Case Study 2

Patient 2: RECURRENT THROAT AND CHEST INFECTIONS, CHRONIC FATIGUE, ANXIETY, SUBFERTILITY, POOR LIBIDO.

Female, 
Age 38. 

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

Initial Presentation – 27/01/19

  • Married with one child
  • Ongoing tiredness, weight gain, frequent throat and chest infections for 5-6 years.
  • HPV Infection
  • Unable to conceive for 6 years (after her first child)
  • Hypertension
  • Poor Libido
  • Bloods show higher than normal testosterone
  • Abdominal pain and bloating
  • Anxious all the time
  • Allergies – Nil
  • Past Medical History – Depression and anxiety, CIN – 1, Miscarriage in 2015, HT
  • Weight – 66kg
  • BMI – 27.83

Assessments

  • Hypertensive – controlled with three anti-hypertensives
    • Dysbiosis Score – 44
    • Yeast symptom Score – 187
    • Fatigue Score – 127
  • Patient did not like to do functional testing due to financial reasons

Review – 03/04/19

  • Tired, more depressed and anxious
  • Very stressed as she cannot fall pregnant
  • Low energy levels
  • Insomnia
  • Weight – 60.9kg
  • Diet changed, supplements added after reviewing her assessment forms

Review – 18/06/19

  • Feels much better
  • Happy, more energetic
  • Patient stopped treatment due to financial reasons
  • Advised on smoking cessation, regular exercise and healthy diet

Review – 16/07/19

  • Feels very devastated, lack of sex drive, irritability, increased smoking, putting on weight, family stressors, missed periods
  • Did not start any treatment as she was found to be pregnant
  • She was very happy knowing that. This is 6 years after her first child.