Advanced Naturopathic Case Taking: Case Example

Question 1

Main details

Answer 1

• Name / age - Mike, 27yrs.
• Height / weight - 180cm, 90kg
• Job - Bricklayer (day), pizza-maker (evening).
• Presenting symptoms: Asthma, eczema, Low energy.
• Medications: Ventolin, fusiderm(topical corticosteroid), piriton.
• Family:
  o Father —asthma, hay fever, eczema (atopic conditions);
  o Mother —low mood;
  o Brother (three years younger) —no health issues.

Question 2

Presenting Symptoms

Answer 2

• Asthma: Re-started two years when started working as a bricklayer (exposed to brick dust). Becomes breathless and wheezy.
• Eczema: On flexor surfaces of elbow; re-started 18 months ago after starting pizza job (eating the food / exposed to flour).
• Low energy: Started 18 months ago after taking on his second job

Question 3

Medical history and timeline:

Answer 3

• Birth: Emergency caesarean (C-section babies have a greater tendency to atopic conditions). Bottle-fed (creates a different microbiome to breast-fed infants and higher incidence of atopy). Had childhood vaccinations, no immediate reactions.
• No registered health issues as new-born.
• 9 months: Chest infection —three weeks antibiotics.
• 11 months: Eczema —topical steroids on and off until aged two.
• 3–11 years: Asthma —inhalers used.
• 12–18 years: Cystic acne, four courses of antibiotics.
• 19 years: Hay fever —piriton(current).
• 22 years: House-sharing. ↑ alcohol, using cannabis, fast food
• 25 years: Pizza-maker and builder. ↑ Asthma and eczema

Question 4

Diet:

Answer 4

• Eating ↑ fast food. Developed loose stools twice a day, cramping, smelly gas, bloating.
• Breakfast: Bacon sandwich, tea (milk, one sugar) or nothing.
• Lunch: Subway sandwich / baguette tuna sweetcorn/ salad.
• Snacks: Banana, apple, KitKat.
• Fluid:1.5 L water, two teas (milk, one sugar), Ribena.
• Evening meal: Microwave meal (meat / veg, lasagne, curry).

Question 5

Medication:

Answer 5

• Past two years —daily medication (steroid cream / steroid inhaler).

Question 6

Systems review:

Answer 6

• Nervous system: Light sleeper. Feels anxious if lack of sleep. Five hours sleep but disturbed from feeling itchy about 3am (lung in the TCM clock).
• Digestion: Stool type 6. Occasional morning urgency. Two BM daily.
• Urinary: Urine frequency 8–10 x daily. Urine colour quite yellow.
• Endocrine: Energy not too bad. Struggles between 3–6pm.(TCM: Bladder / kidneys or lungs / large intestine). Some sugar cravings in the afternoon (possible blood sugar issues).
• Respiratory: Impacted by pollen count, brick dust, flour when making pizzas, cannabis use. Feels he can’t breathe sometimes.
• Cardiovascular: Pale skin colour, can experience dizziness (a red flag).
• Skin: Brick dust, flour, heat, itching, red, dry (not weeping).
• Lifestyle: Alcohol, cannabis, more fast food and sugars.

Question 7

Antecedents:

Answer 7

• Genetic weakness (family history), C-section, bottle-fed.

Question 8

Triggers:

Answer 8

• Antibiotics, brick dust, flour.

Question 9

Mediators:

Answer 9

• Steroids, anti-histamines, poor diet, poor work / life balance.

Question 10

Timeline:

Answer 10

• Born : C-section
• 9–10 months: Chest Infection, Antibiotics
• 11 months –2 years: Eczema, Steroids
• 3–12 years: Asthma, Inhalers
• 12-18 years: Acne, Steroids Inhalers, Antibiotics
• 19 years – present: Hay fever and piriton (19 – now), Eczema, asthma steroids (25 – now), Brick dust, flour (25 years)

Question 11

Systems under stress:

Answer 11

• Respiratory (asthma, hay fever)
• Skin (eczema)
• Nervous (awaking early hours)
• Digestion (loose bowel movements)
• Urinary (frequency)
• Endocrine (energy dips).

Question 12

Core clinical imbalances:

Answer 12

• Assimilation
• Communication
• Structural integrity
• Transport
• Detoxification

Question 13

Potential red flags:

Answer 13

• Shortness of breath, Dizziness.

Question 14

Hand-outs to guide Mike on lifestyle balance:

Answer 14

• Sleep hygiene, blood sugar balancing.