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

Author

Dr. Priyanta Thotagamuwa (MBBS, FRACGP)

Dr. Priyanta Thotagamuwa (MBBS, FRACGP)

Dr. Priyanta Thotagamuwa (MBBS, FRACGP) is operating Wandal Medical Centre in Rockhampton with the aim and interest of treating patients in a holistic manner. As a GP he offers medical assistance to patients of all ages, seeking advice, treatment or minor procedures.

Dr. Priyanta Thotagamuwa (MBBS, FRACGP)

Dr. Priyanta Thotagamuwa (MBBS, FRACGP)

Dr. Priyanta Thotagamuwa (MBBS, FRACGP) is operating Wandal Medical Centre in Rockhampton with the aim and interest of treating patients in a holistic manner. As a GP he offers medical assistance to patients of all ages, seeking advice, treatment or minor procedures.