Case Study 1

Patient 1: CHRONIC FATIGUE, BRAIN FOG, URINARY INFECTIONS AND UNSETTLED GUT.

Female, 
Age 45, 
Truck Driver. 

This is a real patient history. Their identification details have been removed to maintain the patient’s privacy.

Initial Presentation – 18/02/19

  • Frequent urinary tract infections
  • She was short and obese.
  • Height – 151cm
  • Weight – 70kg
  • BMI – 30.88
  • Reported history of PCOS, but conceived easily – two pregnancies
  • Suffering from IBS, tiredness, brain fog, anxiety, feels unable to continue her job (doing shift work)
  • No other significant past history
  • Allergies – None
  • Never smoked
  • Alcohol – 2 – 3 times a month
  • Social History
    • 3 Children
    • Marital stress
  • Examination
    • Obese
    • Diffuse abdominal tenderness
    • Nil other significant findings
  • Investigations
    • Faecal culture and PCR – Negative
    • Faecal Calprotectin – 10
    • Normal Iron Studies
    • Patient could not afford to do private functional medicine testing
  • Assessment with Questionnaires
    • Yeast symptom Score – 208
    • Dysbiosis symptom Score – 62
    • Multiple symptoms score – 124
    • Fatigue Questionnaire Score – 123
    • Headache Questionnaire – Frequent headaches present, Worst from 15 – 28th day of cycle
    • Hormone Questionnaire – Mild to Moderate Oestrogen Related Symptoms

Review – 23/05/19

  • Gut symptoms much improved
  • Some itching in skin
  • Feels bit depressed
  • Tiredness is still there

Review – 21/06/19

  • Yeast symptom Score dropped to 95
  • Dysbiosis Score – 17
  • Toxin score dropped to 40
  • Fatigue Score – 65
  • Patient has had Mirena inserted for contraception
  • Weight – 67.7 kg
  • Feels much better, happy, brain fog is very much reduced, but still yeast score was significant

Review – 11/10/19

  • Yeast Symptom Score – 87
  • Dysbiosis Score – 79
  • (Patient has been on a normal Australian diet)
  • Toxin Score – 56
  • Fatigue Score – 77
  • Patient had been on a normal western diet.

Review – 03/12/19

  • Toxin Score – 35
  • Yeast Score – 70
  • Dysbiosis Score – 35

Review – 04/02/20

  • Patient feels very energetic
  • Gut symptoms are minimal
  • Feels much happier
  • Weight – 65kg
  • To be reviewed in 3 months
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