Patient Info (From Holly)

[bwoeller]

56 yo man with longstanding sleep initiation problems. Relies on Ambien for sleep. Also experiences ‘jolts’ when sleeping.
Main complaint: Anxiety
Dx ulcerative colitis about 20 years ago.
Depression mild for years, escalated with recent changes

prescriptions:
Cymbalta (was on Paxil before for 20 years) starting this morning
Crestor: couple of years
Aprezo for UC since 3mo.
Ambien: 4 years
Horazant: for leg jolts, gabapentin

OATs and 401H unremarkable except for enterobacter?
Any advice beyond treat for dysbiosis and nutrient support as outlined in interpretive guide?

[Holly]

(labs for the above patient attached)

[DrWoeller]

Holly,
His Phosphoric is very low which often coincides with low Vitamin D. I would look to put him on Vitamin D3 supplementation.

His B6 and Vitamin C are low, as is the 5-HIAA. Take a look at the Neuroserene product from New Beginnings Nutritionals under the Mental Health section.

Also, if you can, I would recommend performing a salivary adrenal profile too.

Dr. Woeller

[Holly]

He is currently taking 1,000IU vitamin D/day, and has been for quite some time. I was wondering if the continued low value could be due to malabsorption? If so, would you consider a food antigen panel?

This patient has been also seeing a chiropractor who ordered an ASI at the same time the OATs/GI Path,. I’m interested in why you recommend that though- surly he’s adrenally stressed from being in the state he has been for the past 20 years. What would you expect to see in the ASi that would change your clinical steps?

Thank you!

h

[DrWoeller]

Holly,
Low adrenal function can cause and/or exacerbate anxiety, depression and sleeping problems. For this individual these seem to be the most concerning issues, as well as Ulcerative Colitis.

Sincerely,
Dr. Woeller

[Holly]

Thanks!

[Author]

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