40 yo male ongoing, chronic pain and burning sensation throughout body (especially legs), fatigue, restless legs, and sleep difficulties secondary to diagnosed fibromyalgia, history of multiple surgeries and complex medical background.
– History of Present Illness: 40-year-old male with a significant medical and surgical history including:Ongoing and new symptoms (primarily in the past year):
– Three herniated cervical discs (C4–C7) leading to artificial disc placement approximately three years ago.
– Post-operative complications: developed obstructive sleep apnea (OSA) and right phrenic nerve palsy, resulting in right diaphragmatic elevation and reduced right lung function (54%).
– Underwent diaphragmatic plication in October , complicated by post-op pleural fluid collection—required chest tube and hospitalization.
– Gradual improvement in breathing since surgery, but full benefit may not be seen for up to 16 months post-op.
– Persistent, widespread burning sensation, skin flushing, and significant discomfort.
– Significant leg pain described as burning and spasms from calves to feet; legs “restless.”
– Sleep apnea now characterized as mild (12 apneic episodes/hr, down from 37/hr); currently using BiPAP, pending fitting for dental mouth guard for OSA.
– Extreme fatigue, feeling “burned out,” with fluctuating energy—sometimes unable to get out of bed.
– Chronic pain not responsive to Lyrica (pregabalin); current regimen is gabapentin 600 mg 2–3x/day, which reduces burning but causes significant sedation and less relief for aches/pains/restless legs.
– Recent trial of Cymbalta (duloxetine) poorly tolerated—dizziness, mood changes.
– Diagnosed with fibromyalgia at Mayo Clinic after exclusion of other causes (neurology, autoimmune, and serological tests negative except for low vitamin D).
– Recent episodes of prostatitis, intermittent pain and hematuria—PSA and urine cultures normal at last check.
– Intermittent erectile dysfunction, managed with tadalafil (daily) and as-needed sublingual agents.
– TMJ pain post neck surgery—receives regular Botox to masseter/temporalis; PRP injection and dental splint being pursued.
– Diet: Variable, reports healthy options at home but increased fast food, pizza, and processed foods, especially while traveling (2–3 weeks/month); excessive caffeine (2 cups coffee, 2–3 diet cokes/day); sweets/snacking in evenings.
– Alcohol: Moderate, socially at home and more while on the road; finds temporary pain relief but no preference or dependence.
- He is on carvedilol and gabapentin daily.
Cholesterol 239, HDl 59, LDL, 156, Trig 122
B12 967, Folate 5.23, Homocysteine 10.5
MCV 92.6
WBC 9.2
LDH 269
ESR 17
Hs-crp 1.6
DHEA-s 42, Tesosterone 347, free T 71
Vitamin D 32
GGT 38, ALT 31, AST 25
CO2 16
Candida Iga, Igm, Igg positive in serum
A1c 5.3, Insulin 7, c-peptide 2.32
OAT testing showing high mercury and Omega imbalance. MTBE high (need clean water), B2 need is high also- which can correlate with the homocysteine.
Plan:
Any peptides that may be helpful to modulate immune function and pain? Would TA1 and TB500 or pentadeca be a good option.
Need to prepare his body prior to trying to eliminate metals and also finding the source of the mercury.
Thought some PC could be helpful as well.
Consider testosterone therapy.
Replete vitamin D with d3/k2.
Thinking cholestyramine to bind bile and toxins and encourage liver to pull more cholesterol to excrete.
Support phase 3 detox, treat yeast, then detox metal last.
Any other thoughts?
