sn15: practitioner initial consult case 1 (pages 1-9) · 2019-05-14 · sn15: practitioner initial...

SN15: Practitioner Initial Consult Case 1 (pages 1-9)

Client Registration Form PIC#211_13/15_1

Welcome to Wellnation Clinic at Endeavour College of Natural Health. The purpose of this clinic is to provide a work-integrated learning

environment for our students, in which they can interact with clients and gain experience in assessing and treating a range of conditions.

Any information you provide will be treated with complete confidentiality as per the Privacy Act 1988

(http://www.oaic.gov.au/privacy/privacyhttp://www.oaic.gov.au/privacy/privacy-act/the-privacy-actact/the-privacy-act). The

College collects personal information in order to assist in the provision of its services. Personal information will not be collected unless it is relevant for a purpose directly related to a function or activity or the College and will only collect information by lawful means as per our published Endeavour Privacy Policy, available at: http://endeavour.edu.au/policies-and-procedures

1. CLIENT DETAILS Please print clearly *Indicates compulsory field

*Mr / Mrs / Miss / Ms / Other *Male / Female / Transgender / Intersex / Other

*Surname Jones *Given Name Rosemary

*Preferred Name Rose *Date of Birth (dd/mm/yyyy) 21/11/1955

*Address U2/170 Wellington St.

*Suburb East Perth *State W.A. *Postcode 6004

*Phone Number *Or Mobile 0400111000

*Email [email protected]

Ethnicity Caucasian Occupation Child care worker

2. EMERGENCY CONTACT INFORMATION

Name John Jones Relationship Husband Phone 9647 2963

3. HEALTH CARE / DOCTOR INFORMATION

Name Dr Francis Jeffs Phone ( 08 ) 9225

2999

Clinic Name and Address East Perth Medcial

4. REFERRAL INFORMATION

Referred by (tick) X Family/Friend

☐ Endeavour Student ☐ Social Media

X Advertisement

Have you attended a consultation at Wellnation Clinic before?

☐

☐

Passing Clinic

Yes

☐ Other

X No

If Yes, which discipline did yo

☐ Acupuncture

u attend (tick below)

☐ Aromatherapy ☐ Homeopathy ☐ Kinesiology

☐ Naturopathy ☐ Nutritional and Dietetic Medicine ☐ Myotherapy ☐ Reflexology

☐ Remedial Massage ☐ Swedish Massage

☐ Tui na (Chinese medical massage) ☐ Other

http://www.oaic.gov.au/privacy/privacy-act/the-privacy-act








http://endeavour.edu.au/policies-and-procedures






© Endeavour College of Natural Health HMCL211_SN15_Case StudySN13_1_1Repeat

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5. DECLARATION I, the undersigned, understand that:

This is a student clinic, not a medical practice and as such it is supervised by a qualified practitioner of the discipline

The supervising practitioner and/or an observing student may be present in the consultation room during my appointment

At any time during my clinic appointment, I can request to see the supervising practitioner

As this is a teaching clinic, it may not be possible to see the same student practitioner at each visit. However, all efforts to facilitate

this will be made

Consultations and treatments vary in length, but may take up to 90 minutes

The appointment time includes consultation time, student review and feedback with the clinic supervisor, and student feedback

regarding any recommended treatment plan

The physical examination I receive may involve partial undressing and having the student/supervising practitioner palpate (i.e. touch)

me

I may choose to terminate the appointment at any time, but may be required to pay in full for the consult according to the Wellnation

Clinics Cancellation Policy

My health records are confidential and will be used for training and/or research purposes only. Under no circumstances will my file

leave the grounds of Endeavour College of Natural Health (unless otherwise approved, as below)

My de-identified case notes may be used for discussion, teaching, research and examination purposes

*Cumulative results from case files may be used for research purposes however individuals cases will not be used for case report

publication/s without your prior specific written consent

It may be necessary from time to time for my case to be discussed with other health professionals (e.g. general practitioners, medical

specialists and/or complementary medicine practitioners) and provide my consent for part/all of my medical case notes to be released

for these purposes only

By ticking this box I accept and agree to the Wellnation Clinics Cancellation Policy and Wellnation Clinics Refund Policy

By ticking this box I am providing confirmation that I have read and accepted the above conditions

Name Rosemary Jones

Signature Rosemary Jones Date 4/9/2018

6. PRE-ASSESSMENT QUESTIONNAIRE

What is your main presenting condition/concern today? (please list 1-2 items maximum) Osteo-arthritis

Do you have any children? If so, please list their ages:

Are you trying to conceive? ☐ Yes X No Have you sought reproductive assistance? ☐ Yes

If yes, for how long have you been actively trying?

