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At the heart of medicine lies the individual and each
patient’s unique story…
At the heart of medicine lies the individual and each
patient’s unique story…
That Story Is Typically Told As…
Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) Family History (FH) Dietary History Supplement and Medication History Lifestyle, Social, and Exercise History Physical Exam Findings Laboratory Evaluation
In conventional medicine, the aim is to arrive quickly at the diagnosis
This emphasis on diagnosis is particularly critical in the acute care setting; rapid diagnosis leads to rapid treatment
Treatment in this setting must be prompt, as it is often designed to “lock down” and control physiology
The chief complaint and history of the present illness become the critical aspects of the story; the rest of the patient’s story is truncated when other information is seen as superfluous to reaching the diagnosis
In acute care, the patient’s story is
squeezed down to the chief complaint and history of the
present illness
while the
diagnosis increases in importance.
Example #1Chief Complaint:
Wheezing
Diagnosis:Asthma Attack
bronchodilators corticosteroids
tightness in the chest
sudden onset
asthmatic history
shortness of breath
History of Present Illness
Example #2Chief Complaint:
Chest Pain
Diagnosis:Heart Attack
angioplasty thrombolytics
sweating
arm numbness
shortness of breath
History of Present Illness
The clinician proceeds directly to the diagnosis –naming the disease – in order to identify as quickly as possible a medication to treat that disease
THE RESULTS: Little attention is paid to the patient’s story beyond
the chief complaint and history of the present illness
The patient’s whole story is not understood Each complaint becomes a discrete issue,
dealt with in isolation from the others
Problems arise when the acute-care model is used to address chronic long-term health issues
Hypercholest-
erolemia
Statin
Gastroesophageal
Reflux Disease
H2 blocker
Depression
SSRI
HypertensionACE
inhibitorMigraines Triptan
Osteoarthritis
NSAID
Irritable Bowel Syndrome
Dicyclomine
…the result is a focus on treating each symptom complex
as a separate and distinct “disease” with a separate and
distinct treatment.
Hypercholest-
erolemia
Statin
Gastroesophageal
Reflux Disease
H2 blocker
Depression
SSRI
HypertensionACE
inhibitorMigraines Triptan
Osteoarthritis
NSAID
Irritable Bowel Syndrome
Dicyclomine
Each individual diagnosis becomes a
distinct entity unto itself. The patient’s whole storynever has a chance to be
heard and understoodIn context.
It is apparent that – in its rush to diagnose – conventional medicine is focused on the branches and leaves of the tree, and not the trunk and roots.
Cardiology Pulmonary
Endocrinology
Gastroenterology
Neurology
Organ System Diagnosis
Urology/Nephrology
Hepatology
AllergySigns and Symptoms
Fundamental Clinical Imbalances Hormonal and Neurotransmitter Imbalances
Redox Imbalance + Oxidative Stress + MitochondropathyDetox/Biotransformation/Excretory Imbalance
Immune ImbalanceInflammatory Imbalance
Digestive/Absorptive and Microbiological ImbalanceStructural Integrity Imbalance
1. Communication- Outside the cell- Inside the cell
Mind and Spirit
Genetic PredispositionExperiences, Attitudes, Beliefs
Psycho-socialPhysical Exercise
TraumaDiet, Nutrients,
Air/Water
Xenobiotics Micro-organisms
RadiationEnvironmental Inputs
2. Bioenergetics/Energy Transformation3. Replication/Repair/Maintenance/
Structural Integrity
4. Elimination of Waste5. Protection/Defense6. Transport/Circulation
Fundamental Physiological Processes
Functional medicine should not be viewed as an alternative, but as a bridge to a more
effective chronic-care model.
??? Where does the symptom come from? That is, what are the antecedents and triggers?
What keeps it going? That is, what are the mediators?
And what can be done to change that dis-eased homeostatic balance point the patient is locked into? That is, what are the underlying points of leverage
where intervention can be most effective?
