At the heart

1
At the heart of medicine lies the individual
and each patients unique story
At the heart of medicine lies the individual
and each patients unique story
2
That Story Is Typically Told As

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)
• Family History (FH)
• Dietary History
• Supplement and Medication History
• Lifestyle, Social, and Exercise History
• Physical Exam Findings
• Laboratory Evaluation

3

• In conventional medicine, the aim is to arrive
  quickly at the diagnosis
• This emphasis on diagnosis is particularly
  critical in the acute care setting rapid
  diagnosis leads to rapid treatment
• Treatment in this setting must be prompt, as it
  is often designed to lock down and control
  physiology
• The chief complaint and history of the present
  illness become the critical aspects of the story
  the rest of the patients story is truncated when
  other information is seen as superfluous to
  reaching the diagnosis

4
In acute care, the patients story is squeezed
down to the chief complaint and history of the
present illness
while the diagnosis
increases in importance.
5
Example 1Chief Complaint Wheezing
History of Present Illness
sudden onset
asthmatic history
tightness in the chest
shortness of breath
DiagnosisAsthma Attack
bronchodilators
corticosteroids
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Example 2Chief Complaint Chest Pain
History of Present Illness
arm numbness
shortness of breath
sweating
DiagnosisHeart Attack
angioplasty
thrombolytics
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Problems arise when the acute-care model is used
to address chronic long-term health issues

• The clinician proceeds directly to the diagnosis
  naming the disease in order to identify as
  quickly as possible a medication to treat that
  disease
• THE RESULTS
• Little attention is paid to the patients story
  beyond the chief complaint and history of the
  present illness
• The patients whole story is not understood
• Each complaint becomes a discrete issue, dealt
  with in isolation from the others

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Dicyclomine
NSAID
Irritable Bowel Syndrome
Osteoarthritis
the result is a focus on treating each symptom
complex as a separate and distinct disease with
a separate and distinct treatment.
ACE inhibitor
Hypertension
Migraines
Triptan
Depression
Hypercholest- erolemia
Gastroesophageal Reflux Disease
Statin
SSRI
H2 blocker
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Each individual diagnosis becomes a distinct
entity unto itself. The patients whole
story never has a chance to be heard and
understood In context.
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It is apparent that in its rush to diagnose
conventional medicine is focused on the branches
and leaves of the tree, and not the trunk and
roots.
Cardiology
Pulmonary
Endocrinology
Urology/Nephrology
Gastroenterology
Hepatology
Organ System Diagnosis
Neurology
Allergy
Signs and Symptoms
Fundamental Clinical Imbalances Hormonal and
Neurotransmitter Imbalances Redox Imbalance
Oxidative Stress Mitochondropathy Detox/Biotrans
formation/Excretory Imbalance Immune
Imbalance Inflammatory Imbalance Digestive/Absorpt
ive and Microbiological Imbalance Structural
Integrity Imbalance
Fundamental Physiological Processes
1. Communication - Outside the cell - Inside
the cell
2. Bioenergetics/Energy Transformation 3.
Replication/Repair/Maintenance/ Structural
Integrity
4. Elimination of Waste 5. Protection/Defense 6.
Transport/Circulation
Mind and Spirit Genetic Predisposition Experiences
, Attitudes, Beliefs
Xenobiotics Micro-organismsRadiation
Physical ExerciseTrauma
Diet, Nutrients, Air/Water
Psycho-social
Environmental Inputs
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Functional medicine should not be viewed as an
alternative, but as a bridge to a more effective
chronic-care model.
12
?
?
In the functional medicine model, the patients
full story is of central importance
Instead of a preoccupation with how to namethe
disease, the critical questions become

• Where does the symptom come from?
• That is, what are the antecedents and triggers?
• What keeps it going?
• That is, what are the mediators?
• And what can be done to change that dis-eased
  homeostatic balance point the patient is locked
  into?
• That is, what are the underlying points of
  leverage where intervention can be most
  effective?

