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WELLNESS CASE STUDY

“The purpose of this example case study is: – To give you an idea of which type of information I would write up before creating an interpretation of the facts. Then I would offer you a wellness plan to help bring you into balance.”

Vanessa Poolian, Director of Bluebell Coaching and Consultancy.

CASE STUDY EXAMPLE- JENNY RICE

Place of birth, West Midlands and lives in Bristol.

The three health issues she would like to work on:-

1        Reducing the size of her fibroid

2        Overactive thyroid

3        Increasing energy levels

 

ROUGH NOTES:-

Her daily routine

Jenny is a Project Manager for a Software Management Company and straight away mentioned that she is micromanaged by her boss. She takes on a lot of stress from others as they see her as the go-to person for any issues that they may have. Overall she does not mind her work. She tends to eat microwaved meals for lunch and a selection of paninis or leftover lunch which varies. Usually it is pizza or sandwiches.

Physical Description

She is average height and build, has good skin and wears a grey top, blue jeans , black shoes. Her favourite colours are blue and purple. These are top two chakras of the body’s energy system.

Energy

Feels tired in the morning but energy levels vary throughout the day. Feels she needs to stay up later because her partner who is not working at the moment wants to spend time with her in the evenings. She had radioiodine therapy and found this has added to her fatigue and her muscles have become more relaxed in her legs and bottom. Both of her legs have had cramps when she travels on the bus. She finds that stretching it resolves the problem. Feeling a bit more emotionally sensitive at the moment.

Motivation

Although Jenny enjoys the work she does, she would prefer to be dancing as that is her passion. Her dream would be to run a dance and recording studio in one. (I can offer her career and life coaching as part of my business). She does not believe she can achieve this at her stage of life. She is also interested in nutrition (referred her to the Nutritional Healing Foundation)

Concentration and memory

She feels she has an average level of concentration but sometimes forgets conversations she has had. Believe this could be linked to thyroid problems.

Sleep

She usually gets up very early around 6-6.30am and very tired but has to wake up early so she does not rush her mornings. She is going to sleep at 12am mainly on Fridays as she has the weekend to relax a bit more.

Head

When the radioiodine treatment was conducted in August she had more headaches but ok now.

Back

She pulled her back last year and did this by lifting a heavy sofa. Around that time she started temping in a new job.

Nose

Left nostril is more open than right.

Ears 

Burst ear drum last year. Slightly deaf in that ear.

Hair

Loss from thyroid and hair was falling out. After the radio-iodine treatment so hair loss.

Skin

Eczema when little.

Urination

If cold she goes more and depends on how much she drinks. If she is on her period she goes more. About five times a day. Most of the time it’s a normal yellow.

Digestion

1-2 time per day after breakfast and in the evening. Stools come out clean she mentioned. Normal brown unless eaten some “beige” food. Some bloating when needing to go but not ready to pass when fibroids are playing up.

Menstruation

Bloating.  She was 10 when she started. Heavy periods but less than longer. 6-7 days and not like before which was 10-12.

 

Past History

Birth

Mum was 39 when she gave birth and was the last child. 11 years difference between her and next sibling.  Her mum went through post-natal depression. Dad did was not a good husband and was cheating on her mother. Her mother tried to divorce him once but he did not want to. They are still together. Her mother mentioned that she was a Caesarean and she was 9lb.  Breast fed.

Infancy

6-10 Vaccine for chicken pox.

10-11 Antibiotics for a fungal infection under the bottom lip.

12-13 Sat in front of fireplace and the heat made her legs itch and would put vaseline on it.

13 -18 met a guy, he was funny and made her laugh but always wanted to borrow money.

11-18 Had BCG at the age of 13 and TB which hurt for a week. Knocked teeth at nursery then added false teeth. She was not happy (puberty) as her mum was going through menopause and she was going through puberty. Mum and dad would argue a lot so not good. Felt stressed and periods would last longer at those times when they would argue.

Her mother would say “you are eating me out of house and home” so there was a guilt associated with that statement. Would go food shopping with her friend, with their pocket money. Mum expected her to go to functions with her. All brothers and sisters had left by the age of 13.

Enjoyed school as saw friends there. Head praefect at school so respected a lot. School was ok and everyone seem to get on. Kids there drank but she never got into it. Racism from some of the kids at school but did not get bullied as she was taller and stronger than the rest of the kids.

16-18 College time.  Mum did not want her to be choreographer. Mum was a cleaner and was a welder and made cake decorations. Dad was a factory worker, nuts and bolts. Parents had to work a lot. She was independent and cooked for the family. Did allow video production. Enjoyed it but thought there would be too much competition. No health issues. Visited sister a lot from 14 to 18 and looked after her niece.

