[INTERVIEW]
Ronda Nelson: All right, we are back with week two of our clinical thinking series. And this week, I have got a good one for you. 28-year-old woman walks into my office with severe anxiety, recurring panic attacks, and a history of thyroid issues. What would you do first? Most of us would probably go straight to the nervous system and adaptogens and all of that. But this case is very different. I want to show you why this anxiety case is actually rooted in the gut — what I did, how I figured it out. I’m going to take you along on the journey. Let’s go.
Welcome to the Clinical Entrepreneur Podcast. I’m Ronda, your no fluff, tell-it-like-it-is business bestie for wellness practitioners just like you who want to build a practice you love and make a bigger impact and a little money while you’re at it. So if you’re ready to ditch the overwhelm, attract your dream ideal patients, and finally run your practice with complete confidence, you’re in the right place. Each week, we’re tackling things from programs to patient retention to marketing strategies that actually work — sprinkled, of course, with a little sass, a lot of heart, and the step-by-step strategies that will help you get there. So grab your cup of coffee, your notebook, or whatever keeps you going, and let’s build a practice you love and a life you love together.
Well, hey friends, welcome back to the podcast. You know that we are in week two of our clinical thinking series, and this one is a good one. I actually picked out quite a few really great ones for you, so I’ll give you a little bit of context before I dive in.
So I get an email, which happens quite often. I get an email from someone who says, “Hey, you were recommended to me or referred to me by someone and I’d like to make an appointment with you.” It’s great. No problem. So I give them all the paperwork, tell them the pricing — everything’s fine. And the person that was emailing me had a name that wasn’t male. It could be male or female, right? So like Taylor — it was not that — but it could be either way. So I didn’t know if I was speaking with a man or a woman. But I think, well, I’ll find out when they send their intake forms back. I’ll know.
So this goes back and forth, back and forth. “Are there any labs you want us to order? I should order ahead of time. Is there anything that I need to do? Is there any information that I can provide to you?” And there’s like a lot of questions happening before the first appointment ever happens. And I’ve done this for so long, I now know — hey, this could be a sign that maybe something’s going on. Like maybe this isn’t going to work out like I think, or maybe there’s a little bit of anxiety here. I don’t know. But I’m just kind of paying attention to the clues, right?
So as I’m going back and forth with this person — “Okay, I’ve got labs. Can I send them over?” Yes, you can upload them into Practice Better. We get closer and closer and the labs finally come through and they were not complete. Not complete. Not complete. Finally, they come through — and I realized that the person’s name — I’m sorry, not the labs — the intake forms come through and the person’s name on the intake form is completely different. Like, okay. So evidently the person that I was speaking with was a husband and I’m actually working with a wife. So I’m like, okay, well, we’re going to just see how this goes. Already this is not setting up well for me, but I’m open and I really do want to help.
So when finally the day comes, we have our first appointment. Here’s the deal. You ready? Buckle up. Because this one’s going to make you think. It’s not hard, but it is going to be kind of — we’re coloring outside the lines a little bit and looking for clues that may not be otherwise obvious.
So here’s the deal. She is a 28-year-old female. She works as an executive administrative assistant in a very high-stress environment. Anxiety was her chief complaint. Not surprisingly, now I’m like, “Oh, I get this.” Because the husband is asking me all these questions. “Do we need this? Do we need that?” So I already kind of have a lay of the land.
So I start asking her. And in my intake form, I have a lot of history. I ask a lot of history — birth mode, breastfed, bottle-fed, mercury fillings in your mother, antibiotics in childhood, the type of food you ate as a child, the social environment you were in as a child. I ask a lot of those questions. So I had all this information. Here is kind of the cliff notes, I’ll say.
So she noticed that she had some depression in elementary school. Now, this one is hard to get out of people without further questioning. And the reason that I like to ask more questions — like the case I talked about last week — you just got to keep asking questions. If something doesn’t make sense, when they say, “Well, I’ve been depressed for a long time.” Well, what does a long time mean? Does that mean since two weeks ago? Or does that mean two months ago? Does it mean two years ago? Does it mean 20 years ago? Does it mean from birth? Did you come out of the vagina depressed? Well, no, they’ll say. And then I say, okay, well, if you didn’t come out that way depressed, were you depressed when you were one? Were you two? Like sometimes I have to exaggerate the end point in order to bring them into a reality check. Like, come on — get with me right here. What are we doing? What’s really happening?
