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.

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.