18 -24 Started seeing a guy and got engaged at 21. Went to London to live with him. Dated 2 years and was looking after boyfriend, who had depression, after they split. He slit his wrist and tried to jump out a window. New boyfriend helped. New boyfriend later moved in with her.

24-31 Moved to Bristol and very content here but her fibroid started to inflame. Going to doctors and they mentioned to have a hysterectomy. Some doctors mentioned she could not have children and she did not want a hysterectomy. Tried different tablets and 3 keyhole surgeries. Has a miscarriage (painful) when 27 but unsure how long. Maybe weeks. Emotionally heavy time and doctors were unsympathetic. Did dance at 26 and was a 2 year course and really enjoyed it.

31 until today. Wisdom teeth, a growth spurt, wisdom teeth are attached and catching a little still. Could not be removed. Still dealing with fibroids at 32 but had an operation called a myomectomy to reduce the size of the fibroid. Her boss paid for her to go private. She was off in June 2012 for a few months. Feeling weak, tired and pain if she moved. 2014 she was 34 the fibroid had grown and she had 4-6 fibroids in there and had a Caesarian operation and there were many fibroids in there. Took out the largest fibroids and went up 3 dress sizes. The doctor mentioned the fibroid was 4 centimetres but the radiologist mentioned it was the size of her hand. She was confused what it really was and mother came to help. Had to rest as much as possible. Ate plenty of fibre and vegetables as well as meat and felt she ate better.

Thyroid issues in 2012. Hyperthyroidism and did not lose weight and went back to normal. Was given thyroid medication. Arms and hands were shaking and went to the doctor and then they did a blood test. In 2014, she was very tired and started to get palpitations again. Given carbimazole for the thyroid and propanolol – Beta blocker for the shaking and palpitations. In 2015 the thyroid levels had increased. Started to take tablets more regularly. Then it was not going down so needed radio-iodine treatment. Delayed the treatment as she started working in her current job so had it in April/May 2018. Thyroid levels had fluctuated between 40 and 60TSH but are currently:-

Level – 0.02 mIU/L

Serum Free T4 Level –  22.7pmol/L

Serum Free T3 Level – 7.5 pmol/L

In August she felt exhausted and hair was falling out. Head was woozy and just wanted to sleep. Found it difficult to breathe and walk and heart was in pain. This was due to the increased thyroid levels (Serum Free T4 Level – 100+ pmol/L), following the radioiodine treatment.  Started to feel better when prescribed tablets but still feels a bit tired.

Allergies – shellfish and mould/damp conditions.

 

Family History

Mother – She has underactive thyroid, high blood pressure. Sisters have thyroid issues and nephew had his thyroid taken out (overactive). Her sister had radioiodine (only for when overactive) and had it 15 years back and now is underactive.  Mother is 78. You could tell if she was sad and upset. She would not hide her emotions.

Dad – Has Type 2 diabetes. Diagnosed 6 years ago. He is 83. Loves to take Epsom salts. He had a few affairs and moved out when she was 7 but then came back. Father has lump on back of neck.

PGF – died at sea, Cause unknown.

PGM  – died of old age but was told she “went senile” before death.

MGF – died of stomach cancer.

PGF – she went to hospital for a minor operation in her vaginal region but then died of cardiac arrest and apparently the doctor was drunk.

Diet

Breakfast – Normally eats cereal with a piece of wholemeal toast or pitta with water or juice. Cereal can be the following:-

  • Bran flakes
  • Shreddies
  • Crunchy Nut Cornflakes
  • Ready Brek
  • Fruit n’ Fibre

Has the above with standard hot milk, apart from the Fruit n’ Fibre.

If she has time at the weekend, sometimes she will have scrambled eggs on toast with honey or beans on toast with tomatoes and mushrooms, with cheese on top. That is her treat. But if not, then its cereal and toast.

Normally has a sip of water before breakfast.

Lunch – any of the following:-

  • A sandwich from either Subway or Sainsburys or somewhere else.
  • Chicken panini
  • Soup
  • Chips
  • Vegetable sausage roll
  • Tart
  • Rice box from Baobun. Normally rice with chicken and tofu.

Dinner – any of the following:-

  • Chicken enchiladas with Mexican rice
  • Some form of Indian curry with either chicken or turkey
  • Turkey with veg
  • Vege mince and veg in tomato sauce with either pasta, rice or potatoes
  • Pasta and veg in tomato sauce (tinned) with cheese on top
  • Beans on toast with tomatoes and mushrooms with cheese on top
  • A cheese and salad sandwich (mild cheddar)
  • Cereal
  • Tofu with pak choi

Sometimes eats pizza or Chinese food. Also sometimes rice with veg and tofu and a side order of salt and pepper chicken wings or ribs.

