Nutritional Medicine Initial Case Taking FormNMDC221

Patient Identification Code (PIC): NMDC221
Consultation date: 18th March 2020 Consultation time: 10:00 AM
Student practitioner: Student Observer:
Supervisor:
Health Priorities/Presenting Complaint: What are the main things that the client wants to work on?
(Location, Onset, Provocation/Palliation, Quality, Radiations, Severity, Timing, Understanding, History of Complaint)
Health Priorities System
Priority 1, 2, 3 …
1. Priority 1: The client wants to work upon improvement in terms of
reducing her current symptoms of irritable bowel symptoms, which has
a history since her adolescence.
2. Priority 3: The client wants to work upon regulating her present
symptoms of frequently acquiring allergic illnesses like hay fever
3. Priority 4: The client want to work upon improving her current digestive
problems associated inability to tolerate packaged and processed
foods like packaged biscuits and cakes.
4. Priority 2: The client wants to work upon improving her present health
condition by enhancing her levels of energy and losing to achieve a
healthy level of weight.
5. Priority 5: The client wants to work upon controlling her current sensory
intolerances in response to temperature changes and response to
strong smelling substances.
6. Priority 6: The client wants to work upon controlling her current
symptoms of dysmenorrhea or painful menstruation which have
recently resurfaced.
1. Gastrointestinal
system
2. Immune System
3. Impaired Gluten
digestion/Gluten
Intolerance
4. Metabolism
5. Cardiovascular
system and
Sensory functions
6. Endocrine/
Respiratory
system
Nutritional Medicine Initial Case Taking Form-
NMDC221 (PART A)

REVIEW OF SYSTEMS
1 Gastrointestinal system (Priority 1).
 Location: Cramping in abdomen
 Onset: Since adolescence and recently since childbirth
 Provocation/Palliation: Consumption of processed, packaged foods
 Quality: Urgent and Sharp symptoms of water unformed, foul smelling, unformed
bowels with mucous
 Radiations: Abdomen, absence of radiation
 Severity: 5/10, 4 times per day
 Timing: Early Evenings, afternoons
 Understanding: Fully aware of nature and frequency of symptoms
 History: since Adolescence
2 Immune system (Priority 2)
 Location: Itching throat and sneezing, runny nose and eyes.
 Onset: Spring season
 Provocation/Palliation: Spring season
 Quality: Constant symptoms of sneezing and irritation in nose and throat
 Radiations: NA
 Severity: NA
 Timing: Spring season
 Understanding: Fully aware of nature and frequency of symptoms
 History: NA, possibly since childhood
3 Impaired Gluten Metabolism and Digestion/Gluten Intolerance (Priority 3)
 Location: Abdomen
 Onset: Since childbirth
 Provocation/Palliation: Consumption of processed and packaged foods like cakes and
biscuits
 Quality: Intermittent symptoms of bloating and flatulence
 Radiations: NA
 Severity: 3
 Timing: Early evening and afternoons
 Understanding: Fully aware of nature and frequency of symptoms
 History: Possibly since childbirth
4 Metabolism (Priority 4)
 Location: NA
 Onset: signs and symptoms of low levels of energy and weight gain after childbirth
 Provocation/Palliation: NA
 Quality: NA
 Radiations: NA
 Severity: NA
 Timing: NA
 Understanding: Fully aware of nature and frequency of symptoms
 History: Was initially fit and healthy during childhood

5 Cardiovascular System and Sensory functions (Priority 5)
 Location: Head and feet
 Onset: Symptoms of cold feet during night, symptoms of headache in the presence
of perfumes and cleaners
 Provocation/Palliation: Upon inhalation of perfumes and cleaners, at night while trying to
sleep
 Quality: Constant
 Radiations: NA
 Severity: 4
 Timing: Night
 Understanding: Fully aware of nature and frequency of symptoms
 History: Since childbirth and weight gain
6 Endocrine/Reproductive system (Priority 6)
 Location: Lower abdomen
 Onset: Since childbirth, recently
 Provocation/Palliation: Since childbirth, Day 1 of period
 Quality: symptoms of clotting and heaviness on day 1, intermittent pain
 Radiations: NA
 Severity: 3
 Timing: Day 1 of periods
 Understanding: Fully aware of nature and frequency of symptoms
 History: Experienced in past, has now resurfaced recently
MEDICATIONS, SUPPLEMENTS AND HERBAL MEDICINES
 Over the counter medications for diarrhea: Unidentified, prescribed previously upon complaints of irritable
bowel syndrome
 Zyrtec: 10mg, daily, for management of allergic symptoms of Hay fever
 Menstrual Pain: Panadol, Nurofen every month, dosage and frequency unidentified.