X No

Do you have any known allergies (please list)? No

If you do have allergies, please define what happens upon contact/ingestion:

Have you had any previous fractures and/or surgeries? If yes, please list the body parts that were fractured and dates of injury (including car

accidents / motor vehicle trauma). Please also list any past surgeries:

Broke right arm – 6yo, Appendix removed 17yo, Skin cancer removed last year.

Are you a smoker? ☐ Yes No Quantity / Day Are you seeking to stop smoking? ☐ Yes ☐ No


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7. PAST AND CURRENT CONDITIONS Please tick (√) all current or past conditions that apply to you (C - Current and / or P – Past).

Symptoms C P Symptoms C P Symptoms C P Symptoms C P

Pain / Stiffness Digestive System Skin Other

Neck / Jaw Diarrhoea Rashes Diabetes Mellitus

Back C Gastric ulcers Itching Cancer

Shoulder / Arm / Hand C Nausea / Anorexia Wounds slow to heal Hepatitis B / C

Leg C Constipation Urticaria / Hives HIV / AIDS

At Night C Abdominal discomfort Bruise easily ADHD / Autism/ Asperger’s

In Morning C Indigestion Dermatitis Women Only

Pins & Needles / Tingling Reflux Psoriasis Difficult menstruation

Arms / hands / fingers Renal System Eczema Breastfeeding

Legs / feet / toes Frequent urination Neurological System Menopause P

Other Poor urine stream Confusion Pregnancy

Numbness Feeling of incomplete emptying Memory loss Premenstrual syndrome

Arms / hands / fingers Urinary tract pain Altered alertness Painful intercourse

Legs / feet / toes Incontinence Changes in vision Fertility problems

Other Interstitial cystitis Muscle cramps Low / Loss of libido

Cold Extremities Immune System Seizures Men Only

Hands Frequent colds / flu Body fatigue Prostate problems

Legs/feet Frequent UTIs General muscle weakness Testicular pain

Swelling of Extremities Chronic fatigue Depression / Anxiety Fertility problems

Arms / hands Fibromyalgia Senses Low / Loss of libido

Legs / feet IBD – Crohn’s or UC Headache Erectile dysfunction

Balance Multiple sclerosis Dizziness / Light headed General Wellbeing

Weakness / clumsiness Glandular fever Heavy headed Fatigue

Loss of balance Allergies Fainting Tension

Vertigo Heart & Circulatory Visual light sensitivity Fog

Respiratory System Chest pain Blurred vision Stress

Difficulty breathing Heart problems / Angina Visual impairment Irritability C P

Cough Pacemaker Tinnitus Nervousness

Chronic cough High blood pressure C P Loss of hearing Sleep problems

Sinus problems Low blood pressure Speech impairment Fevers

Hay fever Varicose veins Other (add if not listed) Sweats

Asthma Blood clots / DVT Loss of smell

Chronic bronchitis Stroke (CVA) Loss of taste


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8. CURRENT MEDICATIONS / SUPPLEMENTS / HERBAL REMEDIES

Medication Name Dosage (mcg/mg and # per day) Duration of Medication Related Condition

Panadol Osteo (655mg paracetamol) 2 tabs every 4-6 hours, as

required

6 mo. Osteo-arthritis

Monopril (ACE Inhibitor) 1 tab a.m. 4yrs. High blood pressure


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Client expectations: I would like my pain levels to change.

Social norms: I am a childcare worker, so I need to look conservative and trustworthy.

Social considerations/ limitations: I help my single-mother daughter look after her children, 5

afternoons per week & every second Saturday, so I have little free time.

