WHAT TO EXPECT IN AN EVALUATION

At Sanctuary Integrative Medicine, we provide complete and personalized integrative care in partnership with you.  And while science and technology are both important components in our approach, we also understand that the practice of good medicine begins with good listening. The first thing our staff of practitioners will do when meeting with you is listen to you, and learn your unique story. What are your top health concerns at the moment? What does your medical history look like?  Your family history? What is going on in your life at the moment? How are your stress levels? By understanding you as a whole person, rather than simply trying to fix an “isolated” pain or ache, we can better partner with you and assist you in achieving optimal health and well-being.
 
This personalized approach means that every patient's evaluation will be different. Your evaluation may include any of the following:
• a review of your health history and medical records;
• a physical examination;
• diet evaluation;
• nutritional and supplement recommendations;
• treatment recommendations;
• therapeutic lifestyle recommendations;
• referrals to other practitioners
 

SAMPLE EVALUATION - 55-year-old female self referred to Sanctuary Integrative Medicine for a chief concern of joint pain and swelling that limits function. Her initial appointment, at her request, was with a Naturopathic Physician.

History of present condition: Sally was first diagnosed with osteoarthritis 8 years ago, at the age of 47. She had been noticing mild stiffness of her shoulders, right knee, fingers, and right foot (especially in the morning). She saw her primary care physician at the time, and after some blood tests and X-rays (knees, shoulders), was told that she had Degenerative Joint Disease. He recommended that she start taking ibuprofen for the pain. She has gradually increased the dose in order to control her symptoms, and is currently taking 400 mg 3-4 times daily. She notes an increase in the frequency and severity of her joint pains and swelling over the last three years, which prompted a self-referral to a rheumatologist. He confirmed the diagnosis (calling it idiopathic generalized osteoarthritis), and ordered multiple radiographs (x-rays). He added that her shoulder injury is more likely osteoarthritis by exam, as opposed to a rotator cuff injury, which was suggested by her PCP. He offered to perform an intra-articular corticosteroid shoulder injection, but Sally declined, worried about the long-term side effects. She has come to The Integrative Medicine Clinic seeking alternatives to what she views as potentially dangerous interventions.

Patient's concept of condition: Sally believes in the power of "natural" therapies. Following her rheumatology visit, she started taking numerous supplements on the advice of her neighbor, who also has "bad joints." She feels that these were helpful, in terms of increased mobility, with less pain. She stopped a few months ago because of concerns about drug interactions with her prescribed medications.

Goals of visit: To explore natural therapies to improve pain and halt the progression of the condition.

Past medical & surgical history
Hypothyroidism (low thyroid), diagnosed at 35 ; umbilical hernia repair, at 40 ; hysterectomy (fibroids), at 46 ; osteopenia, diagnosed 6 yrs ago by (PCP recommended Fosamax; patient refused); insulin resistance ('pre-diabetes, metabolic syndrome').

Allergies
Medicinal allergies: none
Environmental allergens: none
Food allergens: mild lactose intolerance

Medications
Ibuprofen 400 mg three to four times daily; levo-thyroxine (thyroid)125 mcg daily; baby aspirin 81 mg daily; occasional extra-strength acetaminophen; Zantac OTC almost every day ‘for years’.

Herbs, vitamins and supplements
Multivitamin supplement, calcium, Vitamin D.

Experience with Integrative Medicine:
None

Family medical history:
Mother: osteoarthritis, hypertension, diabetes
Father: hypertension and coronary artery disease

Personal history:
Non-smoker; drinks wine (one glass per week); lives with husband

Social history:
Recently retired from admin secretarial position

Travel history:
No travel outside North America

Lifestyle:
Home environment: stable; married x 32 yrs; no children

Physical activity:
Walks 20 minutes once or twice a week at the mall.

Spirituality:
Sally and her husband practice a fundamentalist Christian faith, and are members of a supportive church community. Many of her friends are from church.

Relaxation:
Reading, television

Sleep:
Overall adequate; she has more trouble falling asleep than staying asleep, and often takes up to an hour to fall asleep; occasional sleep disruption due to joint pains.

High risk behaviors: none

Diet and nutrition:
• Breakfast: 2 scrambled eggs, 3 slices bacon, ½ grapefruit, toast with margarine, 2 cups coffee with flavored cream
• Lunch: half an apple, brie cheese and toasted French bread
• Snack: small piece lemon cake (homemade) w/icing
• Dinner: baked breaded chicken breast, lime jello w/ pear, dessert (mango sorbet), red wine (1 glass)
• Caffeine: coffee 2-3 cups; Earl Grey tea 2 cups
• Vegetables: 1 servings veggies; occas fruit
• Snacks: some crackers and chips with cheese
• Water: 1/2 glasses/day

Relevant review of systems:
Occasional tension headaches; multiple actinic keratoses (age spots)on face; episodic reflux symptoms (heartburn) with no associated cardiac symptoms; no association with activity; prompt relief with antacids. Mild depression, especially in winter months.

