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.