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Male 54 PC: Gallstones, fatty liver disease, overweight, high…
Male 54 PC: Gallstones, fatty liver disease, overweight, high cholesterol, high BP.
Family
Married
2 kids
Family history: anxiety, migraines,
hypertension,
CVD,
hypertension
, IBS, bowel cancer, cirrhosis, stroke, lung cancer, gallstones,
hypertension
, stroke.
Health history
Caesarean birth, breast fed, Full set of vaccinations, Food introduced at 4 months old, Appendectomy age 14, started drinking at 16 y.o, insmonia and anxiety
N.S
Lack of physical activity
Insomnia
Gallstone pain
Nocturia
High stress work
sales executive
frequent headaches
Hepatic
Recent diagnosis of
gallstones
Stools:2-3/day Loose,
yellow and foul smelling
Fatty liver disease
Alcohol consumption.
Immune
Past smoker
2-3 colds per year
Reproductive
Occasional erectile dysfunctional
Mild prostate enlargement
Urinary
Nocturia, difficulty starting and driblling (prostate)
Diet
Low in protein
Alcohol consumption
High sugar
Low in Omega 3's
Physical examination
High BP- 141/87
75bpm
BMI 32.2 (In Obese range)
Tongue: beefy, teeth marks, central crack, white/yellow coating.
Nails: Vertical ridging, brittle and break easily.
Skin: Ruddy, Yellowish
GIT
Heartburn and reflux > large meals and beer.
Stools: 2-3 times daily, loose, yellow and foul smelling.
Abdominal pain and nausea > fatty meals and alcohol
Circulatory
Cold hands and feet
occasional intermittent claudication
Erectile dysfunction.