Naturopathic Doctor Note

Sarah Jenkins’s Goals

Resolve chronic postprandial bloating, regulate bowel movements, and improve afternoon energy levels through targeted dietary and lifestyle interventions.

Complaints

1. Abdominal bloating and alternating bowel habits: Onset 8 months ago following a bout of acute gastroenteritis. Severity 6/10 daily, worsening to 8/10 in the evening. Aggravated by dairy, garlic, onions, and high-stress workdays. Partially relieved by passing flatus, applying heat, and peppermint tea. Trialled over-the-counter simethicone 125 mg PO PRN with minimal relief. Recent GP workup showed negative celiac serology (tTG-IgA) and normal faecal calprotectin.
2. Afternoon fatigue: Onset 6 months ago. Severity 5/10, peaking between 14:00 and 16:00 daily. Aggravated by poor sleep and heavy carbohydrate lunches. Temporarily relieved by caffeine or sugar intake.

Diet

Breakfast (07:30): Instant oatmeal with 2% cow's milk and brown sugar, or 2 slices of whole wheat toast with peanut butter.

Morning snack (10:30): Greek yogurt with berries or a granola bar.

Lunch (13:00): Leftover pasta, or a turkey and cheese sandwich on sourdough with mixed greens.

Afternoon snack (15:30): Handful of almonds and 2 squares of dark chocolate.

Supper (18:30): Grilled chicken or salmon, white rice or roasted potatoes, and steamed broccoli or asparagus cooked with garlic.

Fluids: Water 1.5 L/day, coffee 2 cups (500 mL total) before 11:00 with oat milk, peppermint tea 1 cup in the evening, red wine 2 glasses (300 mL total) on Fridays. No juice or carbonated drinks.

Cravings: Craves salty snacks (potato chips) and sweet baked goods during the mid-afternoon slump and luteal phase.

Appetite: Absent hunger upon waking; ravenous by 18:00. Early satiety when severely bloated.

Digestion

BMs occur 1x every 2–3 days, alternating with 2–3 loose stools per day during high-stress periods. Typically occurs in the morning. Bristol Stool Scale Type 1–2 (hard, lumpy, dark brown) alternating with Type 6 (mushy, light brown, foul-smelling).

Denies hematochezia or melena.

Occasional clear/white mucus noted on tissue during loose stool phases.

Visible undigested leafy greens and corn kernels noted occasionally.

Mild cramping in the LLQ (4/10) prior to loose bowel movements, relieved by defecation. No tenesmus or anal pain.

Daily abdominal distension; flat abdomen upon waking, progressively distending after lunch, peaking at 19:00. Triggered by fructans, lactose, and large meals. Relieved overnight.

History of acute viral gastroenteritis (06/2025). Uses polyethylene glycol 3350 (RestoraLAX®) 17 g PO PRN (approx. 2x/month) for constipation. No abdominal surgeries or endoscopies.

Sleep

Bedtime at 23:00, falls asleep within 15 minutes. Wakes 1–2x/night around 03:00 due to racing thoughts; takes 30 minutes to return to sleep. No nocturia. Wakes at 06:30 via alarm feeling unrefreshed (4/10). Reads on a tablet for 30 minutes in bed prior to sleep.

Stress

High occupational stress (accountant); rates daily stress at 7/10. Manages stress via occasional evening walks and listening to podcasts.

Energy

Morning energy 6/10, drops to 3/10 between 14:00 and 16:00, rebounds slightly to 5/10 at 19:00. Able to complete ADLs and work tasks, but lacks motivation for evening exercise.

Mood

Generally euthymic, though experiences mild irritability and tearfulness 4–5 days prior to menses.

Mental Health

Subclinical generalised worry related to workload and gut symptoms. No formal psychiatric diagnoses, history of depression, or ADHD. Denies brain fog or memory impairment.

Menstruation

Regular 29-day cycles, 4 days of flow. Moderate volume (changes regular pads every 4 hours on days 1–2, no clots). Mild dysmenorrhea on day 1 (3/10, no analgesics required) and premenstrual breast tenderness.

Social History

Married, no children. Works full-time as a senior accountant (sedentary). Enjoys gardening and reading. Exercises 1–2x/week (30-minute gentle yoga or neighbourhood walk in the evenings). Alcohol: 2 drinks/week. Denies tobacco, vaping, or recreational drug use.

Lives in a detached home with her husband and 1 cat.

Personal History

Seasonal allergic rhinitis (tree pollen); NKDA.

Cetirizine (Reactine®) 10 mg PO daily PRN during spring.

Cholecalciferol (Vitamin D3) 1,000 IU PO daily; Magnesium oxide 250 mg PO HS.

Mild eczema in childhood (resolved).

