Functional Doctor Template

Consultation: History: * Patient presents with chronic fatigue, which began insidiously approximately 18 months ago, gradually worsening over time. * Fatigue is constant, described as a profound lack of energy that impacts all aspects of daily life. * It is worse in the mornings and after physical exertion, slightly alleviated by rest but never fully resolves. * Previous episodes include a bout of glandular fever five years ago. * Impacts daily activities significantly, making it difficult to maintain employment and social engagements. * Associated symptoms include brain fog, muscle aches, and disturbed sleep. * Timeline: Onset 18 months ago, gradual progression, reached current severity in the last 6 months. Symptom Review: Assimilation: Patient reports bloating, occasional abdominal pain, and inconsistent bowel movements, suggesting issues with digestion and microbiome balance. Defense And Repair: Experiences frequent colds and prolonged recovery from minor infections, indicating compromised immune function. Energy: Profound fatigue is the primary complaint, severely impacting mitochondrial function and metabolic efficiency. Biotransformation: Reports sensitivity to certain foods and environmental chemicals, potentially related to liver function and toxic load. Transport: No specific cardiovascular or lymphatic issues mentioned, but overall lethargy could indirectly affect circulation. Communication: Experiences mood swings, difficulty concentrating, and increased anxiety, pointing to potential imbalances in neurotransmitter and endocrine function. Structural Integrity: Muscle aches and joint stiffness are reported, indicating possible issues with musculoskeletal health. Mental, Emotional And Spiritual: Significant impact on mood with feelings of hopelessness and reduced sense of purpose due to chronic fatigue and its limitations. Past Medical History: * November 2019: Diagnosed with Glandular Fever (Epstein-Barr Virus). * March 2021: Appendectomy for acute appendicitis. * August 2022: Managed mild iron-deficiency anaemia with oral supplementation. * Social History: Works as a graphic designer (currently part-time due to fatigue), lives with partner, occasional alcohol consumption, non-smoker. * Family History: Mother has Type 2 Diabetes, Father had hypertension. * Exposure History: Works in an office environment, no known significant chemical exposures. * Immunisation History: Up-to-date with routine vaccinations. Lifestyle Factors: Nutrition: Patient reports a diet high in processed foods and refined sugars due to lack of energy for meal preparation. Often skips breakfast and relies on caffeine. Sleep: Sleep is restless and non-restorative, typically getting 6-7 hours but waking frequently. Difficulty falling asleep and staying asleep. Movement: Exercise is minimal due to fatigue, limited to short walks once or twice a week. Mindset: Patient expresses significant frustration and sadness about their current health, often feeling overwhelmed. Stresses: High job demands before fatigue onset, now stress from financial strain and inability to engage in usual activities. Community: Reduced social interaction due to fatigue, leading to feelings of isolation. Review Of Supplements And Medications: * Multivitamin: 1 tablet daily, started June 2023, ongoing. * Vitamin D3: 2000 IU daily, started September 2023, ongoing. * Iron Bisglycinate: 25 mg daily, started August 2022, ended March 2023. Examination: General: Appears fatigued but alert and cooperative. No acute distress. Weight 70 kg, Height 170 cm, BMI 24.2. Cardiovascular: Heart rate 72 bpm, regular rhythm. Blood pressure 120/78 mmHg. S1, S2 audible, no murmurs. Peripheral pulses palpable and equal. Respiratory: Respiratory rate 16 breaths per minute, clear breath sounds bilaterally, no adventitious sounds. Abdominal: Soft, non-tender, non-distended. Bowel sounds present in all four quadrants. No hepatosplenomegaly. Neurological: Cranial nerves intact, good tone and power in all four limbs. Reflexes 2+ bilaterally. No sensory deficits. Romberg's negative. Musculoskeletal: Mild tenderness on palpation of trapezius muscles bilaterally. Full range of motion in major joints, but patient reports generalised muscle aches with movement. Review Of Test Results: * November 2023: Full Blood Count - Hb 13.5 g/dL (NO UNITS