results
26 Elizabeth, 15 yo F Additional testing MTHFR Heterozygous for C677T Heterozygous for A1298C
27 Elizabeth, 15 yo F Treatment Plan NT Uplift 2 qam on empty stomach Magnesium 2 caps at night (titrate up as tolerated) Probiotics Methyl B12 injections Methyl Assist (Methyl B12, 5 MTHF, P5P) Thyroid supplement (selenium, Milk Thistle, iodine, guggal)
28 Elizabeth, 15 yo F Follow-up Anxiety 2/10 Depression 2/10 Constipation resolved 2 months later weaned off Lexapro Repeat NT results pending
29 Lee,17 yo F History/Symptoms Anxiety 8/10 Depression 3/10 Weight gain, fatigue Occasional difficulty sleeping Asthma and headaches Started on Lexapro with no improvement. Changed to Viibryd with so far little change but increased weight gain.
30 Lee,17 yo F Work-up Labs TSH 1.403, FT3 3.1, FT Vit D 28 (30-100) B MTHFR Heterozygous for A1298C Negative for C677T
31 Lee,17 yo F Neurotransmitter Results
32 Lee,17 yo F Treatment Plan Vit D 10,000 Methyl Assist Methyl B12 injections NT Uplift 1 BID L-theanine 1 BID
33 Lee,17 yo F Follow-up Significant improvement in symptoms Anxiety 1-2/10 Depression 1-2/10 No headaches Normal sleep Weaned off Viibryd after 3 months Repeat NT results pending
34 Janet, 52 yo F History/Symptoms Anxiety 8/10 Depression 6/10 Dizzy spells Fatigue 8/10 Weight gain On BHRT no major hormone symptoms
35 Janet, 52 yo F med list Buproprion 150mg QD Abilify 5mg QD Viibryd 40mg QD BuSpar as needed Eve Primrose Oil Magnesium Oral B12 Complex BHRT topical cream not recently tested
36 Janet, 52 yo F Initial Work-up Labs B TSH 1.33, FT3 3.7, FT4 0.9 Vit D 30.9 CBC wnl CMP elevated liver enzymes, glucose, nl hgba1c
37 Janet, 52 yo F Saliva test
38 Janet, 52 yo F Treatment Plan Phase 2 adrenal support Adjust BHRT dosage slightly Vit D 10,000 Consider NT testing
39 Janet, 52 yo F NT test MTHFR Heterozygous for A1298C
40 Janet, 52 yo F Treatment 5 HTP 100mg BID DopaLift 2 am L-theanine 100mg BID Methyl B12
41 Janet, 52 yo F Follow-up Symptoms significantly improved Depression 3/10 Anxiety 2/10 No dizzy spells
42 Janet, 52 yo F Cortisol Test Results NT test pending
43 Janet, 52 yo F 6 months later Off Buproprion Off Abilify Weaned down to 10mg Viibryd with plans to go off in the next few weeks! Update Jan 2015 on Viibryd 5mg every other day.
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