?
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To answer these questions requires a new
perspective on the chronic-care model
First, the full story must be understood within
the context of antecedents, triggers, and
mediators
antecedents and triggers
mediators
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Nutrient excess
Excessive exercise
Infectious micro- organisms
Nutrient insufficiency
Spiritual angst
Dysbiosis
Structural or physical damage
Situational stressfear, anxiety, worry
Xenobiotics
The story is no longer just the CC and HPI, but
is expanded to encompass all the patients
history that may reveal the source(s) of symptoms.
Adiposity
Hypoglycemia
Aging
Disrupted light cyclescircadian dysrhythmias
Drug side effects
Toxic metals
Radiation
Excessive noise
Hyperglycemia
Genetic pre- disposition (SNPs)
Emotional trauma
Food toxicants (allergens, stimulants, etc,)
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These fundamental clinical imbalances are the
underlying mechanisms of disease
Detoxification and Biotransformation
Structural Integrity
InflammatoryProcess
Nutrient excess
Excessive exercise
Infectious micro- organisms
Nutrient insufficiency
Spiritual angst
Dysbiosis
Situational stressfear, anxiety, worry
Xenobiotics
Next, the patients story is filtered through
these antecedents, triggers, and mediators, which
leads to an understanding of where key imbalances
may reside
Structural or physical damage
Adiposity
Psychological and Spiritual Equilibrium
Disrupted light cyclescircadian dysrhythmias
Immune Surveillance
Drug side effects
Hypoglycemia
Hyperglycemia
Toxic metals
Noise
Radiation
Genetic pre- disposition (SNPs)
Emotional trauma
Food toxicants (allergens, stimulants, etc,)
Aging
Digestion, Absorption,and Barrier Integrity
Oxidative/Reductive Homeodynamics
Hormone andNeurotransmitter Regulation
The diagnosis remains useful, but is less
important.
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Counseling
Exercise
Phytonutrients
Minerals
Meditation
The expanded model permits the clinician to
choose from an enlarged toolkit of therapies.
Diet
Drugs
Yoga
Surgery
Acupuncture
Vitamins
Manipulative Therapies
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Lets apply the functional medicine model to an
apparently simple case a 37 year old female
with a chief complaint of chronic headaches.
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Weve already seen how she might be
treatedusing the existing model.
Chief ComplaintHeadaches
History of present illness
Diagnosis Migraines
Treatment Triptan
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But her case may not be as simple as it appears
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Detoxification and Biotransformation
InflammatoryProcess
Structural Integrity
From a functional medicine perspective, the CC
and HPI must be filtered through the relevant
antecedents, triggers, and mediators. To
understand the patients complete picture, past
medical history, family history, diet,
medications, and lifestyle all need to be viewed
through this lens as well.
Psychological and SpiritualEquilibrium
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Hormone and Neurotransmitter Regulation
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Detoxification and Biotransformation
InflammatoryProcess
Structural Integrity
A variety of potential antecedents, triggers, and
mediators might be present in a woman with a
chief complaint of chronic headaches
Psychological and SpiritualEquilibrium
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Hormone and Neurotransmitter Regulation
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Detoxification and Biotransformation
InflammatoryProcess
Structural Integrity
Headaches triggered by menstrual cycle
Estrogen dominance
Headaches triggered by exposure to toxins MSG,
aspartame, smoke, perfume
Headaches triggered by changes in sleep
Psychological and SpiritualEquilibrium
Immune Surveillance
Circadian rhythm
Circadian rhythm
Exposure to toxins
Exposure to toxins
Headaches triggered by food allergen
Headaches triggered by fasting
Hypoglycemia
Food allergen
Food Allergen
Food allergen
Headaches triggered by stress
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Situational stress
Hormone and Neurotransmitter Regulation
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Detoxification and Biotransformation
Exposure to toxins
Inflammatory Process
Food Allergen
Circadian Rhythm
Structural Integrity
Exposure to toxins
Surgeries
Adiposity
Adiposity
Accidents, injuries
Past medical history leads to additional clues
Accidents, injuries
Exposure to toxins
Surgeries
Psychological and Spiritual Equilibrium
Adiposity
Chronic antibiotic use
Situational Stress
Immune Surveillance
Accidents or Injuries
Adiposity
Food Allergen
Emotional trauma
Past or recurrent infections
Past or recurrent infections
Chronic disease
Exposure to toxins
Exposure to toxins
Chronic antibiotic use
Oxidative/Reductive Homeodynamics
Emotional trauma
Digestion, Absorption, and Barrier Integrity
Chronic Disease
Past or recurrent infections
Accidents, injuries
Exposure to toxins
Food Allergen
Chronic disease
Hormone and Neurotransmitter Regulation
Surgeries
Chronic antibiotic use
Emotional trauma
