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Clinical treatment protocol emphasis on nutrition - A to Z part two of a collectible series.

BENIGN PROSTATIC HYPERPLASIA

History

* Age of patient

** 50% of men will be affected in their lifetime

** Increased incidence with age

** Idiopathic, but hormones suspected

** Decrease in free testosterone after 50 yo which causes an increase in DHT

** DHT increases hypertrophy

** Increase in Estrogen

** M/C benign neoplasia in males

* Dietary habits

** Vitamin and mineral deficiencies

* Signs and symptoms

** Progressive urinary frequency: obstructive symptoms

** Hesitancy, intermittency with decreased force, dribbling and intermittency

** Possible hematuria

** Frequency

** Dysuria

** Groin Pain

** Urgency

** Nocturia

* Environmental exposures

** Pesticides

** Diethylstilbestrol (DES)

Evaluation

* Care should be taken to properly have a good DDX for cancer since supplements will have some positive effects on symptoms (inflammation) but will mask the cancer.

* DRE is said to be unreliable due to half of men with palpable enlargement being symptomatic and half without palpable enlargement being symptomatic

** Cadmium DRE

** Hyperplastic, smooth, rubbery without nodules and median groove may be lost

* Labs

** PSA <10 ng/mL to rule out prostate cancer

** Transrectal US: estimation size

** X-ray to rule out malignant mets

** Lipid panel

** Vitamin/mineral deficiencies

** U/A to r/o infection

** Chem Screen

** Bun & creatinine to r/o obstructive urinary problem

Treatment Overview

* Diet and supplementation

* Botanicals

* Medications (Beware of nutrient deficiencies)

* Normalize prostate nutrient levels

* Restore steroid hormones to normal levels

* Inhibit excessive conversion of testosterone to

DHT

Step #1

Diet and Nutrition

1. Avoid saturated and trans fats

2. Anti-inflammatory diet

3. Increase fruits and vegetables

4. Increase cold water fish

5. Limit alcohol

6. Limit cholesterol rich foods

7. Increase olive oil

Step #2

Supplements

1. CoQI0 l00mg q.d.

2. Vitamin B6 100-250 mg q.d.

3. Omega 3 fatty acid 1,500 mg q.d.

4. Selenium 100 meg q.d.

5. Magnesium citrate 750 mg q.d.

6. Calcium citrate 1,500 mg q.d.

7. Glycine 200 mg q.d.

8. Alanine 200 mg q.d.

9. Glutamic acid 100 mg q.d.

10. Zinc 50-100 mg q.d.

Step #3

Botanicals

1. Lycopenes 20 mg q.d.

2. Pygeum Africnum 100 mg q.d.

3. Pumpkin seed extract 80 mg q.d.

4. Saw palmetto 150 mg q.d.

5. Stinging nettle 150 mg q.d.

6. Flax seed oil 1 tbsp b.i.d.

BIPOLAR (Manic depression)

History

* Patient exhibits at least three of the following:

** Excessive self-esteem or grandiosity

** Reduced need for sleep

** Extremely talkativeness, excessive telephoning

** Extremely rapid flight of thoughts, along with feeling that the mind is racing

** Inability to concentrate; easily distracted

** Increase in social or work-oriented activities, often with sixty-to-eighty-hour work week

** Poor judgment, as indicated by sprees of uncontrolled spending, increased sexual indiscretions, and misguided financial decisions

Evaluation

* Psychological referral for appropriate evaluation and testing

* Medications list

* Behavioral patterns

* Thyroid panel

Treatment Overview

* Diet and supplementation

* Botanicals

* Medications

* Correct low levels of thyroid hormone

Step #1

Diet and Nutrition

1. Increase chicken and cold water fish

2. Increase fruits and vegetables

3. Low-vanadium diet

4. Eliminate refined foods

5. Decrease saturated and trans fats

Step #2

Supplements

1. Vitamin C 1,000 mg q.d.

2. Vitamin E 600 mg q.d.

3. B-100 complex q.d.

4. Folic acid 400 mcg q.d.

5. SAMe 400 mg q.d.

6. Omega 3 fatty acids 1,500 mg q.d.

7. 5-HTP 150 mg q.d.