CURRENT PATHOLOGY RESULTS/ RECENT RESULTS
2 months ago, general practitioner upon complaints of irritable bowel syndrome
symptoms
Reported intolerances to packaged and processed foods like biscuits and cakes,
possible allergies to dust, pollen and spores during spring due to Hay fever
PERSONAL MEDICAL HISTORY (major or recurring conditions)
Birth – 5 years None
6 – 11 years None
12 – 17 years Onset of Irritable Bowel Syndrome, Hay fever, Dysmenorrhea
Adulthood After childbirth: weight gain, resurfacing or irritable bowel syndrome, intolerance
of packaged and processed food, Hay fever, resurfacing of dysmenorrhea,
excessive weight gain, low levels of energy, hypothermia at night, headaches in
response to perfumes and cleaners.
Overseas travel
(List location & date)
None
Last medical
check up
Allergies or
Intolerances
Paternal Siblings
Father: GF: GF:
GM: GM:
Uncles, aunts, cousins: Other:Uncles, aunts, cousins:
Mother:
Maternal
FAMILY HISTORY
Brother: lactose
intolerant,
Sister: Asthma
Niece: Frequent
diarrhea
OverweightGastritis

LIFESTYLE FACTORS:
Physical Activity Type, Duration, Frequency, Incidental
 Type: Aerobic exercise, power walks
 Duration: 45 minutes, 3 to 4 times a week
 Frequency: Daily in the evening, 3 to 4 times a week
Energy Levels x/10, vitality, best and worst time of day, consistency
 Low levels of energy throughout the day after childbirth, especially before exercise.
 Consistency: Daily, 3/10
Sleep Hrs, quality, quantity, waking times etc
 Hours: 8 hours,
 Waking times and quality: frequent disturbances due to hypothermia
Social and Lifestyle Factors
Relationships, occupation, chemical exposure, moods (x/10), hobbies, interests
 Hobbies and interests: wishes to resume kindergarten teaching
 Occupation: Homemaker since childbirth
 Mood: 5/10
 Chemical exposure: Headache in response to perfumes and cleaners
 Relationships: Positive relationship with husband and children
Drug Use
Tobacco – cigs/day: NA How long have you been a
smoker?
NA
Recreational drugs (Type and
frequency)
NA

Monday – Friday Weekends
Breakfast
Time: 7
to 7:30
AM
 Toast and jam : two pieces
 Weakly brewed English white tea: 1 cup
 Cereal (Just Right): 2
tablespoons
 Soy milk: 1 bowl
Lunch
Time:
12: 00
PM
Instant noodles or instant tomato soup: 1 bowl
Any fruit: 1 piece
Salad sandwich made with
whole meal bread, lettuce,
carrot, cheese, tomato, ham: 2
sandwiches
Dinner
Time:
7:30
PM
 Pasta with meat or vegetable sauce : 1 plate OR
 Steam vegetables, chicken skewers with rice : 1
plate
Hokkien noodles with
vegetables and chicken: 1 plate
OR
Vegetable pasta, grilled
chicken, avocado and
cucumber salad: 1 plate
Snacks
Time:
5: 00
pm
Chocolate: 1 bar Chocolate: 1 bar
Beverages
(Water,
Coffee, Tea,
Soft drinks,
Juices,
Alcohol)
 Water: 2 to 3 glasses, daily
 White tea: 4 cups, daily
 Alcohol, 3 nights per week, 1 to 2 glasses
 Water: 2 to 3 glasses,
daily
 White tea: 4 cups, daily
 Alcohol, 3 nights per
week, 1 to 2 glasses
Eating out
(Frequency,
Cuisine of
choice)
None
Dietary Analysis - Please record brands, portions and frequency