Chronic antibiotic usedysbiosis
Estrogen dominance
Circadian Rhythm
Hypoglycemia
Adiposity
Emotional trauma
Exposure to toxins
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Detoxification and Biotransformation
Exposure to toxins
Inflammatory Process
Food allergen
Circadian Rhythm
Structural Integrity
Exposure to toxins
Surgeries
Adiposity
Adiposity
Accidents, injuries
Family history may indicate genetic
predispositions
Accidents, injuries
Exposure to toxins
Predisposition to inflammation
Psychological and Spiritual Equilibrium
Allergies
Situational Stress
Immune Surveillance
Adiposity
Food allergen
Emotional trauma
Inflammatory conditions such as RA, UC, etc.
Past or recurrent infections
Chronic disease
Exposure to toxins
Chronic antibiotic use
Oxidative/Reductive Homeodynamics
Digestion, Absorption,and Barrier Integrity
Past or recurrent infections
Accidents, injuries
Exposure to toxins
Food allergen
Chronic disease
Hormone andNeurotransmitter Regulation
Surgeries
Chronic antibiotic use
Emotional trauma
Chronic antibiotic usedysbiosis
Estrogen dominance
Circadian Rhythm
Hypoglycemia
Adiposity
Emotional trauma
Exposure to toxins
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Detoxification and Biotransformation
Exposure to toxins
Nutrient insufficiencies sulfur, amino acids,
etc.
Inflammatory Process
Food allergen
Dietary toxin-mercury
Circadian Rhythm
Structural Integrity
Exposure to toxins
Surgeries
Adiposity
Adiposity
Accidents, injuries
Accidents, injuries
Exposure to toxins
Predisposition to inflammation
Dietary History
Nutrient insufficienciesEFAs, etc.
Nutrient excesssaturated fat
Dietary insufficienciesantioxidants, magnesium,
fiber, EFAs, etc.
Psychological and Spiritual Equilibrium
Immune Surveillance
Food allergen
Situational Stress
Past or recurrent infections
Dietary toxinsmercury, exogenous estrogens, etc.
Adiposity
Exposure to toxins
Emotional trauma
Chronic antibiotic use
Chronic disease
Nutrient insufficiencies
Dietary toxinmercury
Oxidative/Reductive Homeodynamics
Dietary excesses saturated fat, simple sugars,
caffeine, alcohol, etc.
Digestion, Absorption, and Barrier Integrity
Past or recurrent infections
Accidents, injuries
Exposure to toxins
Food allergen
Chronic disease
Surgeries
Hormone andNeurotransmitter Regulation
Chronic antibiotic use
Emotional trauma
Nutrient insufficiencies antioxidants
Chronic antibiotic usedysbiosis
Estrogen dominance
Nutrient insufficiencies zinc, glutamineleaky
gut
Circadian Rhythm
Dietary toxin mercury
Dietary toxins exogenous estrogens
Hypoglycemia
Nutrient excessalcohol
Adiposity
Dietary toxinmercury
Nutrient excess simple sugars
Emotional trauma
Exposure to toxins
Nutrient insufficiencies
Nutrient excesscaffeine
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Detoxification and Biotransformation
Exposure to toxins
Nutrient insufficiencies sulfur, amino acids,
etc.
Inflammatory Process
Food allergen
Dietary toxin-mercury
Circadian Rhythm
Structural Integrity
Drug side effects-inhibit or promote
Exposure to toxins
Surgeries
Adiposity
Adiposity
Accidents, injuries
Accidents, injuries
Exposure to toxins
Predisposition to inflammation
Medication History
Nutrient insufficienciesEFAs, etc.
Nutrient excesssaturated fat
Drug side effects
Psychological and Spiritual Equilibrium
Immune Surveillance
Food allergen
Situational Stress
Past or recurrent infections
Drug side effects
Adiposity
Exposure to toxins
Emotional trauma
Chronic antibiotic use
Chronic disease
Nutrient insufficiencies
Dietary toxinmercury
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Past or recurrent infections
Accidents, injuries
Exposure to toxins
Food allergen
Surgeries
Chronic disease
Hormone andNeurotransmitter Regulation
Emotional trauma
Chronic antibiotic use
Chronic antibiotic usedysbiosis
Nutrient insufficiencies antioxidants
Estrogen dominance
Nutrient insufficiencies zinc, glutamineleaky
gut
Circadian Rhythm
Dietary toxin mercury
Dietary toxins exogenous estrogens
Hypoglycemia
Nutrient excessalcohol
Adiposity
Drug side effects
Dietary toxinmercury
Nutrient excess simple sugars
Emotional trauma
Exposure to toxins
Drug side effects
Nutrient insufficiencies
Nutrient excesscaffeine
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Detoxification and Biotransformation
Exposure to toxins
Inflammatory Process
Nutrient insufficiencies sulfur, amino acids,
etc.
Food allergen
Circadian Rhythm
Dietary toxin-mercury
Exposure to toxins
Drug side effects-inhibit or promote
Adiposity
Structural Integrity
Lack of exercise
Accidents, injuries
Inhibit or promote
Surgeries
Exposure to toxins
Adiposity
Predisposition to inflammation
Accidents, injuries
Nutrient insufficienciesEFAs, etc.
Over or improper exercise
Nutrient excesssaturated fat
Lifestyle
Drug side effects
Psychological and Spiritual Equilibrium
Immune Surveillance
Hobbies
Situational Stress
Food allergen
Adiposity
Past or recurrent infections
Emotional trauma
Exposure to toxins
Chronic disease
Relationships
Recreational Drugs
Chronic antibiotic use
Lack of exercise
Nutrient insufficiencies
Loneliness
Dietary toxinmercury
Spiritual angst
Lack of exercise
Oxidative/Reductive Homeodynamics
Exercise
Spirituality
Loneliness
Digestion, Absorption, and Barrier Integrity
Past or recurrent infections
Accidents, injuries
Exposure to toxins