So we finally figure out — yeah, she had a little bit of that in elementary school. She had some separation. She didn’t really have any friends. She just didn’t feel like she fit. But in middle school, she kind of found her stride. She started running and she was doing track and she was doing some longer distance running. And so within that culture or community of the other athletes there, she made some friends. She found out that she really loved it, and she actually became a very, very good athlete. She was tall, she was very thin — which made her a perfect fit for running.
So at around 13, for some reason — and this is according to her — for some reason, she started to gain weight. Now remember, she’s just super thin, and she started to gain some weight. I don’t know what that means. I don’t know if that was 100 pounds, if it was 20 pounds, if it was five pounds. It’s all she told me. In hindsight, I probably should have asked a few more questions. So her dad took her to the doctor and the doctor diagnosed her with hypothyroid and put her on Armour Thyroid. I said, you know, the chances of you being hypothyroid when you were 13 are slim and none, but maybe… you know… maybe.
So she also said she had some reflux and some digestive issues, but she said, “I think they were kind of worse — like if I got anxious about running or a meet or something that was coming up, I would get kind of anxious and then I would have some digestive symptoms.” And I thought, okay, you know, I can kind of understand that.
So then we move into high school. I know this is going slow, but you’re going to get it here in a minute. In junior year of high school, she has her very first panic attack. She described this panic attack as being more of like — almost like an out-of-body kind of experience — like her body went numb, and she said, “I just was not even connected with my body.” And so now I’m starting to get more of the story. She said, “I was super worried that there was something horribly wrong with me, and I always wondered if there was something horribly wrong with me.” Now I’m hearing the anxiety. Now I’m hearing the worry. Now I’m hearing the — oh my gosh — the dark dread, I like to call it.
So of course she has something wrong. And so what does her dad do? Takes her to the doctor and they ran all these tests. A ton, ton, ton of tests. They were just sure that she had MS because, of course, her dad has MS and her dad has celiac and all these other — bunch of other things. So they were just sure. She was sure that that was what was going to happen. And the anxiety kind of continued, but she didn’t have another panic attack. So now she gets still anxiety before she goes on running events, but she said there’s really no other apparent trigger. But the reflux kept going on. So of course, dad being a good dad takes her back to the doctor and it says esophagitis and gastritis. Okay — news flash — inflammation. Okay, fine. But what’s causing it? Why? And they did test her for celiac. She was negative for that.
So now here we are in like 2025-ish. She gets married in 2025 — less than a year ago as of the recording of this podcast. And before they got married, she got promoted at work and her stress went up dramatically. So they get married, she’s going to take a vacation, they go to Costa Rica for their honeymoon, and she was quite anxious about the trip. “What am I going to eat? What if it’s not safe? What if I don’t feel safe?” Do you hear all this anxiety coming through? Right? So no wonder she has digestive issues. No wonder she’s having panic attacks.
So as I’m listening to her, I’m thinking, “Oh, well, we just need some adaptogens and probably some digestive support. I don’t know.” Just thinking. And so she goes out and they go on the honeymoon and she had — like two days out — she had another panic attack. That numb, out-of-body kind of episode. And it was so bad that it completely wiped her out the next day. Then two days after that, her and her husband both got food poisoning from eating street food — you know, from the vendors — and so then they had diarrhea lasting for a couple of days.
Now in my mind I’m like, there it is — for sure — parasites. I’m already thinking, you know how you do, right? You’re talking to somebody and you’re thinking, “Okay, it could be this. It could be this. How are we going to manage this?” So she came home after the honeymoon. The diarrhea went away after a couple of days. Anxiety is still there, of course. And she comes home and she notices that she’s having light-colored stools, and that fatty foods are bothering her, and she’s having a lot of reflux and a lot more anxiety. And I thought, “Oh, well then that’s it for sure. It’s got to be her gallbladder.” You guys are all probably tracking with me, right? Of course this is going to be her gallbladder.
