Patient 7: CHRONIC INSOMNIA FOR 30 YEARS.
Female,
Age 42.
This is a real patient history. Their identification details have been removed to maintain the patient’s privacy.
Initial Presentation
- Mother of five children
- Unable to fall asleep since the age of 12
- She sleeps only 2 – 3 hours every two to three days
- She had been experiencing perimenopause symptoms for some time
- Other than high blood pressure, she does not have any other chronic diseases.
- She said that she practises mindfulness to calm her down
- Physical Exam
- Normal including blood pressure (she has been on blood pressure tablets), heavy smoker
- Blood Tests
- High Estrogen, Low progesterone
- Increased eosinophils
- Normal Serum Copper
- Blood Cortisol (Stress Hormone)
- Very High at 8am, 12 noon and 4pm
- Fasting Insulin was higher than normal
- Fasting blood sugar was elevated (almost close to diabetic level)
- Normal Thyroid Levels
- Iron, Vit B12, Magnesium and Calcium were normal
- Slightly raised homocysteine
- Analysis of Intake Forms
- Features of extremely severe dysbiosis
- Severe fatigue score
- Non-specific headaches twice a month (non-hormonal)
- In her health appraisal form, she scored high for the following systems indicating poor functions:
- Gastrointestinal Tract
- Colon
- Thyroid System
- Symptoms of PMS (Pre-menstrual Syndrome)
- Muscles
- Small Intestines
- Liver/Gall Bladder
- Fatigue and Adrenals
- Menopausal Symptoms
- Detoxification Issues
- Psychological History
- Mild Depression and Anxiety Symptoms
Appropriate treatments started targeted towards causative factors.
- Outcome
- Within one month, her blood pressure medication could be halved
- Had started feeling better, less stressed
- Her blood sugar levels normalised
- She had started to sleep for 6 hours every night without a trouble
- After 3 months of treatment
- She did not have high blood pressure anymore. Blood sugar was normal. Her sleep was restful and lasting 6 – 8 hours without difficulty in falling asleep.
- Patient was discharged as she did not have any more issues. Her blood pressure medication was ceased.
Author
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) 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.