Assessment of Individual with Fatigue
The following is a basic outline for the initial intake and assessment of someone with a condition related to fatigue. This can apply to Chronic Fatigue Syndrome, fibromyalgia, or any other case of fatigue with unknown cause. It is possible for case history to lead to factors not in the summary. This is only intended as a basic outline, to be modified as needed - not a rigid protocol.
Subjective - Review of Symptoms
The following is a brief outline - much more can be covered in a visit - depending upon what direction the case points to.
- Energy level throughout the day. Any time feel better or worse?
- Sleep. Need to sleep/nap in the middle of the day? Insomnia? If so can't fall asleep insomnia or waking up in the middle of the night?
- Review of systems
- Digestive system: gas, bloating, pain, tenderness on palpation
- Immune system. Often get sick? Frequent use of antibiotics? Never get sick (can be a sign of depressed immune system)
- Musculoskeletal: any aches or pains? In joints? Muscles? tender point Vs trigger point
- Cardiovascular symptoms?
- G/U symptoms. UTI's infections?, kidney pain? Frequent urination?
- Women: PMS or other illness associated with reproductive system, or any symptoms with cycle (if not current, then past?)
- Respiratory system. Coughs, bronchitis, swollen lymph nodes?
- Nervous system
- Emotional stress - emotional trauma, losses, grief, anger, worry, fear?
- Lifestyle and diet. Any special diet? Any foods currently avoiding and why? Review diet for common allergens (wheat, dairy, corn, soy are at top of list - although more). Lifestyle - especially stress or long work hours? Stress at home? Healthy environment at home?
- Current medications or supplements
- Constitutional signs: Hot/Cold, stagnation, constriction, dampness. See page on herbal medicine for more information. This assessment is very important to determine what herbs are best for the individuals, as part of treating the person rather than the disease.
Past medical history
- Childhood illness or infections
- Dental work, infections?
- History of antibiotic use
- Reoccurring past infections - even if doesn't have it anymore (may be a sign that the body is not longer producing that symptoms, as the "disease" has moving deeper inside the body).
- Emotionally traumatic events
- Any past surgeries including tonsillectomy, appendectomy, gallbladder?
- Potential toxic exposures?
- Health history time line: Taking note of all symptoms past and present and charting it out in order to progression. Often people seem to have different diseases at different times, when in fact it's the same disease process that never goes away, but rather just presents as different symptoms. Symptoms may be very different, effecting various systems, so this may not be obvious at first
Objective - Lab Work and Physical Finding
All blood work should be reviewed carefully. Official reference ranges are often very large and have more to do with establishing norms for official diagnosis categories, then determining overall health.
Very sick people may have "normal" blood work. However on closer inspection labs are often not in optimal range. For example, the official reference range for monocytes may go up to 13%, but optimally it should be less than 7%. Anything higher can indicate a chronic infection.
Typically the most relevant blood work includes:
- CBC and differential: White Blood Cell count (WBC) and differential may be very important, as infections (acute or hidden chronic ones) can be a major cause of fatigue
- Thyroid hormone: TSH, T3, T4, thyroid antibodies
- Anemia? Iron, TIBC, Ferritin in addition to CBC (RBC, hemoglobin, hematocrit)
- Blood sugar: glucose, HgA1c
There are specialty labs typically used by "alternative" practitioners: NDs, functional medical doctors, DC, etc. They are generally not covered by insurance. Although at times valuable, it's important to order them carefully or else it turns into a large out of pocket expense. It's also possible for patient to end up with a large collection of functional lab tests that do not show where the problem is - when the problem could be more easily seem through a comprehensive history and some basic in office exam.
Partial list of some functional labs tests:
- Hormone tests
- Stool test for parasites, allergens, dysbiosis, inflammation
- Food allergies
- Toxicity: porphyrin tests, metals
- Other labs tests, amino acids, organic acid
- Bennett and chapman reflux point.
- Tongue diagnosis. fingernails, skin, visual signs
- Muscle testing (go here for more information)
Sample Case - Chronic Fatigue Syndrome
Summary of actual case - posted with permission of family
This is not a fully detailed description of every visit and protocol (that would be quite lengthy). The purpose of this is to show how individualized assessment is used in breaking down a case and proper treatment.
- 18 year old male. Symptoms getting progressively worse over past 2 1/2 years
- Extreme fatigue. Even standing up is difficult. Has had to stop going to high school because he is incapable of doing any school work
- Insomnia - despite fatigue can not fall or stay asleep. Sleeps about 2 hours a day at random times
- Chronic constipation, stomach aches and heartburn
- Daily headaches and whole body aches (at time of initial visit - has had a constant migraine for past 3 days)
- Frequent urination and pain after urination. Has to pee every 20 minutes. (Earlier on in illness was even suspended from school for going to the bathroom so much)
- Bone pains, says legs hurt, like growing pains
- Elevated heart rhythm
- Blurry vision
- Frequent temperature changes - calls it "hot flashes"
- Sensitive to sounds
- Conventional treatment including anti-depressants did not work
- Numerous supplements for energy and adrenal function did not work
Initial plan was some compound homeopathics for energy and sleep. Functional lab tests ordered: saliva cortisol, stool test and porphyrin test for toxicity
2 1/2 week follow up
Sleep is slightly better, except innervated (sleeping more at night). Basically feels the same. Labs show an increased toxic burden (porphyrin test). Cortisol is basically normal.
