Nutrional Services

Nutritional Consultation - Injury Recovery/Prevention

October 30, 2003

Dear___________:

__________ was seen on October 30, 2003, for a nutritional consultation. She was a mentally alert, cooperative female, 18 years of age. She required crutches to ambulate and her right foot was bandaged. She was accompanied by her mother.

REASON FOR CONSULTATION: Improve athletic performance including the reduction and/or prevention of injuries.

CURRENT MEDICAL COMPLAINTS:

Right ankle pain.
Right foot pain.

PAST MEDICAL HISTORY: The patient's past medical history is void of any automobile accidents. On July 3, 2003, while playing volleyball, she had a severe sprain of her right ankle and a small fracture of her talus bone. On October 15, 2003, she had surgery on her right ankle. In 2002 the patient contracted viral meningitis. She has a history of sinus infections that are described by both her and her mother as chronic and seem to generally present during the months of September and January every year for as long as they can remember. Menarche began at the age of 16 but she only has 2 or 3 periods per year. Furthermore, when they do present, Ms. _______ and her mother describe the flow as extremely hemorrhagic. In 2001, under the care of her gynecologist, she attempted the use of oral contraceptives to solve this problem, but had a severe reaction to the medicine including nausea, vomiting, and weight gain. Her sinus infections escalated to the point where she was referred to an ear, nose, and throat specialist who, based on her history, advised allergy testing. However, shortly after her consultation she contracted meningitis and, therefore, has not followed through with his recommendation.

LIFESTYLE: Ms. ________ denies the use of tobacco and alcohol. Her caffeine intake consists of 2 or 3 servings of Diet Coke per week. When I asked her about her sleep, she states that since her injury in July she has had sleeping problems. She is unable to fall asleep until 4 o'clock in the morning. Although she will sleep until 10 or 10:30, she will awaken 1 or 2 times every night. She further states that she averages 2 or 3 45 minute naps daily.

EXERCISE: She is currently unable to exercise.

MEDICATIONS: Current medications include Darvocet and Percocet.

HISTORY OF CURRENT PROBLEM:

As previously mentioned, on July 3, 2003, while playing volleyball, she suffered a severe injury to her right ankle resulting in a fracture and torn ligaments. She underwent rehabilitation under the management of you, orthopedist ________, and a physical therapist. On September 15, 2003, she was cleared to resume volleyball. She also started school at that time. Three weeks later, on October 8th, during the second match of a volleyball game, upon landing her ankle locked up, causing her to fall, injuring both her right knee and right ankle. An MRI revealed a small tear in the meniscus of her right knee. Due to the fact that her ankle failed so soon into her season, it was decided that surgical correction was required and, on October 15, 2003, she had an operation on her right ankle performed by orthopedic surgeon Warren Kramer.
As previously mentioned, her sleep dysfunction began after her July 3, 2003, injury. She states that after her injury she was unable to fall asleep at night until very late. She was able to function and rehabilitate her ankle with this abnormal sleep pattern throughout the months of July and August. When she started school in September she states that she would not fall asleep until 2 or 3 in the morning. Due to classes, she had to wake up at 6. Thus, in the 3 weeks prior to the second injury she was only getting 3 or 4 hours of sleep per night and, due to classes and volleyball practice, was unable to nap during the day. Further questioning on her sleeping problem revealed that when she is trying to sleep she will experience brief muscle twitches and tremors in her arms and legs consistent with the beginnings of a restless leg syndrome. I then asked her mother if anyone in her family had ever had a thyroid problem. Mrs. _____ answered that there was a very strong family history of thyroid disorders in almost all of the women in their family.

SUPPLEMENTS: Ms. _____ denies taking any kind of vitamin, mineral, herbal, or other supplement.

DIET ANALYSIS:

Breakfast: Six days a week she does not eat breakfast.
One day a week she will have bacon, eggs, and pancakes.

Midmorning Snack: She denies a midmorning snack.

