Case Study:
Jacob is a 15-year old male who comes to the clinic for an integrative consult for his GERD.
He says that he’s had multiple daily stomachaches since he was little. His mother explains
he was a “fussy” baby and diagnosed with GERD at 3 months of age and was started on
Zantac. She was breastfeeding but her pediatrician took him off breast milk and put him on
a hypoallergenic formula. She reported minimal improvement, so he was referred to
multiple GI physicians. After multiple tests, all of which were normal, including an
abdominal ultrasound upper GI, and barium enema, he was switched to Prilosec then
Prevacid, without improvement. Eventually, mom was told he was just fussy and she would
have to deal with it. However, with increasing age, his symptoms worsened. He has seen
multiple physicians who have continued him on acid blockers and 2 years ago, did and
exploratory laparotomy that found nothing. He reports he has daily stomachaches that feel
like he is “being punched in the stomach” associated with nausea. Episodes last
approximately 1 hour. The pain is colicky in nature, 8/10 on a pediatric pain scale, and has
no obvious pattern or associations with time of day, foods or activity. The discomfort
prevents him from doing most extracurricular activities and wakes him occasionally at
times from sleep. He’s had normal growth and there have not been fevers, diarrhea, bloody
urine or rash.
Past Medical History
Born full-term C- section for failure to progress after uncomplicated pregnancy. Mom was
15 years old at time of birth, P1G1.
GERD- has tried Zantac, Prilosec and Prevacid, elimination diet tried for short periods of
time without any improvement.
Constipation- takes 17 gm of Miralax daily to achieve 1 BM daily described as “pebbles”
ADHD- diagnosed in kindergarten, has been on multiple medications (Ritalin, Adderall,
Strattera, now on Concerta) with modest improvement
Headaches – has tension headaches 1-2 times per week, takes ibuprofen PRN, since age 11.
Eye exam normal
Social History:
Born to an unwed teen mother who cared for him without family assistance after being
kicked out of the house. Residence in a shelter allowed her to finish high school and is now
married and in a stable home. He does not like to discuss his time living in the shelter. He
has 2 half siblings, brother age 7, sister age 4. He gets along well with stepfather who he
addresses by his first name. He attends school and gets average grades. He likes sports but
cannot play due to chronic abdominal pain. He does not see or know his biological father.
His closest friend was a similar aged cousin who he had been close to for the majority of his
life, recently lost cousin to heroin drug overdose. He denies any drug, alcohol abuse. Not
sexually active and denies any sexual trauma.
Family History:
Paternal family history unknown. Maternal family significant for colon cancer in maternal
grandfather and maternal migraines managed with Imitrex.
Medications:
Prevacid 30 mg, Motrin 400-600 mg as needed (but admits to using it at least 1 x day)
Concerta 54 mg per day, Miralax 17 gms per day
Allergies: NKDA
Surgeries: Exploratory Laparotomy at age 13.
Hospitalizations: None
Immunizations: UTD
Travel: Never left the continental US.
Nutritional History:
Jacob reports he mainly eats a processed carbohydrate diet. He routinely skips breakfast
and eats lunch at the cafeteria at school. Dinner is usually whatever mom cooks, mainly
pasta and meat and potatoes. They eat fast food 2 nights per week with minimal fruit and
vegetable intake.
Sleep:
Jacob reports difficulty getting to sleep most nights and sleeps with the TV on in his room.
He often wakes at least once usually between 2 and 3 am. Denies nightmares. He does not
wake feeling rested.
Spirituality/Religion: doesn’t feel “connected” to any religion or spiritual path. When asked
what was important to him, he said ‘my mom.’
Physical Exam
Weight 114 lbs Height 5’ 4” normal BMI pulse 80 RR 18
General: Pale but well formed/well groomed, poor eye contact; answering only direct
questions
HEENT: tympanic membranes clear, pharynx clear, no halitosis, no rhinorrhea
Neck: No lymphadenopathy, no thyroid abnormalities
CV: regular rate and rhythm, no murmur
Resp: clear to auscultation bilaterally
Abdomen: mild tenderness below xyphoid process, very active bowel sounds + mild
distention and increased tympany, no hepatosplenomegaly
GU: Tanner stage 4, bilateral descended testes
Extremities: good peripheral pulses
Derm: No rashes, birthmarks
Psych: paucity of speech, poor eye contact, good judgment and insight on his current
medical situation, depressed mood. No hallucinations or suicidal thoughts.
Lab: CBC, CHEM20, stool culture, urinalysis and lipids all normal
Kidney-urinary-bladder X-ray showed retained stool but normal anatomy
25-OH vitamin D level -18 ng/ml, ferritin 30
Celiac screen normal H. pylori negative
Assessment: 15-year old male with lifelong history of abdominal pain. Additional concerns
constipation, insomnia, headaches, ADHD and possible depression.
Questions:
1. What are you thinking when you read this case? What stands out?
2. We’re working on the GI section, so don’t focus too much on ADHD and headaches
but beware of the possible connections between these systems, particularly when
thinking of your formulations.
3. Make a list of Jacob’s problems.
4. For each problem, write down a couple of thoughts and ideas as far as treatment
approaches.
5. Are there any dietary changes or supplements that you would want to recommend?
Mind-body-relaxation-energy practices? Social support? Exercise? Counseling?
6. For each of Jacob’s problems, make a list of the ACTIONS you would consider when
choosing an herbal approach.
7. When you look at the herbal actions, begin to write down herbs that would fit into
these categories and look for areas of overlap. You want to find the herbs that are
most appropriate for Jacob – narrowing the number.
8. Once you have a list of herbs, think of those that might be best as a tea, in tincture,
glycerite or as a standardized extract.
9. Now create your formulation. Use your Materia Medica chart under Herbal
Preparations to look for daily and weekly maximums for your herbs. Create a dose
for Jacob and instructions for taking the formulas.
10. Summarize your recommendations in a proposed treatment plan. Remember, I want
to understand how you came up with your formulations and herbal
recommendations. I want to see your thought process.