8. Tryptophan 500 mg q.d.

9. Phosphatidylcholine 500 mg q.d.

Step #3

Botanicals

1. St John's wort 250 mg t.i.d

2. Valerian 150 mg q.d.

3. Ginkgo biloba 150 mg q.d.

4. Passion flower 100 mg q.d.

5. Kava 175 mg q.d.

Watch Contraindications with drugs and supplements/herbs (i.e. SSRl's and St. Johns Wort)

BONE TRAUMA (Fracture)

History

* Due to a traumatic injury

* Can be caused by a sneeze or cough in the elderly

* Closed skin is simple

** Pain, swelling and hematoma

* Open skin is compound

** Skin cut, abraded or torn

** Increase risk of infection

* Two pieces or comminuted

* Avulsion, impaction, stress, compression, incomplete or pseudofracture

* Orientation: Spiral, oblique or transverse

* Phase 1: Circulatory or Inflammatory

** Cellular 10 days

*** Inflammatory cellular response, apopotosis and granulation tissue accumulation

** Vascular 10 days

*** Open capillary network around fracture

*** Periosteum deviated and responds

*** Primary callus forms 10 days

*** Vasculature becomes well established and raw materials for new tissue are available

* Phase II: Metabolic

** Osteoid is removed and replaced by mature bone

** Sealing, buttressing, bridging, uniting and healing occur

* Phase III: Remodeling or Mechanical

** Realignment and remodeling of bone according to Wolffe's law

** Bone marrow is restored to the marrow cavity

* May take years

* Possible complications include compromise of the arterial vasculature (brachial, femoral, popliteal, aortic, iliac or axillary), Volkmann's ischemic contracture (compartment syndrome), gas gangrene, fat embolism, osteomyelitis, reflex sympathetic dystrophic syndrome, refracture, post-traumatic osteolysis, myositis ossificans, synostosis, deformity or delayed union

* Delayed complications are degenerative joint disease, osteoporosis, nonunion or malunion or osteonecrosis

* Skull

** Linear (most common), depressed and diastatic

** Beware of dsytaxia, dysphasia, paresthesias, weakness, confusion, blurry vision, diplopia, anisocoria, lethargy

** Other signs include otorrhea or rhinorrhea (leakage of CSF), hemotympanum, Battle's sing (postauricular ecchymoses) and raccoon eyes (periorbital ecchymoses and edema)