Lunch: Two days a week-bean and cheese burrito with a Diet Coke or water.
Two days a week-one-half of a Subway tuna sandwich (meat and bread only) with water or milk.
Two days a week-2 hard-boiled or poached eggs on 1 piece of whole-wheat toast.
She skips lunch on average of once a week.

Midafternoon Snack: Daily midafternoon snacks tend to go in phases. For the last 2 weeks she has been eating Ritz crackers. Other phases of afternoon snacking will include a Nutrigrain bar, Wheat Thins, Triscuits, or bagels. Two days a week she will have a banana.

Dinner: She denies eating dinner on a regular basis. One to 2 times a month when out with the family she will generally order a chicken and rice dish.

Bedtime Snack and Dessert: She denies bedtime snacks and desserts.

Please note: At this time I repeated her diet to both Ms. _______ and her mother. They reported no other solid food, which troubled me, due to the fact that her food intake was extremely hypocaloric. Further questioning revealed that her milk intake consists of 5 16-ounce glasses of 1% milk daily. This solved the mystery of where her calories were coming from.

IMPRESSION:

Disordered sleeping versus sleep disorder.
Secondary amenorrhea with menorrhagia.
Rule out subclinical hypothyroidism (due to strong family history).
Rule out subclinical iron deficiency anemia (no red meat, no vitamin supplements, heavy bleeding, and early stages of restless leg syndrome).
Rule out hypercalcemia. The amount of milk she consumes yields a calcium intake of approximately 2800 mg per day. This is even higher on the days that she has cheese.
Rule out allergies for seasonal sinusitis.
Nutritional imbalance (diet nearly void of all fruits and vegetables with majority of calories coming from milk, bean and cheese burritos, tuna sandwiches, and crackers).

RECOMMENDATIONS:

Supplements:

Dr.______, I am going to search for a strong multivitamin, multimineral supplement that is either calcium-free or very low in calcium. I do not feel that she will be able to comply with bottles of individual pills, but do feel it is important that she does ingest a nutritional supplement.
We will consider sleep aids only if the following recommendations concerning this problem fail and medical examination does not elicit an organic cause.

Diet:

Keep a diet diary for 1 month.
Try to eat 2 servings of fresh fruit daily. I suggested to Ms. ______ and her mother they try Satsuma mandarins, which are currently in season, for 1 of the servings, with the other rotating in the fruits that she does like, which are bananas, grapes, and cantaloupe.
One salad as a main meal each week consisting of the limited vegetables she will eat, which are broccoli, carrots, spinach, corn, tomatoes, and pinto beans.
Instead of Ritz crackers, Wheat Thins, Goldfish, or Triscuits, try Kashi brand TLC crackers from Trader Joe's. They are made of whole grains and are absent of all hydrogenated oils.
Snack on homemade trail mix consisting of raw nuts and raisins.
Next month, if she is able to follow the above recommendations, we may try to decrease her milk intake.

Sleep:

Discontinue all daytime napping. Attempt "lights out" at midnight.
Before bed, try reading something she finds uninteresting, complex, and boring.
Have a small bedtime snack (4 ounces of milk and 4 or 5 crackers).

Medical: I advised Ms. ______ and her mother to make an appointment with Dr. ______, who is their family doctor, to:

Rule out subclinical hypothyroidism.
Rule out subclinical iron deficiency anemia.
Rule out hypercalcemia.
Undergo allergy testing for seasonal sinusitis.
Rule out an organic cause of sleeping problem.
Inform him about the problems with Ms. ______ periods.
Make a followup appointment with me in 30 days.

Dr. _____, thank you for the referral of this most pleasant young lady. What I thought was going to be an easy, one-hour appointment turned into a rather complex, 90 minute session with a 60 minute followup planned in 30 days. I look forward to continuing to work with you and her other doctors in solving the problems of this young lady. Should you, Ms. ______, her family, or her other physicians have any questions concerning this matter, please do not hesitate to contact me at my office.

Sincerely,

G. Douglas Andersen, DC

GDA/sdm

916 E. Imperial Hwy., Brea, CA 92821 Ph. 714-990-0824 Fax. 714-990-1917

gdandersen@earthlink.net
www.andersEnchiro.com