GIVEN), WCC 7.2 x 10^9/L (NO UNITS GIVEN), Platelets 280 x 10^9/L (NO UNITS GIVEN). All within normal limits. * November 2023: Thyroid Function Tests - TSH 2.8 mIU/L (NO UNITS GIVEN), Free T4 16 pmol/L (NO UNITS GIVEN). All within normal limits. * November 2023: Liver Function Tests - ALT 25 U/L (NO UNITS GIVEN), AST 20 U/L (NO UNITS GIVEN). All within normal limits. * November 2023: Vitamin D - 45 nmol/L (NO UNITS GIVEN). Suggests insufficiency. Antecedents: Predisposing Factors: Genetic predisposition to inflammatory responses, suggested by family history of autoimmune conditions. Acquired: History of Glandular Fever in 2019, which can sometimes precede chronic fatigue syndromes. Prolonged period of high stress prior to symptom onset. Triggers: The onset of severe fatigue coincided with a period of intense work pressure and a viral illness (non-EBV). Mediators And Perpetuators: Poor sleep quality, inadequate nutrition, lack of exercise, and chronic stress are perpetuating the current fatigue. Assessment: * Likely Diagnosis: Chronic Fatigue Syndrome (CFS) / Myalgic Encephalomyelitis (ME) based on symptom presentation and duration. * Differential Diagnoses: Hypothyroidism (ruled out by TSH/T4), Anaemia (previously treated, now normal), Depression (co-morbid but not primary cause). * Root Causes: Post-viral immune dysregulation, mitochondrial dysfunction, gut dysbiosis, nutrient deficiencies (Vitamin D insufficiency), chronic stress response. Allergies: * Penicillin: Hives. * Dust Mites: Rhinitis. Overall Plan: Patient education on CFS/ME and the functional medicine approach to chronic illness will be provided. The plan aims to address underlying imbalances identified, focusing on gut health, mitochondrial support, stress reduction, and lifestyle modifications. Gradual reintroduction of gentle exercise will be encouraged, with careful monitoring to avoid post-exertional malaise. Regular follow-up appointments will be scheduled to monitor progress and adjust the treatment plan as needed. Nutrition: * Eliminate processed foods, refined sugars, and inflammatory oils. * Increase intake of whole, unprocessed foods, focusing on diverse vegetables, fruits, lean proteins, and healthy fats. * Consider a temporary elimination diet to identify potential food sensitivities (e.g., dairy, gluten). * Incorporate fermented foods (sauerkraut, kimchi) to support gut microbiome. Rest And Renew: * Implement daily mindfulness meditation (10-15 minutes). * Practice diaphragmatic breathing exercises for 5 minutes, three times a day. * Explore gentle yoga or stretching to promote relaxation and vagal tone. Sleep: * Establish a consistent sleep schedule, aiming for 8-9 hours per night. * Optimise sleep environment: dark, cool, quiet room. * Avoid screens at least 1 hour before bedtime. * Limit caffeine intake, especially in the afternoon. Movement: * Start with short, gentle walks (10-15 minutes) two to three times a week. * Gradually increase duration and intensity as tolerated, listening to body signals to prevent overexertion. * Avoid high-intensity exercise initially. Supplements: * CoQ10: 200 mg, capsule, twice daily, for mitochondrial support. * Magnesium Glycinate: 200 mg, powder, once daily at night, for muscle relaxation and sleep. * Probiotic: Daily, capsule, once daily, for gut health. * Vitamin D3: 5000 IU, capsule, once daily, to correct insufficiency. Medications: * No new medications prescribed at this time. Products And Tests: * Comprehensive Stool Analysis: To assess gut microbiome, inflammation, and digestive function. Order in 2 weeks. * Organic Acids Test (OAT): To evaluate mitochondrial function and neurotransmitter balance. Order in 4 weeks. * Adrenal Stress Index (ASI): To assess HPA axis function and cortisol rhythm. Order in 3 weeks. Next Steps: * Schedule follow-up consultation in 4 weeks to review initial progress and test results. * Patient to maintain a symptom diary to track energy levels, sleep quality, and digestive symptoms. * Referral to a nutritionist for personalised dietary guidance. Notes: Patient expressed strong motivation to adhere to the treatment plan and is keen to understand the root causes of their fatigue. Emphasised the importance of patience and consistency in the functional medicine approach. Advised to contact the clinic if any new or worsening symptoms arise.