So then a couple, three days after she gets home — now she’s still got light-colored stools. She’s still not quite right. Her bowels are either constipated, diarrhea — something’s going on in there. She has her third full-blown panic attack after a very stressful day at work. It lasted about 45 minutes when she was numb, she said, and out-of-body. So this is how she comes to me.
So now I have all these hypotheses running around in my brain thinking, well, could be this, could be this, maybe this, maybe this. She already had the foresight — and probably her anxiety was driving this a little bit — but she went out and got her own labs and sent them in to me. And there were some things that were missing from the labs as you would expect. But I said, “Well, we don’t need to order anymore. I’m not going to do a whole bunch of testing. Let’s just see what your blood labs say and then I’ll work from there.”
So here’s what basically her primary complaints were: fatigue. She’s tired. She always feels like her body is fighting something. Those were her words — “It’s like it’s fighting something.” If she gets cold — this is key — if she gets cold at all, and she lives in a cold state where there’s snow, if she gets cold, she starts shaking uncontrollably for 20 minutes or so. Like cannot stop. When she’s going to sleep at night, she jolts — like jerk. Like full-on jerk. Like her husband is like, “What happened?” She has difficulty falling asleep. She has difficulty staying asleep. Her reflux is worse than it’s ever, ever been.
She has significant back pain at the bottom edge of her bra line — enough that it keeps her up at night. And in fact, when she comes home from work, she’s uncomfortable enough that she will take her bra off right away because it’s uncomfortable. And right there, my first thought was, “Oh my gosh, is she having a heart attack?” Because that’s a common thing for women that are having a heart attack — they get tightness around the chest, like bra line. But she said, “It’s better, but it kind of never goes away.” And it had been going on for a while. So I was like, okay, I’ll hold that as a possibility, but it’s not at the top of the list. She said her upper abdomen is tender to the touch. Like, if you push on it, it’s tender. Then she said she’s also always burping. Always burping. Releasing air from the stomach.
But then in her notes, this is what she says to me: “Well, I’m positive that this is all related to my thyroid. I’m sure it’s my thyroid. I’m just 100% sure that it’s my thyroid. So, I really just need you to check my thyroid.” Okay. I’ll do that. No problem. Don’t you love it when they tell you what they think the problem is? Yeah.
So now let’s walk through her labs. And you may want to write this down because you’re going to find some nuggets in here. I had to kind of think this one through and go back and look at the quick start guide — for those of you that have taken my functional blood chemistry course. There’s a quick start guide and that quick start guide has all these little shortcuts in it. And I wrote it and I cannot remember all the details because there’s so much in there. So I literally use it every time I have a lab test. I’m looking to try and piece the things together. I’m trying to go, okay, well, this marker — if it’s high, what could that be? If it’s low, what could it be?
So here’s her labs. I will tell you this: at first glance, her labs looked pretty benign. They were like — meh — nothing really too much on here. But this is one of those cases where the labs do not scream pathology, but they’re just quietly telling you what’s going on with her physiology. Does that make sense? It’s not telling me there’s any kind of pathology. It’s just confirming what I see happening in her physiology — like what’s really going on. So this is not really what I thought at all. It’s really about her stress hormones. This is what this is. So I’m going to show you. Let’s walk through these.
The first one is — drum roll, please — her fasting glucose was 71. Yes. 71. Now I looked at that and went, “Oh, well, hold on. That should not be that low. What is the problem?” So I looked to make sure it’s a fasting test and it was. So I asked her, listen, when did you have this test taken? And she said, “Oh, about 2:30 in the afternoon.” And I thought instantly — right away — I dismissed it. I was like, “Oh, well then that’s why her glucose is low, because she hadn’t eaten all day.” But then I started to think, well, wait a minute. There are times when sometimes we don’t eat all day, and that doesn’t mean that if you don’t eat all day — I’m not saying that’s good — but if you don’t eat all day, does that mean that I’m automatically hypoglycemic? No. That’s not actually what that means.