Food allergen
Chronic disease
Surgeries
Chronic antibiotic use
Hormone andNeurotransmitter Regulation
Emotional trauma
Nutrient insufficiencies antioxidants
Chronic antibiotic usedysbiosis
Estrogen dominance
Nutrient insufficiencies zinc, glutamineleaky
gut
Dietary toxins exogenous estrogens
Dietary toxin mercury
Circadian Rhythm
Hypoglycemia
Nutrient excessalcohol
Nutrient excess simple sugars
Drug side effects
Adiposity
Dietary toxinmercury
Lack of exercise
Drug side effects
Emotional trauma
Lack of exercise
Lack of exercise
Exposure to toxins
Alcohol-leaky gut
Loneliness
Nutrient insufficiencies
Spiritual angst
Nutrient excesscaffeine
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Detoxification and Biotransformation
Inflammatory Process
Structural Integrity
Psychological and Spiritual Equilibrium
Immune Surveillance
A variety of potential laboratory assessments can
then be useful in confirming key imbalances on
which to focus.
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Hormone andNeurotransmitter Regulation
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Detoxification and Biotransformation
Inflammatory Process
Structural Integrity
Psychological and Spiritual Equilibrium
Specifically, what was this37 year old females
story?
Immune Surveillance
Food allergen
Headaches triggered by diet
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Food allergen
Hormone andNeurotransmitter Regulation
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Detoxification and Biotransformation
Inflammatory Process
Inflammatory damage
Structural Integrity
Structural damage
Psychological and Spiritual Equilibrium
What are the clues in her past medical history?
Immune Surveillance
Food allergen
History of chronic sinusitis
History of multiple antibiotics
History of osteoarthritis of the knee
Gas and bloating
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Food allergen
Dysbiosis
Drug side effects leaky gut
Hormone andNeurotransmitter Regulation
Digestive enzyme/HCL insufficiency
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Detoxification and Biotransformation
Inflammatory Process
Inflammatory damage
Structural Integrity
Nutrient insufficiency low EFAs, high AA
Structural damage
Psychological and Spiritual Equilibrium
What are the clues in her diet and medications?
Immune Surveillance
Food allergen
Standard American Diet
NSAIDS for OA
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Food allergen
Dysbiosis
Digestive enzyme/HCL insufficiency
Hormone andNeurotransmitter Regulation
Drug side effects leaky gut
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Detoxification and Biotransformation
Inflammatory Process
Inflammatory damage
Structural Integrity
Nutrient insufficiency low EFAs, high AA
Structural damage
Inflammatory genetic predisposition
What are the cluesin her family history?
Psychological and Spiritual Equilibrium
Immune Surveillance
Food allergen
Ulcerative Colitis
Eczema
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Food allergen
Dysbiosis
Digestive enzyme/HCL insufficiency
Hormone andNeurotransmitter Regulation
Drug side effects leaky gut
33
Detoxification and Biotransformation
Inflammatory Process
Inflammatory damage
Structural Integrity
Nutrient insufficiency low EFAs, high AA
Structural damage
Psychological and Spiritual Equilibrium
Through critical thinking and pattern
recognition, a therapeutic plan can be
developed. In this case, the primary focus
centers on three areas
Immune Surveillance
Food allergen
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Food allergen
Dysbiosis
Digestive enzyme/HCL insufficiency
Hormone andNeurotransmitter Regulation
Drug side effects leaky gut
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Detoxification and Biotransformation
Inflammatory Process
Inflammatory damage
Structural Integrity
Nutrient insufficiency low EFAs, high AA
Structural damage
Hs-CRP RBC fatty acids
Psychological and Spiritual Equilibrium
Immune Surveillance
Laboratory analysis can be used to help confirm
the prioritization
Food allergen
IgG/IgE food allergy
Oxidative/Reductive Homeodynamics
Digestion, Absorption, and Barrier Integrity
Food allergen
Dysbiosis
Digestive enzyme/HCL insufficiency
Hormone andNeurotransmitter Regulation
Drug side effects leaky gut
Digestive stool analysis Ova and
parasite Intestinal permeability
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Dietary changes to lower arachidonic acid and
the inflammatory cascade
Phytonutrients such as rutin and quercitin to
decrease IP
Detoxification and Biotransformation
Botanicals such as bromelain and curcumin to
decrease inflammation
Omega-3 fatty acids to decrease inflammation
InflammatoryProcess
Structural Integrity
Foodeliminationdiet
The prioritization of certain key clinical
imbalances then leads to potential treatment
options
Psychological and SpiritualEquilibrium
Immune Surveillance
Digestion, Absorption, and Barrier Integrity
Oxidative/Reductive Homeodynamics
Decrease alcoholto decrease intestinal
permeability
Hormone and Neurotransmitter Regulation
Pre and probiotics
Hydrochloric acid/digestive enzyme
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Functional medicineenlarges thechronic care
model to encompass the full and uniquestory of
the patient