** CT scan is the method of choice for analysis of a hematoma

* Facial Fractures

** Zygomaticomaxillary complex (Tripod) most common

*** Zygomatic arch, orbital and maxillary process

** Lefort complex next most common

*** Types I, II and III

** 60-70% involve the orbit

*** "Blowout fracture" of the ethmoid bone in the orbit

* Mandibular fracture

** Body most common

** Angle second most common

** "Ring rule"

*** Rings more likely to break in multiple locations

* Cervical spine

** Evaluate for ligamentous injury as well as fracture

** Flexion is the most common force vector of a fracture

** 40% of fractures cause nerve damage

** Atlas fracture

*** Burst or Jefferson fracture

** Dens fracture

*** Type 1 tip of the dens

*** Usually stable unless apical and/or alar ligaments are compromised

* Type 2 at the base of the dens

** Most common

** Hyperextension or hyperflexion force vectors

** Surgery in adults

** Transverse ligament is usually intact

** Instability can cause spinal cord compression and paralysis

* Type 3 involves the vertebral body

** Usually heals spontaneously may require fusion of joint

* Hangmans fracture

** Traumatic spondylolisthesis C2

** Common in diving accidents

** Unstable fracture requires halo immobilization and sugery

* Clay shoveler's fracture

** Avulsion fracture of spinous process

** Sudden load exerted on flexed spine

* Burst fracture

** Highly unstable with high incidence of neural damage

** Requires surgery

* Teardrop fracture

** Caused by severe flexion

** Fracture and dislocation

** Compromises multiple ligaments

** Results in acute cervical cord syndrome

*** Quadriplegia and loss of touch, pain and temperature

* Wedge fracture

** Compression fracture

* Thoracic spine

** Fractures occur from fall from heights, automobile accidents and penetrating trauma

** Burst

** Wedge fracture

*** Compression fracture most likely pathological

**** Metastasis, osteoporosis or infection

* Rib

** Complications include hypoventilation, hypercapnia, hypoxia, atelectasis, pneumothorax or damage to an organ

*** Pleural effusion

** Middle ribs most commonly fractured

** Multiple fractures in young children suspect child abuse

** Stress fractures can occur in rowing or golf from repetitive movements

* Lumbar spine

** Caused by fall from heights, automobile accidents and penetrating trauma

** Fractures include burst, wedge and chance

** Chance-Seatbelt fracture most common at L2

*** Divides the vertebra into superior and inferior halfs

** Complications are disruption of the disc, rupture of internal organs or compromise of the spinal cord

** Commonly seen with Malgaigne fracture of the pelvis

* Spondylolisthesis

** Congenital (dysplastic), spondylolytic

(isthmic), degenerative, traumatic, pathologic or iatrogenic (postoperative)

** Fracture of pars interarticularis

** High risk activities are gymnastics, rowing, wrestling, weightlifting and football

** Begin as chronic stress fractures that impair bone healing

** Also due to a combination of osteoarthritic changes in the facet joints, eburnation, erosion and loss of disc height

** Complications include spinal canal stenosis

* Sacrum

** Fall on the buttocks

*** Horizontal and vertical more common

*** Suicide jumper fracture S2 horizontally

* Coccyx

** Transverse fracture

* Lower extremity

** Pelvis

*** 60% of trauma causes hemorrhage

*** "Ring rule"

**** Malgaigne's

***** Ipsilateral double vertical fracture of inferior ring and diastatic sacroiliac joint

***** Most common pelvic fracture

***** Unstable results in a short lower leg

**** Bucket handle

***** Fracture of the ramus with contralateral sacroiliac joint

*** Avulsion fractures common at anterior superior iliac spine, anterior inferior iliac spine and ishcial tuberosisty

*** Iliac wing

**** Duverny's (vertical fracture), apophyses and avulsion (ASIS or AIIS)

*** Pubic and ischium

**** Straddle, symphysis avulsion, Rider's bone

* Hip

** Salter-Harris fractures in long bones

*** Involve the epiphysis, metaphysis and/or epiphyseal plate

*** Epiphyseal plate can lead to inhibition of growth

*** Type I-V

** Intracapsular or Extracapsular (neck and trochanter)

*** More common in females

*** Mostly osteoporotic

*** Risk of thromboembolic disease and avascular necrosis

*** Intracapsular: subcapital (most common), midcervical and basicervical

*** Extracapsular: intertrochanteric, trochanteric and subtrochanteric

* Knee

** Distal femur

*** Supracondylar

**** Transverse or oblique

**** Comminuted

**** Occurs with dislocations of the hip and tibial fracture

*** Femoral condyle fracture

**** T or Y

**** Always intraarticular

**** Can lead to osteochondral defect

** Proximal tibia

*** Tibial platue aka bumper fender

**** Lateral plateau most common

*** Trampoline fracture

**** Tibial metaphysic

*** Segond's fracture

**** Avulsion of TFL from tibia

**** Anterior cruciate ligament and meniscal tears in 3/4

** Fibula

*** Associated with plateau fracture and ligamentous and capsular damage

** Patella

*** Transverse most common or vertical

*** Comminuted in 1/4 of cases

* Ankle

** Medial or lateral malleolus fractures

** Avulsion usually accompanied by talar dome fracture

** Bimalleolar and trimalleolar

*** Trimalleolar aka Cotton's fracture includes posterior process of tibia

** Pott's

*** Mid-fibular fracture above the lateral malleolus with rupture of distal tibiofibular ligaments and parial dislocation