The bigger thing to ask here is: how well did her body handle her fasting state? What if she did a three-day fast? What if she did a five-day fast? What if she was intermittent fasting — albeit 2:30 is a little late to start eating — but nonetheless, what happens when you’re sick and you don’t eat? You don’t crash and burn. Your body just adapts, right? With a low glucose like this, what her body is telling me is that her metabolic resilience is low. And this could contribute to the shaking when she’s cold, the panic — like after she has stress and she goes into a panic — basically her whole body, her blood sugar is being propped up by cortisol and adrenaline because she did not handle a fast well. Her glucose dropped out. So her blood sugar is not being maintained by glycogen and like normal liver output, which there should be three to four days of stored glycogen in the liver. Why does she have low glucose? What’s happening? Because the whole system’s broken and she’s being propped up by cortisol and adrenaline. And adrenaline feels just like anxiety. Exactly like anxiety. When there’s a big push of adrenaline, that’s what’s going to happen.
In fact, one time she said to me — it was actually in a follow-up text, I’ll clarify — after I had seen her, she said, “I had another panic attack.” So she’s had several more since I talked to her before her supplements came. But she said, “It felt like someone injected me with something.” Those were her words. I was like, “Yeah, baby. That’s that adrenaline hit. Come on.” And so her wiring is so off that when she gets that adrenaline hit, that’s what it feels like. It feels like a panic attack to her.
So now let’s look at A1C. Her A1C was 4.6. On paper, you’d go, “Oh, well, hey, that looks pretty good.” But I think in a wired and tired patient — which is what she is — a lower A1C can mean that glucose may be dropping pretty frequently, right? We’re not getting that glycation level up around that 5.0, 5.1 where we want it. So her glucose could be dropping too frequently, too often — and that’s going to be driven by stress hormones. She doesn’t have a lot of metabolic buffer. Think about it like that. So that explains why she might be jerking at night or not falling asleep — like she falls asleep and then she jerks awake. And even the out-of-body could be because of that loss of metabolic buffer.
Now her bilirubin — another marker — was just a tiny, tiny bit elevated. It wasn’t really, really high. Her AST and her ALT were normal. Alk phos was normal — all of that. So I wasn’t thinking like, oh my gosh, we have a big liver problem. But what that does tell me when it goes up like that is that bile flow is often compromised. And I already know that because she has the light-colored stools, she’s intolerant to fatty foods, she gets bloated when she has fatty foods, and that mid-thoracic rib pain around there — that’s a classic sign for insufficient bile. So I thought, okay, there’s a check mark for me on that. Bile. I got that. That seems to be pretty clear.
And then her thyroid. All right — so we have to look at the thyroid numbers. Her TSH is right where it needs to be. And I don’t really look at TSH first. I’m always looking at total T4. I love total T4. It is my favorite thyroid marker. And very rarely will you get it. And of course, I didn’t. I got free T4 and free T3. Both of those were fine. And so her antibodies were just a tiny bit elevated at 40. So I wasn’t really too worried about that. But the thyroid does not explain what I’m seeing. It doesn’t explain the panic attacks. It doesn’t explain after having her Costa Rica food poisoning. It doesn’t explain any of that to me. I’m like, the thyroid seems fine. And she’s been on Armour since she’s 13 and she’s still on it. So really her thyroid’s kind of coasting along just fine. I wouldn’t touch the thyroid. But now I’ve got to address this with her because remember what she said? “Oh, it’s my thyroid. I just know it.” So I’ve got that in the back of my head. Like, how am I going to navigate this with her?
And then there were a couple of other ones. Her white blood cell count was just a tiny bit elevated. But all that tells me is that stress is causing immune vigilance. It’s not that there’s anything really wrong. It’s just that her immune system is vigilant. It’s just kind of watching. It’s like it’s on a little bit of a higher alert — okay, maybe something might be going on. We better just take care of it. And usually that’s because of stress cortisol. Her vitamin D was just a bit low at 24.4. I don’t think that was a 911 for me. But I do know this: low vitamin D equals low vagal tone, and I need the vagus nerve to get upregulated. And also, when there’s low vitamin D, we’re going to have lower barrier integrity and lower threshold for anxiety. It’s not the clinical core driver, but it’s a factor. It’s like vitamin D — when it’s low — it just kind of makes everything louder. Like it just sort of amplifies the things that are not right. It’s not the one that’s starting the fire. Everybody wants to make it the thing — “Oh, your vitamin D is low.” It’s not. It’s just one piece of the puzzle. And hers is just a little bit low.
