CNM N1 S2 Case Study (sample1)

Question 1

SECTION C – Case Study (20 marks)
Name: Fletch
Sex: Male
Age: 57 years
Height: 178cm
Weight: 87kg
Occupation: Marketing Director
Prescription medication: Occasional steroid cream for eczema on his knees and
elbows.
Supplements: None.
Presenting symptoms: Fletch wants to try something new for his eczema which he
has had since his teenage years. It flares up mostly on the inside of elbows and
backs of his knees, but it can spread into his scalp and across his abdomen. When
asked about his skin, Fletch also mentions he has an itchy, crusted mole on his right
arm.
Stress and drinking alcohol make his eczema worse and also affects his digestion.
He suffers with loose stools, which can be black and tarry on occasion. He
experiences digestive pain in the lower left quadrant at least once or twice a week.
This pain has intensified over the last 3 months. His father has digestive issues too.
He sleeps well except at weekends when he has drunk more than a bottle of wine.
He finds that he drinks more when work is demanding, which has been the case
recently. This also means a flare up of his eczema.
Medical history: Suffered some anxiety through high school. Stress has always
affected his digestive tract and he started suffering from loose stools more
frequently.
Family history: Mother suffers with IBS and vaginal thrush. Father has high blood
pressure and had a heart bypass operation in his 50’s.
Diet:
Breakfast: 2 cups of strong black coffee, no sugar. Two boiled eggs and 2 piece of
plain whole wheat toast with margarine
Morning snack: Café bought banana and chocolate chip muffin and a cup of plain
black tea.
Lunch: Thai or Vietnamese take away – usually noodles with beef and vegetables. A can of coke.
Afternoon snack: A small apple or clementine and a cup of black coffee. Every
second day he will have a chocolate bar or an energy drink.
Evening meal: Beef pasta or lasagne, or cheese pizza with half a bottle of red wine.
Cravings: Coffee and chocolate.
Water: Drinks 2L of water per day.
Alcohol: Half a bottle of wine with dinner on weekdays, and a bottle or more on a
Friday night. He doesn’t drink on Sundays.
Lifestyle: Fletch will run 5km on a Sunday. He enjoys the theatre and visiting
galleries. He has a long-term girlfriend and no children. He works from 8am – 6pm, 5
days per week, in a demanding but enjoyable role. He would like to do more
exercise.

Answer 1

triggers and mediators next card

Question 2

What are the likely triggers in this case?
Please explain your rationale (5 marks)

Answer 2

Trigger: excessive caffeine (1mark) and alcohol (1 mark) in the diet

Question 3

What are the likely mediators in this case? Please explain your rationale (5 marks)

Answer 3

Mediators:
high sugar;
alcohol;
dysbiosis/poor gut health;
low dietary omega 3 and high Omega 6/trans fats; demanding job/stress- cortisol;
caffeine;

(0.5 each-3 max)

Question 4

State any red flags identified (1 mark)

Answer 4

Blood in stool – black tarry stool.
Along with the bowel changes/diarrhoea/pain
Itching crusted mole

(1/2 mark each to max 1 mark)

Question 5

3. Formulate THREE therapeutic aims based on your naturopathic summary (3
   marks)

Answer 5

• Reduce inflammation to improve skin health.
• Support nervous system to reduce the effects of stress on his skin.
• Support the digestive system to improve absorption of nutrients and regulate transit time/reduce pain.

Question 6

4. List THREE nutrients you would initially recommend. Provide a rationale for
   your answer (3 marks)

Any sensible nutrient (½ mark) with sound rationale (½ mark) maximum tot

Answer 6

• (Examples (any sound advice linked to summary):
• Probiotics- S.boullardi digestive support
• Zinc – skin health
• Omega 3 – skin health/ anti inflammatory
• Magnesium – stress/anxiety, blood sugar control, energy- stress as a trigger for eczema
• B vitamins – stress and alcohol intake and CHO metabolism
• Fibre- digestive health/microbiome/biodiversity etc.

Question 7

List TWO positive things about the client’s diet (2 marks)

(any sensible positive dietary point)

Answer 7

• Takes vegetables every day.
• Fruit daily
• Drinks water
• Whole grains etc

Question 8

6. List TWO negative things about the client’s diet (2 marks)
   - Not an exhaustive list

- Not an exhaustive list

Answer 8

• Excessive caffeine – must mention.
• Excessive alcohol – must mention.
• Limited EFAs – no fish
• Low fibre
• Low variety/phytonutrients
• Evening meal is unbalanced and quite inflammatory.
• Excessive wheat/gluten etc

Question 9

7. What FOUR dietary changes could you suggest to Fletch? Please explain your reason for these recommendations (4 marks)

Answer 9

• Incorporate protein with every meal – help balance blood sugar.
• Increase vegetable intake to a minimum of 5 portions – support gut microbiome
  and micronutrient intake.
• Increase hydration to 2L a day – supporting detoxification.
• Reduce alcohol consumption, ultimately eliminating it – reducing toxin burden.
• Remove refined carbohydrates and replace with unrefined carbohydrates – help
  balance blood sugar.
• Increase legumes and wholegrains – help balance blood sugar and improve
  detoxification/gut health.
• Include oily fish – anti-inflammatory/skin health.
• Reduce sugar intake – help balance blood sugar. Etc.