*** Jumping injury

** Dupuytren's

*** Distal fibular fracture with diastasis of tibia, lateral dislocation of the talus, rupture of tibiofibular ligament and displacement of the foot

** Maisonneuve's

*** Proximal fibular shaft fracture with rupture of distal syndesmosis

*** Caused by forced inversion

** Tillaux's

*** Fracture of medial malleolus, diastasis of distal syndesmosis, anterior tubercle avulsion of distal tibia and fracture of distal fibula

** Toddler's

*** Spiral frature of tibia

*** 9 months to 3 years of age

*** Mechanism is caused by foot caught in the crib slats

*** Known as boot top fracture in adults

* Foot

** Calcaneal most common

** Most commonly in the body

** Caused by compression or avulsion

*** Anterior process most common avulsion

*** Associated with rupture of Achilles

** Talus

*** Body, dome, neck or head

** Metatarsals and phalanges

*** Caused by dropping a heavy object on the foot

*** Jones or Dancer's fracture at the base of 5th metatarsal

*** LisFranc fracture/dislocation

**** At the base of the metatarsals

** Hallux rigidus

*** Stiff and painful 1st metatarsal phalangeal joint

*** Premature degenerative arthritis

*** Sesamoids in dancers, jumpers and runners

**** Medial more common

* Upper extremity

** Most common injury of the pectoral girdle is the clavicle

*** Occurs in children and adolescent athletes

** Clavicle

*** Proximal, middle (most common) or distal

*** Greenstick

*** Fracture is most common birth trauma

** Scapula

*** Body (most common), process or Bankhart lesion

**** Due to direct trauma during a fall or automobile accident

**** Associated with fractures of thoracic spine

**** Bankhart lesion is an avulsion of the inferior portion of the glenoid cavity at the triceps insertion

** Humerus

*** Flap, Hill-Sachs, proximal anatomical or surgical or shaft

**** Flap is avulsion of greater tuberosity

**** Hill-Sachs is a hatchet deformity

*** A majority of fractures extend into the elbow

** Elbow

*** Most common in children

*** Usually the result of athletic activities 1/2 adult fractures are at radial head (chisel)

*** 3/5 of pediatric fractures are supracondylar

*** Intercondylar

**** T or Y shape

**** Side swipe injury

*** Condylar

**** Caused by an angular force

**** Extends into the articular surface

**** Trochlear or Kocher's fracture

*** Epicondylar

**** Avulsion

**** Associated with baseball in adolescents

*** Radial neck

**** Caused by impaction of the head

**** Occurs with a dislocation is called Essex-Lopresti

*** Nightstick or parry

**** Transverse through the shaft

*** Monteggia

**** Proximal ulnar shaft with anterior dislocation of proximal radius

*** Galeazzi

**** Reverse Monteggia or Piedmont

**** Fracture at distal 1/3 of radius with dislocation of distal radioulnar joint

*** Incomplete

**** Transverse or hickory fracture

**** Torus or buckling fracture

***** Impaction fracture

*** Bowing fracture

**** Bent bone with no disruption of the cortex

* Wrist

** Colles

*** Posterior radius angulation

*** Due to fall on outstretched hand

*** 1/2 have ulnar styloid fracture

*** Complications include radial shortening, deformity, reflex sympathetic dystrophy, median nerve damage, osteoarthritis or ulnar impaction syndrome