So if I looked at all of those things, you see there was really nothing super significant on the labs — except that low glucose. If I look at it all together, I think, okay, well, her labs don’t show me anything that’s overtly wrong. It doesn’t justify any kind of aggressive intervention. Like I don’t need to do a parasite cleanse or anything like that. She’s definitely not a psychiatric case. Like that’s for sure. She just is running on stress hormones and she’s having difficulty maintaining her metabolic stability. So her body is basically sending danger signals to the brain going, “I’m not safe. I’m not safe. I’m not safe. Help, help, help, help.” And then the brain is doing what the brain is trying to do, which is protect her.
So if I had started with anxiety stuff and adaptogens and all that, I think that they wouldn’t have worked. And here’s why. I believe that the bigger issue is the digestive issue. Because we know that when digestion doesn’t work — when they’re not breaking food down — and she’s miserable… I mean, her abdomen is tender, she’s having trouble eating, she’s burping and bloating… If I just went and threw a bunch of adaptogens at her and said, “Oh, let’s just get your panic under control, your anxiety under control,” and if I hadn’t started with the digestion — I’m giving away the case — I think that it would have failed. And I can’t tell you how many times I’ve done that in the past because I just wasn’t being fully present. Or thinking, “Oh yeah, you’re stressed out here. Ashwagandha works great for everybody.”
But excuse me — she had red flags for me as I was listening and taking notes. The red flags were that she’s had reflux and some kind of gastric something since she was really an adolescent. She has had off and on light-colored fatty stools. She had food poisoning. We can see bile insufficiency on her lab work. Fatty foods bother her. Oh — she did say that she has a little bit of greasy film on the top of the water after she has a bowel movement. She’s burping — get that like air burp kind of thing — so probably hypochlorhydria. Her upper abdomen is tender. She’s got that mid-back pain. Like all of these things are pointing — screaming — digestion, digestion, digestion.
Oh, I forgot to tell you. When she had food poisoning, they “resolved” it with Cipro. I didn’t even have any words to say at that point. Like… why? But, you know, I was not around. So there we go. I’m thankful she’s okay. Cipro is a bad guy.
So now I have to think about digestion and I have to think about blood sugar. Her A1C was 4.6. Her fasting glucose is 71. This explains why she cannot regulate at night because her whole system is basically being strung together by cortisol and adrenaline. And that’s why she even feels like she’s fighting something. She just runs out of capacity to respond, really. So her gut’s probably been compromised — and I say gut, I don’t mean like lower gut. I mean upper digestion and probably the lower gut too. But I think it’s just been compromised for a really long time.
So she’s not breaking down fat. Well, that absolutely is going to affect neurotransmitter production. It’s going to have a huge impact on dysbiosis because bile helps to sterilize and normalize the gut bacteria. So she’s not digesting her fats well. She’s not going to clear her hormones well without bile. And she’s not detoxifying well. And then probably that vagus nerve is not firing the way that it needs to as well. It’s probably inflamed and dysfunctional and lord knows what. So she has all this stuff going on.
I think that the food poisoning in Costa Rica and the panic attack there and all that — it didn’t really trip… it wasn’t really the trip wire, I don’t think. I think that it just exposed what the bigger problem was.
But here was an interesting finding. She dropped this at the very end. Isn’t it funny how they do that? They’re always at the end. They’re like, “Oh, yeah, and one more thing.” She said every single time that she’s had a panic attack, every time she’s had chocolate that day. Now, I’m not saying chocolate’s the cause. I’m not saying histamines are the cause. I am saying when the same food shows up associated with several different events in different periods — days or times or on the timeline — I’m going to be paying attention. Because her gut’s already inflamed. I know it’s inflamed. She’s tender. She doesn’t feel good. And that food — chocolate — is high in histamines. So maybe, maybe not. But that was another little box that I’m putting over to the side going, okay, I might want to be keeping an eye out for that.