In the functional medicine model, the patient’s full story is of central importance
Instead of a preoccupation with how to namethe disease, the critical questions become:
First, the full story must be understood within the context of
antecedents, triggers, and mediatorsantecedents and triggers
mediators
To answer these questions requires a new perspective on the chronic-care model
Infectious micro- organisms
Structural or
physical damage
Nutrient insufficiency
Xenobiotics
Disrupted light cycles—circadian
dysrhythmias
Radiation
Emotional trauma
Spiritual angst
Nutrient excess
Food toxicants
(allergens, stimulants, etc,)
Drug side effects
Adiposity
Toxic metals
Aging
Situational
stress–fear, anxiety, worry
Genetic pre-
disposition (SNPs)
Hyperglycemia
Hypoglycemia
Excessive exercise
Excessive noise
Dysbiosis
The story is no longer just the CC and HPI, but
is expanded to encompass all the
patient’s history that may reveal the source(s)
of symptoms.
Infectious micro- organisms
Structural or
physical damage
Nutrient insufficiency
Xenobiotics
Radiation
Emotional trauma
Spiritual angst
Nutrient excess
Food toxicants
(allergens, stimulants, etc,)
Drug side effects
Adiposity
Toxic metals
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/Reductive Homeodynamics
InflammatoryProcess
Aging
Genetic pre-
disposition (SNPs)
Next, the patient’s story is filtered through these
antecedents, triggers, and mediators, which leads to an understanding of where key imbalances may reside
Disrupted light cycles—circadian
dysrhythmias
HyperglycemiaHypoglycemia
Excessive exercise
Noise
Situational stress–fear, anxiety,
worry
Dysbiosis
The diagnosis remains useful, but is less important.
These fundamental clinical imbalances are the underlying mechanisms of disease…
Exercise
Acupuncture
Manipulative Therapies
Phytonutrients
Minerals
Vitamins
Diet
Yoga
Drugs
Surgery
Counseling
The expanded model permits the clinician to choose from an enlarged toolkit of
therapies.
Meditation
Let’s apply the functional medicine model to an apparently simple case…
…a 37 year old female with a chief complaint of chronic headaches.
Diagnosis: Migraines
Treatment: Triptan
Chief Complaint:Headaches
History of present illness
We’ve already seen how she might be treatedusing the existing model.
But her case may
not be as simple as it appears…
From a functional medicine perspective, the CC and HPI must be
filtered through the relevant antecedents, triggers, and mediators.
To understand the patient’s complete picture, past medical history, family
history, diet, medications, and lifestyle all need to be viewed through
this lens as well.
Psychological and SpiritualEquilibrium
Detoxification and Biotransformation
Structural Integrity
Immune
Surveillance
InflammatoryProcess
Hormone and
Neurotransmitter Regulation
Digestion, Absorption,
and Barrier Integrity
Oxidative/Reductive
Homeodynamics
Psychological and SpiritualEquilibrium
Detoxification and Biotransformation
Structural Integrity
Immune
Surveillance
InflammatoryProcess
A variety of potential antecedents, triggers, and
mediators might be present in a woman with a chief complaint
of chronic headaches:
Hormone and
Neurotransmitter Regulation
Digestion, Absorption,
and Barrier Integrity
Oxidative/Reductive
Homeodynamics
Psychological and SpiritualEquilibrium
Hormone and
Neurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune
Surveillance
Digestion, Absorption,
and Barrier Integrity
Oxidative/Reductive
Homeodynamics
InflammatoryProcess
Food allergenFood AllergenFood allergen
Circadian rhythm
Situational stress
Exposure to toxinsExposure to toxins Headaches triggered by food
allergen
Headaches triggered by menstrual cycle
Headaches triggered by stress
Headaches triggered by exposure to toxins
MSG, aspartame, smoke, perfume
Headaches triggered by changes in sleep
Headaches triggered by fasting
Estrogen dominance