*** Most common in elderly women

** Barton's

*** Posterior rim

*** Anterior rim is reverse Barton's

** Smith's

*** Fall on hyperflexed wrist

** Chauffeur's or Crank

*** Radial styloid process fracture

*** Scapholunate dissociation, osteoarthritis and ligament damage may occur

** Scaphoid

*** Most common carpal fracture

*** Avascular necrosis can occur

*** Presence of fat stripe

** Triquetral

*** Second most common

* Hand

** Boxer's, shaft or base

*** Boxer's transverse fracture through distal metacarpal

*** Barroom fracture of 4th or 5th digit

** Bennett's

*** Fracture/dislocation through the base with dorsal and radial displacement

** Rolando

*** Comminuted Bennett's fracture

* Finger

** Volar plate (avulsion), shaft, intra-articular, open tufts, baseball or mallet finger

Evaluation

* Physical exam

** Tuning fork test

* Imaging

** X-ray or CT

*** Earliest time of visualization of callus is 14 days

*** Detect and assess the extent of osseous, ligamentous, neural and soft tissue injuries

*** Stable vs. unstable

*** Cervical spine

**** Atlantodental interspace in adults <3 mm and children 3-5 mm

**** Retropharyngeal space 2-7 mm

**** Retrotracheal space 9-22 mm

* Pelvis

** Waldenstrom's teardrop less than 2 mm

** Klein's line for slipped femoral capital epiphysis

* Long bones

** Fat blood interface sign or fat pad sing

* Calcaneus

** Boehler's angle is 28-40 degrees

** Identify compression fracture

* MRI

** Soft tissue injuries

Treatment Overview

* Casting or bracing

* Diet and supplementation

* Botanicals

* Adjunct therapy after healing has taken place

Step #1

Diet and Nutrition

1. Increase caloric intake to promote healing as high as 4,000-6,000 calories q.d.

2. Increase cold chicken and water fish

3. Avoid alcohol, caffeine and smoking

4. Increase fruits and vegetables

5. Increase complex carbohydrates

6. Avoid food allergens

Step #2

Supplements

1. Antioxidants

a. VitaminA 10,000-50,000 I.U. q.d.

b. Vitamin C 1,000 mg q.d.

c. Vitamin E 600-800 I.U. q.d.

d. Zinc 100 mg q.d.

e. Selenium 100 meg q.d.

2. Copper 1 mg q.d.

3. Calcium citrate 1,200 mg q.d.

4. Vitamin D 5,000 I.U. q.d.

5. Boron 6 mg q.d.

6. Omega 3 fatty acids 1,500 mg q.d.

7. Vitamin K 2 mg q.d.

8. B-150 complex q.d.

Step #3

Botanicals

1. Bromelain 500 mg t.i.d.

a. 2,000-2,500 mcu or gdu

2. Quercetin 200 mg q.d.

3. Curcumin 200 mg q.d.

4. Horsetail 125 mg q.d.

BRONCHITIS (Chronic COPD)

History

* Enlargement of the mucus glands is present due to an increase in PMN and the release of elastase in response to the inflammation present

* Due to enlargement of the mucus glands the airway lumen is narrowed

* History of smoking (at least 20 pack years)

* Other factors are air pollution and Alphal-antitrypsin deficiency

* 60 years of age

* Lead to COPD

* History of productive cough for longer than 3 months during 2 consecutive years with an airway obstruction

* Cough with sputum that worse in the morning

* Chest tightness

* Dyspnea

* Increased respiratory rate

* Fever

* Wheezing during expiration, crackles during inspiration, cyanosis, barrel chest, peripheral edema, barrel chest, hyper-resonance on percussion, and elevated jugular venous pressure

Evaluation

* Spirometry: Chronic bronchitis is an obstructive pulmonary disease therefore there is a decrease in FEV1 and FVC

* Sputum culture: Sputum is mucoid or purulent with macrophages and neutrophils. You also want to rule out Streptococcus pneumoniae and Haemophilus influenzae are

* CBC: Polycythemia can develop in severe cases

* Arterial blood gases: Determine the degree of hypoxia present

* Imaging

** Chest x-ray: hyperinflation, including a flattening of the diaphragm, increased retrosternal airspace, and a long narrow heart shadow

** CT: rules out emphysema because chronic bronchitis does not have bullae in the lung fields

Treatment Overview

* Diet and supplementation

* Botanicals

* Stop smoking

* Bronchodilators (beta2-agonists)