Physical exam:
• VS: Blood pressure 148/88, Heart Rate 82, Respiratory Rate 16, weight 178 pounds (78 kg), height 65 inches (165 cm), Body Mass Index 27.1 (overweight)
• Musculoskeletal: mild swelling in right dominant shoulder joint without redness, tenderness, warmth; normal strength without pain on effort, but somewhat limited extension compared to left shoulder
• Hands: hard tissue enlargement at 1st metacarpal joints (knuckles) bilaterally; mild 2nd and 3rd finger swelling bilaterally.
• Knees: bilateral moderate effusions (swelling) (right greater than left), range of motion limited, general tenderness, but no erythema (redness) or warmth
• Spine: normal spine posture, alignment, mobility
• Hips: asymptomatic and within normal limits
• Skin and nails: skin slightly dry, nails with ridges and white spots.
• Slightly antalgic (painful) gait

Labs:
Initial labs showed no evidence of a more severe destructive arthritis, such as Rheumatoid Arthritis. Also, labs were suggestive of early metabolic syndrome, with elevated insulin, glucose, and cholesterol levels.

Radiology: reports describe features of osteoarthritis.

Other information:
Her primary care physician provided records to document currency with routine health screenings, such as mammography, colonoscopy, and gynecology exams.

Assessment - medical:
• Osteoarthritis
• Osteopenia- thinning of bone
• Hypothyroidism- low thyroid
• Sleep issues, secondary to pain
• Possible GERD (gastroesophageal reflux disease-‘heartburn’)
• Hyperglycemia /Early metabolic syndrome- ‘prediabetes’
• Possible Seasonal Affective Disorder versus Depression

Progress in the Integrative Medicine Clinic:
Sally had always had a fascination with Traditional Chinese Medicine/acupuncture, and wished to try this modality first, as she had promised herself that she wanted, if possible, to get off all the medications she was taking for pain, and had heard from her sister in California that acupuncture really works for osteoarthritis.

Sally had a TCM (Traditional Chinese Medicine) evaluation which provided a diagnosis of Liver Qi and Blood Stagnation with an underlying Kidney deficiency and weekly acupuncture sessions were initiated, along with Chinese herbs to reduce inflammation, with significant reduction in joint pain and swelling in just 2 weeks. She was able to gradually reduce her reliance on Ibuprofen to 1 or two doses every other day in just one month. Her sleep improved dramatically.

Assessment:
Traditional Chinese Medicine diagnosis: Liver Qi and Blood Stagnation with underlying Kidney deficiency.

Because of concerns about Sally’s continuing heartburn, despite reducing the ibuprofen (which is a common cause of heartburn) the TCM (traditional Chinese Medicine) practitioner brought her case to the Integrative Medicine group rounds for review and further suggestions. As a result of that input, a Functional Medicine work-up was undertaken which revealed gluten sensitivity as a likely contributor. It also revealed a vitamin B12 deficiency, likely caused by the long term use of acid lowering drugs, such as Zantac. A vitamin D level was low, despite the history of vitamin D supplementation.

A referral back to the Naturopathic physician resulted in recommendations for elimination of gluten, replacement of low nutrient/high calorie foods with high quality proteins and carbohydrates, multiple servings of fruits and vegetable per day, reduction of caffeine to one cup of green tea per day, all of which resolved not only the heartburn, but resulted in just 3 months to lower her body mass index to 24, and normalize her insulin and glucose values, effectively eliminating further risk of developing diabetes. Fish oil was started. Careful supplementation with Vitamin B12 replacement was undertaken for 6 months until values became normal. Further, supplementation with vitamin D in therapeutic doses was likely responsible in part for relieving her seasonal depression symptoms. At some point along the way, her headaches disappeared.

Sally continued with her acupuncture sessions for several months, and because she was feeling less pain, she was encouraged to exercise and stretch more. She increased her walking to four times per week for 45 minutes, and convinced her husband to take a beginners swing dance class with her. Her arthritis has become quiet, but when she ‘strays’ from her gluten free diet for just a day or two, she feels it, in her gut and her joints.

Summary of case:
Integrative medicine is uniquely positioned to assist people with arthritis. Yet, rheumatology has been more resistant than other medical specialties to Integrative Medicine. This is unfortunate because rheumatological diseases are uniquely responsive to integrative treatment; conventional treatments are suppressive and toxic rather than curative; mind/body interactions are obvious in these conditions; and patient demand for other forms of therapy is very strong. Reflecting the role that lifestyle choices may have in rheumatologic conditions, we often recommend such simple interventions as suggesting that patients increase their intake of fruits & vegetables (as sources of phytonutrients and antioxidants), or add more Omega-3 fatty acid foods or supplements in order to decrease inflammation. Properly chosen and performed exercises can provide therapeutic benefits, and mind-body techniques have been shown to decrease the pain of rheumatoid arthritis. People with arthritis can explore Chinese medicine for pain relief or consider bodywork for improving range of motion of restricted joints. And the judicious and appropriate use of pharmaceuticals can provide pain relief to allow individuals to engage in activities that benefit their whole being. This "integrated" approach to rheumatologic conditions provides the best opportunity for people with arthritis to learn to manage their conditions and enjoy life more fully.