New protocol includes:
- Rhemannia herbal tincture - 1/4 teaspoon twice a day. Rhemannia is an important herb for the kidneys. In multiple ways case points to weakness in kidney: he is preoccupied with fear (in Chinese medicine kidneys are associated with fear), bone pain (again, relates to kidneys in Chinese medicine), frequent urination, and increased heart rate along with insomnia (this again relates to Chinese medicine - where the kidneys are related to the heart - so that if weak, heart symptoms may manifest).
- Teasel herbal tincture - 1/4 teaspoon twice a day. This was given with a similar rational to rhemannia. Teasel is a good herb for many different types of infections. It's often use for Lyme disease. This did not turn out to be a Lyme disease case, but many symptoms matched an overall teasel picture (especially pain in muscles and bones).
- A set of compound homeopathics given to assist in detoxification (primarily to buffer any response from herbs, but additionally porphyrin test showed a toxicity burden)
- SyImmune - a homeopathic for general immune system support added. This given to not just boost immune system function, but calm down potential detoxification effects,
Follow up one week later
Came in for an emergency visit - symptoms actually worsened on the above plan. It was determined that teasel was to strong. It was taken out of plan for now, to be gradually restarted at just 1 drop per day
Came in with additional labs. CBC was "normal" - except for slightly high normal eosinophils on repeated lab tests (about 4.0% - not very much elevated - but this mild elevation was on previous labs as well). Based upon this additional parasitology tests ordered.
One month later
Although still very tired, seeing case turn around.
Urinary frequency and sleep are now normal!
Bone pain is still present
Additional lab tests show elevated anti gliadin antibody (very sensitive to gluten) and antibodies to Entamoeba histolytica (although not typically considered serious, in susceptible people this can cause numerous symptoms and be a major contributing factor to symptoms).
The major turning point was normalizing sleep. Going from 2 hours of disorganized sleep to night, to what was close to a normal sleep cycle in about 6 weeks. Even if every else is done correctly, the body needs to sleep to recover from such illness. Insomnia was not treated with sleeping pills or even sedating herbs. What helped the most was Rhemannia, given according to Chinese Medicine assessment (kidney yin deficiency).
One month later
Went back to medical doctors for extensive testing - the stress of this itself caused a minor setback in recovery
Gastroenterologist found nothing
MRI testing found nothing
Energy gradually improving. Actually began to try exercising. Although this may not sound like good progress, 3 months prior fatigue and muscle pain was so bad - was almost not able to stand and walk.
Note - despite at this point extensive blood work and imaging from numerous medical doctor over past 2 years, the only labs that have show any hint of underlining problem was the slightly elevated eosinophils, Entamoeba histolytica and gliadin antibodies.
Glutamine added to protocol - to aid in repair digestive system function and boost energy.
Isopathics added in - to turn on immune system function.
One week follow-up
Quickly came back concerned over a sore throat since starting isopathics. Was assured that this is a healthy, detoxification response and sign of the immune system turning on. Encouraged to continue with protocol.
One month later
Most symptoms are not present, or very minor (headaches, frequent urination, "hot flashes," increased heart rate, and insomnia),
Fatigue and brain fog and bone pain are still present.
Reports "white" "stringy" stuff coming out in stool - which based upon comparison to online photos appears to be a parasite.
Note: aside from entameba histolytica - no parasite was ever found on lab tests, but it's hard to argue with visual confirmation that the patient is seeing parasite come out.
Summary 4 months later
Gradual improvement although signs of parasite continue. Eventually followed up with an infectious disease doctor who used antibiotics against Entameba histolytica.
After aggressive antibiotic use for 1 month - Entameba histolytica was finally cleared on lab test with infectious disease doctor.
Following this was clear signs of prostate infection. Instead of going back to MD for antibiotics came in for a natural alternative. Isopathics cleared this up in a few days.
After people with severe fatigue have numerous food sensitivities. While it's important to avoid triggering foods, they are often given treatment plans in which foods themselves are considered the enemy. Certain foods such as sugar, conventional dairy, wheat, any junk food, are not healthy. However, severe allergic response to a large range of typically healthy natural foods indicates a different problem.
In this case, he went from being able to eat virtually nothing, to able to tolerate a much larger range of foods once pathogens in digestive system where cleared. So food allergies may be part of a larger problem effecting immune system response, than being the problem in and of itself.