Client’s culture: My parents were English (Sussex & Manchester) and I didn’t emigrate to

Australia until I was 13yo. It is a family habit to drink tea.

Dietary parameters: I have a low-salt diet to help with my blood pressure.

Presenting Complaint/s: Osteoarthritis

L: lumbar spine, left hip, and fingers of left hand, both knees and both feet.

O: diagnosed with an x-ray 2 years prior, subsequent x-ray 6 months ago indicates further degeneration. Had noticed that mobility and range of motion was reducing from around 57yo (menopause).

P: worse for exercise and movement. When first diagnosed, pain was only after strenuous exercise (lifting, climbing) but in the last 6 months pain occurs after walking.

P: better for Panadol (now use up to 4xday if bad), rest (better in the morning)

Q: dull aching, chronic pain.

R: after walks this extends down the back of the legs into the calf muscles, into the right hip and the middle of the back. In the hands this extends to my elbows.

S: pain is 4/10 (o=no pain) when rising, after walks is 7/10, strenuous exercise 8-9/10

T: it is always there but flares up when I start moving around. It has been ongoing every day, but progressively getting worse over the past 7 years.

U: “I am just getting old I think”

HPI: Around menopause at 57, I had trouble sleeping and thought that my achiness was due to being tired. Then I noticed that I had body & joint aches when I had been busy. Then at couple of years ago I really stiffened up & that is when the GP diagnosed me with osteoarthritis.

ROS - if a system is affected in the presenting complaint, please remember to complete a quick

review of the rest of that system.

MSK

I broke my right arm at 6 – I fell out of a tree. It healed fine, no issues.

Twisted and fell on my left knee playing netball at 19years old and couldn’t play for a season.

The GP thought that I split the cartilage, but I didn’t investigate further.

NS

Increased irritability and reduced patience because of pain levels – snapping at my husband

and grandchildren. They get on my nerves as the pain increases. I am anxious about reduced

mobility and less independence.

Generally, I was a calm person, I have always been able to sleep so I didn’t get too flustered

with anything. Since menopause & the osteoarthritis impacting on moving and pain, I have

become moody and snappy.


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CVS

Was diagnosed with hypertension around 4.5 years ago. Trialled low salt diet with exercise

(walking 3 x week) but as the arthritis got worse the blood pressure increased. I was put onto

blood pressure medication (ACE inhibitor) 4 years ago & blood pressure stabilised from 150-

160/100-110 to about 120-130/70-80 mm Hg.

No high cholesterol or heart palpitations.

In the last couple of years, I have very cold hands & feet. My fingers & toes can look blue.

Endocrine:

I have put on 3kg over the last 3 months (now 72kg). It may be due to my decreased activity,

but I am not sure of the reason.

Recently I noticed that I feel the cold more than I used to. I always need an extra jumper and

I really notice it when there is a draft or a chill in the room.

Energy: I wake tired 1-2/10 (0= no energy), then once I get going it picks up a bit, 4/10 but if I

am at work or running after the grandkids it really drops to 2/10.

GIT:

Bowel motions 1-2 per day (1-2xd). Bristol stool chart type 1-2.

Generally mid brown, no undigested foods (occ. corn). Hard lumpy stools 5-7 days a week (5-

7/7). Always been a bit predisposed to constipation, but form has changed, used to be type

3-4, which may be related to the pain medication.

Some straining (3-4 x wk) with occasional blood spotting. Had this checked by the GP & he

said that it is a tiny haemorrhoid.

Had grumbling appendicitis and had my appendix removed at 17yo.

Imm:

I get a cold 1xyr. year in winter. Takes about 1 wk to resolve, rarely goes to chest (1x10yrs.)

or there is a secondary infection. Presents with runny nose, cough, sore throat.

At 24yo. I did have trouble with a cold that didn’t resolve. Turned into a severe sinus infection

& needed a course of antibiotics. At that time my diet was not great and was going out and

drinking. Nothing else significant around that time. Hasn’t happened since.

Resp.

Asthma when I was little, maybe 4-5 years old (yo.), I grew out of it by grade 4 or 5. I carried

a Ventolin but didn’t need to use it.