So I’m definitely not going to be looking at the thyroid. I’m really going to be looking at digestion. And one of the things she told me — on her intake form, she said, “Well, I don’t really believe supplements work.” Well, this is going to go well. This is going to go really well for me. I can just tell. And she said — I ask things like, “Where do they shop? Do you eat out? How often do you eat out? What kinds of things do you buy at the grocery store? Do you prefer organic or non-organic?” And this is what she said: “Oh, well, we shop at Walmart because I was told that organic doesn’t matter.” Because she read it somewhere and it doesn’t really matter. So they just get whatever’s cheap at Walmart.
So I had to have that conversation with her. Like, you know — garbage in, garbage out. We need to increase the — we talked about organic, and it’s true — like the air is contaminated, but would you rather have something that they’re literally spraying a chemical on, or at least a field that they’re not spraying a chemical on? Maybe it’s just getting a dusting from the air because they’re spraying the crop next door. Or maybe it’s in the groundwater, but still — it’s better than having it actually sprayed in or on the soil or on the food. So she understood that. And she also said, you know, “Filtered water is just —” I read somewhere — it cracked me up — “I read somewhere that there’s nothing wrong with tap water. It’s all fine.” Okay. So then we had to have that conversation.
So the first thing I’m going to do is start working on her digestion. Now, you could argue we need to start with adaptogens to get her calm. Well, you wouldn’t be wrong because I’m going to do that in step two. But my number one priority is to get this digestion working. I have got to get the inflammation out of that stomach. Now, I don’t know if she has a bug in there. And I’m not going to go order a whole bunch of tests. But what I am going to do is start simply. I’m going to use some bitters to upregulate and start to prime her digestive system. I’m going to give her a little bit of a zip. I like Zip for just that little bit of digestive support. I’m going to start with one tablet — not much. And then I’m probably going to give her a little bit of bile salt, just to make sure that she’s got enough bile to kind of get her over the hump. Because if I can help with that fat emulsification, it’s going to make a huge difference for her.
I also asked her to eat warm meals, eat regular meals — no more fasting, no skipping meals — eat things that are cooked. I’m trying to take the digestive pressure off while I’m trying to heal and fix that upper digestion. I just don’t want her eating a whole bunch of big raw salads. Not that they’re bad for you, but when your digestive system is compromised, sometimes the body just can’t handle that colder food. We want to give warmer food in there. So I’m not trying to force her digestion to do anything. I’m just trying to gently nudge it and push it in the right direction.
Now, at the same time, if I don’t get her some sense of calm, she’s going to be all over the place anxious. So after we met the first time, I got subsequently three more messages inside Practice Better from her — worried about this thing, worried about that thing. Then she was worried about her cycle and she didn’t have an LH surge, and she’s checking her cycle and how come she doesn’t have an LH surge, and well, why didn’t I have that? “Well, I had a little bit of cervical mucus, but why is there no LH? And what’s wrong with my sex hormones?” Can you hear it? Like the little hamster is running, running, running, running on the wheel in her mind. So I have to respond back and say, this is not what we’re worrying about right now. Okay, it’s very normal. And I gave her a Reader’s Digest version about cortisol, pregnenolone steal — you don’t have enough for your reproductive hormones. It’s okay. They’re going to be a little janky for a little bit. First things first — your body’s trying to prioritize cortisol. That’s what the problem is. We have to fix that system and we have to fix your digestion and the vagus nerve. So they all tie in all together.