* Oxygen therapy

* Acupuncture

* Humidifier

* CMT

Step #1

Diet and Nutrition

1. Decrease dairy products

2. Decrease any mucous producers (bananas, oranges, tomatoes, wheat)

3. Avoid food allergens

4. Increase cold water fish

5. Decrease saturated and trans fats

6. Decrease fatty meats

7. Increase fruits and vegetables

8. Increase olive oil

Step #2

Supplements

1. Omega 3 fatty acids 2,000 mg q.d.

2. Omega 6 fatty acids 1,000 mg q.d.

3. N-Acetylcysteine 500 mg t.i.d.

4. Magnesium citrate 750 mg q.d.

5. Antioxidants

a. Vitamin A 10,000 I.U. q.d.

b. Vitamin C 1,000 mg q.d.

c. Vitamin E 600-800 I.U. q.d.

d. Zinc 100 meg q.d.

e. Selenium 100 mg q.d.

Step #3

Botanicals

1. Borage oil 500 mg t.i.d.

2. Bromelain 500 mg t.i.d.

a. 2000-2500 mcu or gdu

3. Ginger 250-500 mg q.d.

4. Licorice (DGL) 175 mg q.d.

5. Hawthorn 250 mg q.d.

6. Essential oils in humidifier

7. Ephedra 75 mg q.d. (If available)

8. Quercetin 200-250 mg t.i.d.

9. Curcumin 200-250 mg t.i.d.

10. Evening primrose oil 500 mg t.i.d.

References

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* Title: The ABC, Clinical Guide to Herbs Author: Mark Blumenthal, The American Botanical Council__Edition: Thicme Pubs, ISBN 1-558890-157-2 2010_

* Title: Encyclopedia of Natural Medicine Author: Murray and Pizzorno Edition: Prima Publishing, ISBN 1-55958-091-7 1998

* Title: Herbs That Heal Author: Michael A. Weiner, PhD Edition: Quantum Books, ISBN 9-912845-11-2 1995

* Title: A-Z Guide to Drug-Herb-Vitamin Interactions Author: Alan R. Gaby, M.D. Edition: 2nd Edition, Three Rivers Press--ISBN-13:978-0-307-33664-4 2006

* Title: Stockley's Herbal Medicines Interactions Author: Williamson, Driver and Baxter Edition: Pharmaceutical Press. RPS Publishing ISBN 978 0 85369 760 2 2009

* Title: Herb, Nutrient, and Drug Interactions-Clinical Implications and Therapeutic Strategies Author: Stargrove, Treasure, McKee Edition: Mosby ISBN: 978-0-323-02964-3 2008

* Title: PDR for Herbal Medicines Author: Thomson Edition: 2nd Edition ISBN: 1-56363-361-2 2010

* Title: American Herbal Products Associations-Botanical Safety Handbook Author: McGuffin, Hobbs, Upton, Goldberg Edition: CRC Press ISBN: 0-8493-1675-8 2009

* Title: Quick Access Professional Guide to Conditions, Herbs & Supplements Author: Integrative Medicine Edition: First Edition, ISBN: 0-9670772-5-7 2000

* Title: The Clinician's Handbook of Natural Medicine Author: Pizzorno, Murray, Joiner-Bey Edition: 2nd Edition ISBN:978-0-443-06723-5 2008

* Title: Herb-Drug Interaction Handbook Author: Sharon M. Herr, RD, CDN Edition: 2nd Edition ISBN: 0-9678773-1-8 2010

* Title: Harrison's Principles of Internal Medicine, McGraw Hill Author: Fauci. Et. Al. Edition: 16 ISBN 0-07-021530-8 1998

* The pH Balance Health and Diet Guide for GI SystemAuthor: Smith, Hannah and Richardson Edition ISBN: 978-0-7788-0492-5 2014

by: Anna Jurik, DC, RD, LDN, Daniel Richardson, MSc, PhD, CNC, Brett Martin, DC
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Author:Jurik, Anna; Richardson, Daniel; Martin, Brett
Publication:Original Internist
Date:Sep 1, 2015
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