I have a tickly cough in winter, when moving from a warm room to a cold room or there is a

lot of dust or smoke in the air.

Was a smoker in my late teens to 20’s. Smoked 3-4xd, and I didn’t have trouble giving up.


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FRS

Menarche: 13yo.

Menopause at 57yo. Prior, regular menstrual cycle (27 days with 3-day bleed) but entering

peri-menopause, there was 2-3 months in between each cycle, my mood would fluctuate, and

I started having trouble falling asleep, then waking with hot flushes 2-3xnight. The symptoms

flushes reduced after the 1st year, but my aching L knee had started keeping me awake.

2 children 42yo. F and 39yo. M

No history of sexually transmitted infections (STI’s)

Libido is poor to average since I am so exhausted. My partner is very understanding.

Urogenital

Urinate 5-6 xd. Dark to mid yellow.

Don’t need to get up to urinate.

Had a bout of urinary tract infections (UTI’s) around 23yo. I had moved out of home and I had

an unhealthy lifestyle, drinking too much, going to parties. I think that I had 3-4 in 1 year.

They all needed antibiotics to clear them up.

Integ:

Recently noticed that in the last 3 months my skin is very dry and flaky on my lower legs, feet

and hands. I use hand cream & moisturiser any time I remember but it hasn’t improved at all.

I have always bruised easily, I will get undressed and my legs are covered in bruises with no

reason.

Cuts heal quickly (1-2 days).

Had two Basal cell carcinomas (BCC) removed on my hands last year. Healed quickly.

Last Medical Check-up: 6 weeks ago, to refill medical prescriptions

Allergies/Intolerances: Nil

Personal Medical History

Birth-5years: no significant issues

6-11 years: broke my R arm at 6yo. Falling out of a tree.

12-17 years: appendix removed at 17yo.

Adulthood: no significant issues, BCC removed 1 yr. prior

Overseas travel: Bali 8yr ago, Britain 3yr ago. No issues while away


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Family History

Paternal Maternal Siblings

Father: dec.

74yo. End-

stage

dementia

GF: dec. 70’s

heart attack

GM: dec. 64,

stomach

cancer

Mother:

83yo.

Arthritis,

hypertension,

high

cholesterol

GF: dec. 58,

cancer (not

sure what

type)

GM: dec.

74yo.

Complication

of heart

surgery

Sister: 58yo.

Allergies

(hayfever,

psoriasis),

high blood

pressure

Uncles, Aunts, cousins:

Dementia but not sure which

uncle, other dec. bowel

obstruction.

Uncles, Aunts, cousins: Aunty

79yo. Breast cancer in 40’s,

Other: nil

Lifestyle Factors

Physical Activity: try to walk 30 mins/d but after work look after the grandchildren, finds

little time & is too tired. Used to be active.

Energy levels: worst time of day morning & evening. Overall energy is between 3-4/10.

Sleep: Prior to 57yo. never had trouble sleeping (falling asleep or staying asleep). When the

children were little my sleep was affected but it didn’t affect my moods. Now I wake with pain

2-3 times a week. I will take Panadol Osteo during the night but feels worse the next day,

like I am ‘hung over’ so I don’t like to take them, but then I can’t sleep. It seems like a vicious

cycle.

Social & lifestyle: full-time child-care worker. Job satisfaction 7/10 (0=no satisfaction). I do

the before school care & this means that I can leave earlier to collect the grand children from

school.

Married for 44 years. Supportive husband & good relationship with children.

Drug Use

Tobacco – cigs/d 0 cigs How long have you

been a smoker?

Reformed

smoker (19-

25yo)

Recreational drugs

(type & frequency)

N/A


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Dietary Analysis

Mon-Fri Day 2 Weekends

Breakfast

5am

2 pieces of whole meal toast with tomato (2 slices) and feta (50gm block) (3/7) or ½ avocado (1/7) or 2 eggs (3/7)

2 x 250mL mugs of black tea & 1 tsp. sugar (7/7).