Circadian rhythm
Hypoglycemia
Psychological and Spiritual Equilibrium
Hormone and
Neurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,
and Barrier Integrity
Oxidative/Reductive
Homeodynamics
Inflammatory Process
Past medical history leads to additional clues:
Food Allergen
Food Allergen
Food Allergen
Estrogen dominanceCircadian Rhythm
Circadian Rhythm
Situational Stress
Hypoglycemia
Exposure to toxins
Exposure to toxins
Past or recurrent infections
Adiposity
Surgeries
Surgeries
Surgeries
Past or recurrent infections
Past or recurrent infections
AdiposityAdiposity
Adiposity
AdiposityAccidents or Injuries
Emotional trauma
Exposure to toxins
Accidents, injuriesAccidents, injuries
Accidents, injuries
Emotional trauma
Emotional trauma
Emotional trauma
Exposure to toxins
Exposure to toxins
Exposure to toxins
Exposure to toxins
Chronic Disease
Chronic disease
Chronic disease
Chronic antibiotic use
Chronic antibiotic use—dysbiosis
Chronic antibiotic use
Chronic antibiotic use
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption,and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Estrogen dominanceCircadian Rhythm
Circadian Rhythm
Situational Stress
Hypoglycemia
Exposure to toxins
Exposure to toxinsSurgeries
Surgeries
Past or recurrent infections
Past or recurrent infections
AdiposityAdiposity
Adiposity
Adiposity
Accidents, injuriesAccidents, injuries
Accidents, injuries
Emotional trauma
Emotional trauma
Emotional trauma
Exposure to toxins
Exposure to toxins
Exposure to toxins
Exposure to toxins Chronic disease
Chronic disease
Chronic antibiotic use—dysbiosis
Chronic antibiotic use
Chronic antibiotic use
Family history may indicate genetic predispositions:
Food allergen
Food allergen
Food allergen
Inflammatory conditions such as RA, UC, etc.
Allergies
Predisposition to inflammation
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Estrogen dominanceCircadian Rhythm
Circadian Rhythm
Situational Stress
Hypoglycemia
Exposure to toxins
Exposure to toxinsSurgeries
Surgeries
Past or recurrent infections
Past or recurrent infections
AdiposityAdiposity
Adiposity
Adiposity
Accidents, injuriesAccidents, injuries
Accidents, injuries
Emotional trauma
Emotional trauma
Emotional trauma
Exposure to toxins
Exposure to toxins
Exposure to toxins
Exposure to toxins
Chronic disease
Chronic disease
Chronic antibiotic use—dysbiosis
Chronic antibiotic use
Chronic antibiotic use
Food allergen
Food allergen
Food allergen
Predisposition to inflammation
Dietary History
Dietary insufficiencies…antioxidants, magnesium, fiber, EFAs, etc.
Dietary excesses: saturated fat, simple sugars, caffeine, alcohol, etc.
Nutrient insufficiencies—EFAs, etc.
Nutrient insufficiencies –sulfur, amino acids, etc.
Nutrient insufficiencies
Nutrient insufficiencies – zinc, glutamine–leaky gut
Nutrient insufficienciesantioxidants
Nutrient insufficiencies
Nutrient excess—alcohol
Nutrient excess—caffeine
Nutrient excess –simple sugars
Nutrient excess—saturated fat
Dietary toxins…mercury, exogenous estrogens, etc.
Dietary toxin—mercury
Dietary toxin-mercury
Dietary toxin—mercury
Dietary toxins –exogenous estrogens
Dietary toxin –mercury
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Estrogen dominanceCircadian Rhythm
Circadian Rhythm
Situational Stress
Hypoglycemia
Exposure to toxins
Exposure to toxinsSurgeries
Surgeries
Past or recurrent infections
Past or recurrent infections
AdiposityAdiposity
Adiposity
Adiposity
Accidents, injuriesAccidents, injuries
Accidents, injuries
Emotional trauma
Emotional trauma
Emotional trauma
Exposure to toxins
Exposure to toxins
Exposure to toxins
Exposure to toxins
Chronic disease
Chronic disease
Chronic antibiotic use—dysbiosis
Chronic antibiotic use
Chronic antibiotic use
Food allergen
Food allergen
Food allergen
Predisposition to inflammationNutrient insufficiencies—EFAs, etc.
Nutrient insufficiencies –sulfur, amino acids, etc.