So I did give her a product from Gaia that I love called Calm Restore. And she said that she had some success using magnesium glycinate. She seemed to be kind of attached to that one at night. I’m like, okay, that’s okay. I gave her some breathing exercises to do after she eats because I want to start to relax that nervous system. We talked about vagus nerve exercises — so gargling slash gagging, but if you can just gargle deeply, that’s great. And then we talked about rubbing your eyes. We talked about humming being a good exercise to be able to wake up that vagus nerve. And she was fine with that. She was like, “Okay, that all makes sense.” I’m not giving her any GABA. I’m not going down that road. I know that the body is able to heal. So once I get digestion starting to run, and the Calm Restore starting to — if I can decrease the anxiety by 20–30%, it’s a win for me. Because if it was just anxiety or just that stress response panic, then that would be easy to fix. Rarely is. Almost always is a gut problem somewhere — whether it’s upper digestion and a vagus nerve, or hypochlorhydria, or gastritis, or poor bile flow. Or it’s a parasite, or it’s some kind of dysbiosis, or SIBO, or something.
But I asked her: does more of the discomfort happen above the belly button or below the belly button? And she was right away — above. Right away. So I’m like, okay. Well, thank you very much. Now I’m very clear. This is exactly where we need to start.
So then my next kind of place that I’m going to go with her is to start to restore the metabolic signaling. We talked about eating protein with meals and no simple sugars — no refined sugars, no cracker, no cookie, no nothing like that. No cold smoothies. Like everything is warm and easy to digest. No intermittent fasting. Like get up and eat and then nourish throughout the day. The goal here is to keep that blood sugar really stable and steady throughout the day. I’m not messing with her thyroid. There’s no way.
So really all I did was up her digestion. I gave her one thing — one thing — and I told her to order one bottle. Just one bottle. We’re just going to see how you do. Not going to hurt anything. Not that expensive. We’re going to see how you do. And if we have to change it, we’ll change it. But I said, I’m fairly confident that this is going to be just fine. So I said, we’re going to follow up in three weeks after she has her supplement. So it’s about roughly — I usually say four weeks from the time that we spoke the first time.
And here’s what I’m going to check in on. And I always write this down in my notes every time. What are the questions that I need to ask? Because it’s all fresh in my mind when I’m talking to her, but I don’t want to forget it. So I always at the end write down: what do I want to follow up on? I want to ask her about reflux. I want to ask her about any nausea. I want to ask her about buoyancy of the stool or fat in the water. I want to ask her about the burping and belching that’s been happening. I want to ask her about falling asleep and staying asleep. I want to ask her about the body alarm — you know, her body feeling that panicky kind of feeling — if that’s been happening. I’m going to ask her about chocolate. Has she had any chocolate? And if so, did it elicit any kind of a panic attack or any kind of emotional reaction? And then I’m going to ask her if she’s had any kind of fatty foods. I expect that all of those things are going to get better.
And I really didn’t give her more than — let me see — I gave her digestive bitters. I gave her bile support. I gave her bile salts. I gave her gallbladder support. And Calm Restore. So I gave her four things. That was all that I gave her. And I think she’s going to do fine. Now that I’ll change — that’s not how she’s going to be forever. But for right now, that’s all I did.
So she has those four things. Now I know that I’m going to have to write this down for her. And she still texted me back because she’s got anxiety all over the place. But here’s what I did. I took my notes — and you don’t have to do this with everyone — but I just want to give you this as a little side note. Sometimes when you have patients like this that are so anxious, we want to manage their expectations, but I also know that these are the kind of people that need knowledge. Like she needed to know the details. “What’s wrong with me? What’s wrong with my thyroid? What’s wrong? I know it’s my thyroid. Well, what about this? Well, what about this?” She is one of those people that needs the details. And as an executive assistant, I get it. I get it. She is like — her whole life is details, right? So she needs to know those details.
So what I did was — no name or anything — all I did was take my notes from my appointment. “Here’s what I’m seeing. Here’s what we’re going to do. Here’s how we’re going to do it. These are the supplements we’re going to use. This is what I think is going on. Here’s why we’re going to take the approach we’re going to do,” etc. Put all the information in there, and I fed it into AI — and there’s no patient name, there’s no identifying information, nothing like that. And I said, “Please type this up as a recap with these three priorities: number one is optimizing digestion, number two was calming the nervous system, and number three was dietary recommendations.” And then I had a little number four at the bottom that was just basically reassess and then adjust if we need to. It wasn’t complicated. It wasn’t long. It was probably maybe two-thirds of a page. But what it did was it took everything that we talked about during our visit and it just put it into a nice tidy little bundle that I could give her.
