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