Food
Cravings or
aversions?
Prefers to cook one pot meals which can be served to the entire family, enjoys chocolate. Has an aversion
towards processed and packaged foods such as biscuits and cakes since they cause bloating and flatulence.
PHYSICAL EXAMINATION
BP Pulse b/m Temp °C Resp. Rate Weight kg Height m BMI kg/m²
100/58 mm/HG NA NA NA 70.5 kg 165 cm 25.9
(Overweight)
Respiratory (wheezing,
crackles): No identified
abnormalities except for spring:
runny eyes and nose, itchy throat
Cardiovascular (rhythm):
Hypotension
Palpation (GIT, Lymph nodes,
Endocrine): No identified abnormalities
except for menstrual pains, abdominal
cramps, hypothermic in legs, headache in
response to perfume and cleaners
Neuro/ Reflex: No identified
abnormalities
Skin (colouration, turgor): Cold and dry to touch
Nails (ridges, spots, capillary return): white spots with vertical ridging
Tongue: Pink, symmetrical, moist, thin coating of white, slight roughness

PART B: REVIEW OF RELEVANT SYSTEMS AND INTERACTION SCHEMATIC
Health
Priority 1:
Primary Health
Concern:
Gastrointesti
nal System:
Irritable Bowel
Syndrome
(IBS) (sign
and
complaints:
abdominal
pain, watery
diarrhea,
stools have
mucous and
are foul
smelling)
1. Disease
Prognosis and
Aetiology: IBS
associated
with
progressive
dysfunction of
innate immune
system,
reduction in T-
cells,
increased
functioning of
pro-
inflammatory
cytokines,
interleukins,
eosinophil,
macrophages,
and toll-like
receptors.
1. Possible
Predisposition/Ca
usative
Pathology: Recent
mucous in stools
– indicative of
recent bacterial
infection
Precipitating
Complaints: Health
Priority 2: Immune
System: Increase
susceptibility to
autoimmune/allergic
reactions like hay
fever (signs:
sneezing, itchy throat
and nose).
2. Causative
lifestyle and
family
factors:
Consumption
of Zyrtec,
prominent
side effects of
diarrhea,
fatigue,
nausea, family
history and
genetic
predisposition
to gastritis
Disease Prognosis:
Immune system and
Gluten Intolerance:
Health Priority 3:
Celiac Disease (Signs:
symptoms of bloating
and flatulence).
2.
Causative/Aggravating
Lifestyle Factors:
Consumption of
packaged food
containing Gluten
3. Disease
Prognosis:
Bacterial
Overgrowth in
small intestine,
aggravation of
IBS
1. Sustaining environmental
factors and family history:
Spring season, pollen (allergen)
inhalation, family asthma history
Precipitating Complaints, Health Priority 4:
Metabolism: Low levels of energy, fatigue,
impaired metabolism, weight gain, obesity
Precipitating Complaints, Health
Priority 6: Endocrine/Reproductive
system: Possible Endometriosis:
Increased incidence of dysmenorrhea
(Signs: painful periods)
4. Causative
disease
aetiology and
prognosis: Zinc
deficiency, low
levels of zinc
(signs: ridged
nails, thickening
of tongue and
decreased
immunity)
6. Causative
lifestyle factors:
Consumption of
Panadol, prominent
side effects of
nausea, diarrhea
and vomiting.
1. Diet and Disease
Prognosis: Tea
Caffeine/Tannins and IBS
and diarrhea contributes to
decreased nutrient
absorption
3. Disease
Prognosis:
Reduce
carbohydrate
metabolism and
increased fat
metabolism
Precipitating Complaints and
Disease Prognosis: Health
Priority 5: Cardiovascular
system and Sensory
Functioning: Impaired blood
circulation to the limbs due to
endothelial plaque and lipid
accumulation resulting in
Peripheral vascular disease,
(Signs: cold feet)
Decreased immunity and blood
vessel dilation (Signs: sensory
intolerance to perfumes and
headaches)
3. Disease prognosis and aetiology:
Increased endothelial plaque formation
due to increased fat metabolism, alcohol
1. Disease
prognosis:
Impaired immunity
1. Disease prognosis:
Increased circulation of pro-
inflammatory cytokines
responsible for pain such as
prostaglandins
6. Causative Dietary Factors and
Medical History: Increased
Oxidative Stress and
Inflammation due to alcohol,
sodium, caffeine consumption
and Traumatic surgery: Two
Caesarian sections during
childbirth
6. Disease prognosis: Increased
blood loss due to excessive loss of
uterine lining after C section
surgery.
4. Disease Prognosis:
Obesity induced
estrogen imbalance
and increase in
prostaglandins
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