Laparoscopic appendectomy (12/08/2014) for acute appendicitis; uncomplicated recovery.

G0P0.

Family History

1. Mother (64, alive): Hypothyroidism and irritable bowel syndrome (IBS).
2. Father (67, alive): Essential hypertension and hyperlipidaemia.

Review of Systems

Skin: Dry patches on bilateral elbows, brittle fingernails. HEENT: Occasional post-nasal drip in the spring. Cardiorespiratory: Denies chest pain, palpitations, SOB, or chronic cough. MSK: Mild bilateral trapezius tension related to desk posture.

Questions and Synopsis

Sarah asked whether she needs to eliminate gluten permanently and if a probiotic would resolve her bloating. Discussed the pathophysiological mechanism of post-infectious IBS, visceral hypersensitivity, and the role of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). Explained that gluten itself may not be the trigger, but rather the fructans in wheat. Outlined a structured, temporary elimination and reintroduction protocol alongside nervous system regulation.

Objective Findings

Vitals (10:15 America/Halifax): BP 116/74 mmHg (left arm, seated), HR 68 bpm (regular), RR 14/min, Temp 36.6 °C, Height 165 cm, Weight 62.5 kg, BMI 23.0 kg/m². Abdominal Exam: Soft, mildly distended in the lower quadrants. Tympanic to percussion throughout. Mild tenderness to deep palpation in the LLQ; no rebound, guarding, or palpable masses. Normoactive bowel sounds in all 4 quadrants. Skin/Nails: Longitudinal ridging on fingernails; mild xerosis on extensor surfaces of forearms.

Blood tests (drawn 14/02/2026):

• CBC: Hb 128 g/L, WBC 5.4 x 10^9/L, Platelets 245 x 10^9/L, MCV 84 fL
• Ferritin: 22 µg/L (suboptimal)
• Vitamin B12: 310 pmol/L
• TSH: 2.1 mIU/L
• tTG-IgA: < 1.0 U/mL (Negative), Total IgA: 2.1 g/L

Pelvic and abdominal ultrasound (18/02/2026): Unremarkable hepatobiliary tree, pancreas, spleen, and pelvic organs. Moderate faecal loading noted in the descending colon.

Assessment

1. Post-infectious Irritable Bowel Syndrome, mixed subtype (IBS-M), presenting with daily bloating, LLQ cramping, and alternating constipation/loose stools. DDx: Small intestinal bacterial overgrowth (SIBO), non-celiac gluten sensitivity, lactose intolerance, bile acid malabsorption.
2. Suboptimal iron stores (non-anaemic iron deficiency) and sleep maintenance insomnia, contributing to afternoon fatigue and brittle nails. DDx: Subclinical hypothyroidism, inadequate caloric/protein distribution.

Plan

Immediate

1. Initiate a 4-week Low-FODMAP elimination phase; provided Monash University Low-FODMAP diet handouts and app instructions. Emphasise strict avoidance of lactose, garlic, onions, and wheat initially.
2. Optimise meal hygiene: Chew food thoroughly (20x per bite), avoid fluids 30 minutes before and during meals, and implement 5 minutes of diaphragmatic breathing prior to eating.
3. Increase protein at breakfast (e.g., 2 eggs with spinach and sourdough spelt toast, or lactose-free Greek yogurt with pumpkin seeds) to stabilise diurnal glycaemic control and afternoon energy.
4. Discontinue magnesium oxide (poorly absorbed); switch to Magnesium bisglycinate 200 mg PO 1 hour prior to bedtime to support sleep maintenance and nervous system regulation.
5. Commence Iron bisglycinate 25 mg PO every other day with 250 mg Vitamin C, taken away from coffee/tea, to replete ferritin without aggravating GI tract.
6. Sleep hygiene: Eliminate tablet screens 60 minutes before bed; replace with paper books or guided meditation.

To Discuss with MD or Specialist

1. Request copy of previous faecal calprotectin and ova & parasite (O&P) stool results from GP to complete chart records.

Next Visit

1. Follow up in 4 weeks to evaluate symptom response to the Low-FODMAP elimination phase and initiate the structured FODMAP reintroduction protocol.
2. If bloating persists despite FODMAP restriction, discuss lactulose breath testing to rule out SIBO.

3-Month Plan

1. Complete FODMAP reintroduction to identify specific personal triggers and establish a modified, diverse long-term maintenance diet.
2. Re-evaluate energy levels and sleep quality; consider targeted strain-specific probiotics (e.g., Lactobacillus plantarum 299v) if residual IBS symptoms remain.

6-Month Plan

1. Repeat serum ferritin and CBC to assess efficacy of alternate-day iron supplementation.

1-Year/Future Plan

1. Annual wellness review, comprehensive metabolic and thyroid panel reassessment, and maintenance of gut microbiome diversity.