Same as week

MT

9am Sweet biscuit (chocolate coated or Jam-filled) with

1x 250mL mug black tea & 1 tsp. sugar (6-7/7) Cake &

coffee at a café 1/7

Lunch

12pm

Left-over dinners (2-4/7)

W/meal sandwich: salad (lettuce, cheese, tomato, celery, cucumber) & tinned tuna in spring water (2/7) or chicken (3/7)

Same as week

AT

3.30pm Occ. Seasonal fruit (apples, oranges, banana) 1/7 N/A

Dinner

5pm

Stir fry (beef or chicken) & veges. (carrot, snowpeas, corn, celery bok choy), low-salt soya sauce (2/7)

Curry or casserole (beef, lamb or chicken) & veges. (potato, carrot, onion, celery) (4-5/7)

Red meat 5/7 nights, chicken 2/7.

Dessert: ice cream and fresh or tinned fruit (2-3/7)

Same as week on a Sun., Sat out to dinner.

Beverages 3 x 200mL/d water

1x 150mL fruit juice (2/7)

3x black tea/d (as above)

2-3 glass (150mL) red wine (2/7)

Eating out Not during the week. Pizza 1xmo., Chinese, Indian, Thai 1/7.

Food Cravings/ aversions?

Tea & biscuits when tired (every day).

Follow-up notes: To clarify in repeat:

How long has Rose been eating this diet for?

Exact ages of start/stop smoking? Overlap with 1st pregnancy?

Prior to 6mo. What was Rose using for pain relief?

ACE inhibitors deplete: Zn, B6, Mg, K, CQ10. Explore these nutrients for clinical deficiency signs.


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After you have taken the case, show how each of the presenting factors interrelate. Consider aetiology, possible

predisposition, precipitating complaints, causative, sustaining or aggravating lifestyle factors, signs, results of

pathology and screening, penetration of disease and prognosis.

REVIEW OF RELEVANT SYSTEMS AND INTERACTION SCHEMATIC

TIMELINE OF EVENTS

Osteoarthritis (OA): Dx 61yo.

F/U 6mo.= degeneration

lumber, LHS hip & hand, 2x knees &

feet

< exercise/movement. ++ last 6mo.

> Panadol (Rx 6 mo. Up to QID), rest

Pain 4/10 (rest) to 8-9/10 (0=no pain)

GIT

Bristol type 1-2.

Hard/lumpy 5-7/7

Strain 3-4/7

++ last 6mo. (Rx pain

med/panadol)

Dx: small haemerrhoid

FRS

OA 1st present with menopause

Menarch 13yo. -> menopause 57yo.

Grav 1 (F) 21yo, Grav 2 (M) 24yo.

Libido average – husband understands

Endo.

+++3kg in 3mo. (now 72kg)

+++ cold sensitivity (thyroid?)

Energy (0= no energy)

Am: 1-2.10, mid 4/10, pm. 2/10

Pain meds give ‘hangover’

effect lowering energy

Diet – current overview

Protein with each main, 1/2 -1 cup

vege/d, 2 serves fruit/d, wh/meal

grains, low salt. Omega 3?

Lunch chicken (3/7) tuna 2/7

Dinner: Red meat 5/7, chicken 2/7

3x200mL/d water

3xblack tea

2-3 (150mL) red wine W/End

Crave tea (2x5am, 9am) sweet

biscuits (9am)

Sweet with dinner

MSK

19yo. LHS knee

Dx? Split cartilage

Resp

Dx asthma 4-5yo-> 10-11yo.

Smoke late teens->early

20’s (grav 1 at 21yo?)

Urogen

Void: 4-5/d (dark-mid yellow)

CVS

Dx high BP 4.5yr.

Rx ACE Inhib 4yrs. Rx

Depletes: Zn, B6, Mg, K,

CQ10

BP: 12-130/70-80 mmHg

Familial: M, GM(M), GF(F),

sister

Poor peripheral circ. Cold &

blue

Dx

asth

ma

RH

S b

rke

arm

Ast

hm

a

reso

lved

Fro

m U

K t

o

Au

st.

Men

arch

e

Ap

pen

dix

surg

ery

LHS

knee

.