 

Interpretation

It appears that Jenny has been through a huge amount of stress with regards to mind and body in her life but has not really found the opportunity to really reflect on the impact of it. On an emotional level she had to witness an unstable marriage of her parents and the mistreatment of her mother from her father. As she has “a get on with it” type attitude she is a very “hands on” and independent lady but her parents rely on her support.

It seems that lots of people rely on her for different types of support. At work for their issues, her partner for financial reasons and her family for assistance. This can put a lot of strain on an individual and some boundary work would be needed.

With regards to diet, Jenny eats a diet high in carbohydrates and many pre-prepared meals so will need to look at incorporating more natural, fresh foods into her diet as this would help increase concentration levels and enable her to focus more easily. This naturally leads onto creating balance in life and she may find that she would take on less tasks and focus on the ones that she enjoys.

The body has been and is currently acidic therefore miscarriage happens due to a high acidity in the body. Past medication may have added to toxicity in the system in the vaginal area and also possibly adding to thyroid and fibroid issues. Adding to the toxicity is the behaviour of her father and mistreating her mother.

As the body requires omega 3, 6 and 9 for the central nervous system so she may be low in essential fatty acids to produce prostaglandins. These are tissue hormones that feed the brain from her diet and the dehydration levels could explain why she is forgetting information and can affect mood.

Wellness Plan

As parents’ health issues are a reflection of issues that could be experiences, her father with diabetes and mother with thyroid issues, it is important that Jenny eats more freshly prepared foods and less “beige” coloured food. Her diet consists of high amounts of sugar and this is not the obvious type of sugar as it would be present in eating bread and lunch meals.

Therefore, if we can reduce these foods then there is less chance of her developing diabetes for the future. To substitute sugar there are other options such as yacon or stevia. As she has previously had fungus on her bottom lip, there may be some Candida albicans still present in the system and usually develops after a course of antibiotics. Stevia does not react to Candida albicans whereas other sugars do not discriminate and the Candida can feed off them and also does not contribute to tooth decay.

It is very clear that Jenny needs to drink more pure, clean water in her diet. She consumes liquids through other means but its is important that she drinks a pint of water around 30 minutes before each meal, three times a day and first thing in the morning and last thing at night to ensure that she is fully hydrated. I would suggest investing in a good water filter at home or top up from the water filter at work then bring home the water.

As mentioned in other case studies, none of my clients so far would consider doing enemas and they are not comfortable with the idea, so I have to respect their wishes. However, they would be fine to do a castor oil pack so this would be the next best alternative to draw out toxins from the liver.

NOTE:-This can be done once she has increased hydration levels.

Eczema from childhood is usually a manifestation of anger and as anger is stored in the liver it would be good idea to detox the liver in this way. It would be surprising if there is some repressed anger which may manifest itself when she is ready. I have explained to her how she can use a castor oil pack.

The cramping she experiences could be due to a lack of potassium therefore eating more potatoes could help and have also sent her a potassium soup recipe.

A typical meal she could consume throughout the day would be:-

Breakfast – gluten free oats, blueberries, chia seeds and a teaspoon of maca powder with water and almond milk. Blueberries are an antioxidant that remove free radicals from the body and therefore allow the immune system to strengthen itself. The maca powder is immune boosting and provides energy in the mornings and is quite potent.

Lunch – Vegetable soup (carrots, onions, sweet potato, potato as examples)with sourdough bread to fill her up. Soups are easily digested therefore easier on the intestines.

Dinner – Spiced wild salmon with quinoa and peas and spinach/kale (the iodine in these vegetables is beneficial for the thyroid)

I would also recommend Magnesium oil spray to assist in quality sleep and Pukka night time tea so she has quality sleep and does not wake up feeling tired in the mornings.

For the fibroid, it is important to incorporate anti-inflammatory foods such as turmeric, ginger and also adaptogens such as Ashwagandha and Rhodiola to boost the immune system.

Since our meetings she mentioned that she goes to the gym,so it is beneficial for her to continue that but perhaps incorporate some dance as part of her exercise routine as she enjoys dancing very much.

The palpitations can be reduced via meditation. I can send her some you tube links which helps as Jenny likes to listen to music. I find that anyone with a musical ear is more attuned to meditation or sound healing videos than just spoken meditation.

As Jenny is overwhelmed with a lot of tasks to do in her life, I have kept the wellness plan simple as she requested so she is able to take more manageable steps to improve her health.

Disclaimer :- This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or GP/doctor with any questions you may have regarding a medical condition.