Nutrient insufficiencies
Nutrient insufficiencies – zinc, glutamine–leaky gut
Nutrient insufficienciesantioxidants
Nutrient insufficiencies
Nutrient excess—alcohol
Nutrient excess—caffeine
Nutrient excess –simple sugars
Nutrient excess—saturated fat
Dietary toxin—mercury
Dietary toxin-mercury
Dietary toxin—mercuryDietary toxins –exogenous estrogens
Dietary toxin –mercury
Medication History
Drug side effects
Drug side effects-inhibit or promote
Drug side effects
Drug side effects
Drug side effects
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Estrogen dominanceCircadian Rhythm
Circadian Rhythm
Situational Stress
Hypoglycemia
Exposure to toxins
Surgeries
Surgeries
Past or recurrent infections
Past or recurrent infections
Adiposity
Adiposity
Adiposity
Adiposity
Accidents, injuries
Accidents, injuries
Accidents, injuries
Emotional trauma
Emotional trauma
Emotional trauma
Exposure to toxins
Exposure to toxins
Exposure to toxins
Exposure to toxins Chronic disease
Chronic disease
Chronic antibiotic use—dysbiosis
Chronic antibiotic use
Chronic antibiotic use
Food allergen
Food allergen
Food allergen
Predisposition to inflammationNutrient insufficiencies—EFAs, etc.
Nutrient insufficiencies –sulfur, amino acids, etc.
Nutrient insufficiencies
Nutrient insufficiencies – zinc, glutamine–leaky gut
Nutrient insufficienciesantioxidants
Nutrient insufficiencies
Nutrient excess—alcohol
Nutrient excess—caffeine
Nutrient excess –simple sugars
Nutrient excess—saturated fat
Dietary toxin—mercury
Dietary toxin-mercury
Dietary toxin—mercury
Dietary toxins –exogenous estrogens
Dietary toxin –mercury
Drug side effects-inhibit or promote
Drug side effects
Drug side effects
Drug side effects
Hobbies
Exercise
Relationships Recreational Drugs
Spirituality
Lack of exercise
Lack of exercise
Lack of exerciseLack of exercise
Lack of exercise
Lack of exercise
Spiritual angstLoneliness
Loneliness
Loneliness
Spiritual angst
Over or improper exercise
Lifestyle
Alcohol-leaky gut
Inhibit or promote
Exposure to toxins
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
A variety of potential laboratory assessments can then be useful in confirming key imbalances
on which to focus.
Cortisol, DHEAGlucose, insulin, HA1C
TSH, Free T3, Free T4Estrogen, Progesterone, Testosterone 2/16 ratio
8-OHdG
IsoprostanesReduced glutathioneLipid peroxides
Gait Motion AnalysisN-telopeptide
Magnetic Resonance Imaging
X-ray
Bacterial Overgrowth Small Intestine
Fecal Ova and Parasites
Candida Antibodies
Lactulose Mannitol
IgG and IgG food allergyChemical antibodiesSalivary Secretory IgANatural Killer Cell Cytotoxicity Activity
High-sensitivity CRPRBC Fatty Acids
Fecal LactoferrinFecal Calprotectin
Urinary Serotonin, Dopamine
Serum Amino Acids
Homocysteine, folate, B12RBC Fatty Acids
Caffeine Clearance, Glucuronidation, Sulfation
Hair toxic ElementsUrinary Provocation/Challenge
SNP Cyp P450
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Food allergen
Food allergen
Specifically, what was this37 year old female’s story?
Headaches triggered by diet
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Dysbiosis
What are the clues in her past medical history?
History of chronic sinusitis
Food allergen
Food allergen
History ofmultiple antibiotics
Drug side effectsleaky gut
Structural damage
Gas and bloating
Digestive enzyme/HCL insufficiency
Inflammatory damage
History of osteoarthritis of the knee
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Dysbiosis
Food allergen
Food allergen
Structural damage
Digestive enzyme/HCL insufficiency
Inflammatory damage
Nutrient insufficiency –low EFAs, high AA
Standard American DietNSAIDS for OA
Drug side effects – leaky gut
What are the clues in her diet and medications?
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Dysbiosis
Food allergen
Food allergen
Structural damage
Digestive enzyme/HCL insufficiency
Inflammatory damage
Nutrient insufficiency –low EFAs, high AA
Drug side effects – leaky gut
What are the cluesin her family history?