Mar

ried

Gra

v 1

(F)

Gra

v 2

(M

)

Co

ld r

equ

.

Rx

AB

M/p

ause

,

OA

sym

pt

Dx.

Hig

h B

P

Dx

OA

BC

C r

em.

Han

ds

OA

x-r

ay

deg

.

+3kg

(to

72

kg)

4-5

6

10

-11

13

17

19

21

24

57

59

61

62

6m

o.

3m

o.

63

Imm.

Cold 1xyr. 1wk resolve

Integ.

3mo. Dry flake, lower

legs, feet, hands

Ch: bruise easily

Healing: 1-2d.

BCC x2 rem. Last year

NS

++ irritable/ low patience

with pain ‘get on nerves”

“moody & snappy”

++Anxious reduced mobility

& loss independence

SN15: Practitioner Planning & Treatment Notes (pages 10-14)


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Birth Present

ASSESSMENT

Holistic Assessment

Possible knee trauma 19yo may have led to a misalignment of spine & LHS presentation (?)

Menopause (57yo): Drop in oestrogen, alteration to sleep / anxiety may have increased pain sensations/

degeneration of joints. Dx of OA (61yo) with increasing pain.

Degeration of symptoms in the last 6mo, increased Rx pain meds usage, reduced activity, reduced positive

mood (anxiety, low libido), increased weight gain, increased usage of tea & sweet foods to support low energy

(Am: 1-2.10, mid 4/10, pm. 2/10).

Last 6mo. = increasing pain requires increasing pain meds (up to QID), wakes with pain, but Rx gives feeling of

‘hangover’ compounding low energy & exacerbating pain perception & low mood.

Differential Diagnosis

Depression

Hypothyroidism

Other joint/ misalignment issues

Investigations Required

GP referral for exploration of rapid weight gain in short time

Pathology referral (thyroid panel)

Working Diagnosis

Exacerbation of OA, compounded by S/E of Rx pain has exacerbated low mood & increased weight = increased

pain & reduced mobility

TREATMENT AIMS

Short Term What are the most important areas of the case to address?

Support symptomatic pain by reducing COX/LOX mediated pain (omega 3), leading to reduced reported pain

scale (adjunct support of skin integrity, blood thinning, correlation to low mood and CVS disorders)

Explore thyroid function (ACL referral for full thyroid panel (TSH, T3, T4) to rule in/out possible co-morbid/

causative factor in weight gain, low energy, flow mood, dry skin, increased pain, reduced mobility.

Long Term

Slowly increase walking exercise (measured against client’s pain scores) to improve mood around ‘reduced

mobility and loss of independence’

Maintain omega 3 intakes through dietary sources, swapping out 2-3 serves/wk for fish sources

Analyse diet for soluble/ insoluble fibre / water to support adequate stool bulking and fluidity to improve ease

of passing and change stool type (from 1-2 to 3-4)

Analyse diet / case for for micro intakes of Zn, B6, Mg, K, CQ10 and any deficiency signs as these are depleted


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by L/T ACE inhibitor usage.

Nutrient or Dietary Recommendation Anti/inflam (COX/LOX) Blood thinner

Increase omega 3 intake by 2,000mg/d Increase pro-inflammatory body

responses to reduce pain.

Improve mood outcomes.

Support integumentary &

connective tissue support (dry

skin, capillary fragility / bruising)

Support blood fluidity and blood

pressure management

Supplement Justification Dosage

Fish oil Anti-inflam to reduce pain, increase blood fluidity,

support positive mood

1 cap (1,000mg) BID with

breakfast & lunch.


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SN15: Client Repeat Consult Case 1 Responses (pages 13-14)

Client Instructions: give answers at the speed of talking, only read what is presented on the

case, if the question doesn’t have an answer comment “no information”, when answering a

section, tick the box.

General professional greeting Analysis of the presenting complaint

I still feel the pain in my lower back, my left hip, my left hand and both my knees & feet.

I still find that I am worse for using the joints, excess walking or heavy lifting. When I wake up my pain is 3/10 (o=no pain), but I have been going for short 10 min walks per day and after these my pain is 5-6/10. When I have really over-done it, it is 8-9/10

I am finding that I only need to use Panadol up to 3x day, but last week I didn’t take any Panadol for 2 days in a row. I haven’t had a pain medication free day for months.

