Case Study 4

Patient 4: RECURRENT INFECTIONS, UNSETTLED GUT, BRAIN FOG AND FATIGUENESS.

Female, 
Age 40, 
Teacher Aide. 

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

Initial Presentation

  • Feeling sick frequently – for 5 months (in 2019)
  • Sore throat (ongoing)
  • Has had flu needle
  • Very tired all the time
  • Abdominal bloating and moderate tenderness
  • Past Medical History – Nil to note
  • Allergies – None
  • Married – 2 children
  • Mum – Hypertension, no other problems in family history
  • Never smoked
  • Alcohol occasionally
  • Examination
    • Overweight (not obese), weight 85kg
    • Physical Exam was otherwise normal
  • Family History – nil to note
  • Initial Investigations
    • Patient could not afford to pay for additional testing
    • Basic RAST Test – Moderate allergy to house dust mite
    • Iron Studies: TIBC – 65 (Normal), Saturation – 14 (Low), Ferritin 266 (High), CRP – 9
    • Liver Function Test – Normal,
    • Total Cholesterol – Normal
    • ESR – 3
    • Glandular Fever Antibody IgA – Positive.
  • Assessments with Questionnaires
    • Fatigue Questionnaire
      • Score – 92
    • Yeast symptom Questionnaire
      • Score – 196
    • Dysbiosis symptom Questionnaire
      • Score – 29
    • Toxin Questionnaire
      • Score – 107
    • CIRS Screening Questionnaire (biotoxin screening questionnaire)
      • 17/37
    • VCS Screening Test
      • Failed
  • Impression
    • Mold/Candida Infection
    • Dysbiosis
    • HPA Dysfunction (most probably due to gut infections)

Review after 1 month of treatment

  • Improved gut symptoms
  • Increased energy
  • Improved mood
  • No sore throat anymore
  • Memory and focus are improved
  • Sick feeling is gone

Review after 2 months

  • Toxin Score dropped to 35
  • Yeast symptom Score was 74
  • Dysbiosis Score 20
  • More energy and mental clarity
  • Previous protocol continued for one more month

Review after 3 months

  • Energy is very much improved
  • Gut symptoms are completely gone
  • Great mental clarity and focus
  • Lost 5kg (85 à 80kg)

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.