Ulcerative Colitis
Eczema
Inflammatory genetic predisposition
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Dysbiosis
Food allergen
Food allergen
Structural damage
Digestive enzyme/HCL insufficiency
Inflammatory damage
Nutrient insufficiency –low EFAs, high AA
Drug side effects – leaky gut
Through critical thinking and pattern recognition,
a therapeutic plan can be developed. In this case, the primary focus centers on three areas
Psychological and Spiritual Equilibrium
Hormone andNeurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Inflammatory Process
Dysbiosis
Food allergen
Food allergen
Structural damage
Digestive enzyme/HCL insufficiency
Inflammatory damage
Nutrient insufficiency –low EFAs, high AA
Drug side effects – leaky gut
Laboratory analysis can be
used to help confirm the
prioritization
Hs-CRPRBC fatty acids
IgG/IgE food allergy
Digestive stool analysisOva and parasiteIntestinal permeability
Psychological and SpiritualEquilibrium
Hormone and
Neurotransmitter Regulation
Detoxification and Biotransformation
Structural Integrity
Immune
Surveillance
Digestion, Absorption,
and Barrier Integrity
Oxidative/Reductive
Homeodynamics
InflammatoryProcess
The prioritization of certain key
clinical imbalances then leads to potential
treatment options
Dietary changes to lower arachidonic acid and the inflammatory cascade
Omega-3 fatty acids to decrease inflammation
Botanicals such as bromelain and curcumin to decrease inflammation
Phytonutrients such as rutin and quercitin to decrease IP
Pre and probiotics
Decrease alcoholto decrease
intestinal permeability
Hydrochloric acid/digestive enzyme
Foodelimination
diet
Functional medicineenlarges the
chronic care model to encompass the full
and uniquestory of the patient
Finally it increases the range of potential treatment options
It integrates underlying mechanisms of disease into the differential
diagnosis paradigm
Exercise
Acupuncture
Manipulative Therapies
Phytonutrients
Minerals
Vitamins
Diet
Yoga
Drugs
Surgery
Counseling Meditation
Psychological and Spiritual Equilibrium
Hormone and Neurotransmitter Regulation
Detoxification andBiotransformation
StructuralIntegrity
ImmuneSurveillance
Digestion,Absorption,and Barrier
Integrity
OxidativeReductive
Homeodynamics
InflammatoryProcess
Infectious micro- organisms
Structural or
physical damage
Nutrient insufficiency
Xenobiotics
Radiation
Emotional trauma
Spiritual angst
Nutrient excess
Food toxicants (allergens, stimulants
etc,)
Drug side effects
Adiposity
Toxic metals
Aging
Genetic pre-disposition
(SNPs)
Disrupted light cycles – circadian
dysrhythmias
Hyperglycemia
Hypoglycemia
Excessive exercise
Excessive noise
Situationalstress – fear, anxiety, worry
Dysbiosis
The functional medicine model recognizes and prioritizes the patient’s full, unique story and
uses fundamental clinical imbalances as a key to treating complex,
chronic illness
Functional Medicine and the Healthcare System: Additional Important Benefits
Functional Medicine creates a level playing field among practitioners
The Functional Medicine model makes readily apparent that there is a need for many different approaches to helping people become and stay well
Functional Medicine helps to create and disseminate a shared set of concepts and a common language
Ultimately, Functional Medicine can contribute greatly to our ability to create an integrated healthcare system
Cardiology Pulmonary
Endocrinology
Gastroenterology
Neurology
Organ System Diagnosis
Urology/Nephrology
Hepatology
AllergySigns and Symptoms
Fundamental Clinical Imbalances Hormonal and Neurotransmitter Imbalances
Redox Imbalance + Oxidative Stress + MitochondropathyDetox/Biotransformation/Excretory Imbalance
Immune ImbalanceInflammatory Imbalance
Digestive/Absorptive and Microbiological ImbalanceStructural Integrity Imbalance
1. Communication- Outside the cell- Inside the cell
Mind and Spirit
Genetic PredispositionExperiences, Attitudes, Beliefs
Psycho-socialPhysical Exercise
TraumaDiet, Nutrients,
Air/Water
Xenobiotics Micro-organisms
RadiationEnvironmental Inputs
2. Bioenergetics/Energy Transformation3. Replication/Repair/Maintenance/
Structural Integrity
4. Elimination of Waste5. Protection/Defense6. Transport/Circulation
Fundamental Physiological Processes