Prior to being prescribed the Panadol Osteo I was taking regular Panadol, but at the most 1-2 tabs/d. This never gave me the ‘hangover’ feeling afterwards.

The pain is still a dull, chronic aching.

I over-did it at the park with the grandkids last Friday and that evening I was really exhausted

and the lower half of my body just ached until I went to bed.I did take Panadol that night, and

I felt a bit sluggish and slow the next day.

The Fish oil was easy to take, I didn’t miss a dose. NS

My mood has improved a little. I was at the park, and usually I am aching while I am there. I

think that is why I over-did it, as I was pushing my granddaughter on the swing for a lot

longer. I have been able to take the dog for a walk around the block and not need to take

Panadol when I get home. I definitely feel that there has been some improvement which is

exciting.

CVS

I was at the GP last week for a check-up & to get my scripts filled & my BP was 121/71

mmHg.

My hands & feet are still cold & look bluish if I sit still for too long.

Endocrine:

Since my last consult, my weight is the same, at 72kg. That is good, as I was scared that it

wouldn’t stop increasing. Now that I am able to walk the dog again, I think that this will help

also.

Energy: If I have had to have Panadol I wake tired 1-2/10 (0= no energy) but without it it is 3-

4/10. Middle of the day it is around 4-5/10 and then in the evening, I am tired so it is around

3/10.

FRS

My libido is still low.

GIT:

I still pass stool 1-2 per day (Bristol stool chart type 2-3).

The stools are a little lighter in colour, and not as hard and lumpy. I haven’t had to strain as

much, maybe 1-2/7.


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Imm & Resp

No issues with my chest. No colds or infections.

It was chilly the other night & I still had a tickly cough.

I started smoking when I was 17 and quit when I found out I was pregnant with Marie, my first

child at 21 yo.

Urogenital

Urinate 6-7 xd and it is mid yellow.

I still don’t need to get up to urinate.

Integ:

The skin on my hand is slightly less flakey. My heels & elbows hasn’t changed, but my hands

do look and feel a little better.

I still bruise easily, maybe a little bit less.

Client expectations today: I would like to work on increasing my exercise, and ways to

improve my diet to help with my weight.

Diet: My diet has been roughly like this for the past 20 years, with occasional changes.

Mon-Fri Day 2 Weekends

Breakfast

5am

2 pieces of whole meal toast with tomato (2 slices) and feta (50gm block) (2/7) or ½ avocado (1/7), 2 eggs (2/7), sardines (2/7)

2 x 250mL mugs of black tea & 1/2 tsp. sugar (7/7).

Same as week

MT

9am 1x 250mL mug black tea & 1/2 tsp. sugar (6-7/7) Café coffee

1/7

Lunch

12pm

W/meal sandwich: salad (lettuce, cheese, tomato, celery, cucumber) & tinned tuna in spring water (2/7), tinned salmon (2/7) or chicken (3/7)

Same as week

AT

3.30pm Occ. Seasonal fruit (apples, oranges, banana) 1/7 N/A

Dinner

5pm

Stir fry (chicken (1-2/7 & salmon 2/7) & veges. (carrot, snowpeas, corn, celery bok choy), low-salt soya sauce (4/7)

Curry lamb (1-2/7) or chicken (1-2/7) & veges. (potato, carrot, onion, celery) (3/7)

Red meat 1-2/7 nights, chicken 2-4/7, fish 2/7.

Same as week on a Sun., Sat out to dinner.

Beverages 3 x 200mL/d water

1x 150mL fruit juice (2/7)

3x black tea/d (as above)

2-3 glass (150mL) red wine (2/7)

Eating out Not in the last month

Food Cravings/ aversions?

Tea & biscuits when tired, but have cut out the sweets & cut down on the sugar. I have been adding more fish to my diet after we discussed how omega 3 helps my health.

sn15: practitioner initial consult case 1 (pages 1-9) · 2019-05-14 · sn15: practitioner initial...

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