And she was so thankful for that. She said, “Thank you so much for taking the time to really write this out… because it makes my brain be able to understand where we’re going, and when I get anxious, then I can go back and look at it and go, ‘No, we have a plan.'” And now that didn’t really change as much because I still had to remind her — we do have a plan. But this is one of those places where you can lean in and leverage AI a little bit, and it makes your job easier and it also made it much easier for the patient.
So if I was going to kind of distill this case — wrap this thing up — I would say: when you have these patients that have anxiety, you have to ask the question, what’s causing the anxiety? Where did it come from? The body doesn’t just — fine, fine, fine — one day going along, and all of a sudden the body wakes up and goes, “You know, I think today I’m just going to take on some anxiety.” Because it’s not good for the body either. Body does not want that. So why? What happened? Where did the anxiety come from? Was it — I mean, maybe it happened in childhood. Maybe there was a trauma or something that she doesn’t recall or remember. I don’t know. But I do know that there’s always an underlying issue. Is it a parasite? I don’t know. Maybe. I don’t think so. But what if she ends up with H. pylori? What if that’s it? I don’t think so. But I could be wrong. But for right now, I’m not wrong — upregulating digestion.
Now, when I would test — because I can hear you. You’re probably saying, “Well, why didn’t you just test for that?” Because remember, I did not order the test. She had someone else order. But what my philosophy is, rather than do what most functional medicine doctors do — and you know how I feel about this — like I always say, I hate functional medicine, but I am one. I mean, I don’t like some of what it stands for, and I’m in the crowd, but I don’t like the part where we just go order a whole bunch of tests. And even in my Facebook group, so many times I’ll have practitioners that’ll say, “Oh, you need to order this test and order this test and order this test.” And I just go, “No. Why? Why spend the patient’s money? Why?”
I know that what I’m giving her for digestion is going to work — either work or not work — and those supplements are going to cost less than $100 and the test is going to cost way more than that. What if the supplements that I give work great and no problem? What if all she needs is just some digestive support? That’s it. And the reflux is gone. I’ve had hundreds and hundreds and hundreds and hundreds of cases that have resolved like that. I could have spent $1,000 on a stool test and a wheat zoomer and a gut zoomer and this, that. I could have done all of that. Why? How about I just go with what seems obvious? I’m looking at her labs, talking to her. It was clearly a gut — and then anxiety — and there’s some metabolic dysfunction.
I haven’t even addressed that yet because I can’t go in and deal with the blood sugar issue until I deal with the cortisol issue, and I can’t deal with the cortisol issue until I deal with this upper digestion issue. So it has to be in order. We sometimes just go, “Well, you have anxiety. Here’s some Calm Restore. Here’s some ashwagandha or here’s this, here’s that.” That’s never the right thing. I mean, it might be sometimes, but I think sometimes we’re so quick to say, “Well, you know, this is the issue.” It’s like I talked about last week’s podcast — the 30/30 rule. It’s really the third third. The first thing you come up with is probably not right. Probably not the second third either. It’s usually the third third where we start seeing the magic and we go, that’s how all these pieces all fit together. And that’s what I finally got to with this patient. So I didn’t stop with the obvious answer. I just kept going, kept going, kept going. And finally I was able to put it all together. I know I’ve got work to do, but I have to start with first things first. You cannot rebuild Rome in a day.
[CLOSING]
Ronda Nelson: So if you’ve been listening, you know that I have a free resource for you. If you’d like to think like this and learn, get inside my brain and learn how I think about this — or develop this type of thinking in your own practice — I have this free resource and it’s called The Six Principles of Clinical Thinking. This is the exact framework that I use when I work through these cases. You can get to it by going to rondanelson.com/6principles — that’s the number 6 and then principles. You can go there, you can download it and get it. It’s my free brain download to you about how I think through these cases. It’ll give you a foundation that you can use with your own cases and your own patients to kind of ask the right questions, dig a little bit deeper, and figure out what’s actually really going on with them. So thanks for hanging out with me. Next week, I’ve got another saucy case for you. Have a great week. I’ll see you then. Thanks, friends.
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