It integrates underlying mechanisms of disease
into the differentialdiagnosis paradigm
Finally it increases the range of potential
treatment options
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Functional Medicine and the Healthcare System
Additional Important Benefits

• Functional Medicine creates a level playing field
  among practitioners
• The Functional Medicine model makes readily
  apparent that there is a need for many different
  approaches to helping people become and stay well
• Functional Medicine helps to create and
  disseminate a shared set of concepts and a common
  language
• Ultimately, Functional Medicine can contribute
  greatly to our ability to create an integrated
  healthcare system

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Cardiology
Pulmonary
Endocrinology
Urology/Nephrology
Gastroenterology
Hepatology
Organ System Diagnosis
Neurology
Allergy
Signs and Symptoms
Fundamental Clinical Imbalances Hormonal and
Neurotransmitter Imbalances Redox Imbalance
Oxidative Stress Mitochondropathy Detox/Biotrans
formation/Excretory Imbalance Immune
Imbalance Inflammatory Imbalance Digestive/Absorpt
ive and Microbiological Imbalance Structural
Integrity Imbalance
Fundamental Physiological Processes
1. Communication - Outside the cell - Inside
the cell
2. Bioenergetics/Energy Transformation 3.
Replication/Repair/Maintenance/ Structural
Integrity
4. Elimination of Waste 5. Protection/Defense 6.
Transport/Circulation
Mind and Spirit Genetic Predisposition Experiences
, Attitudes, Beliefs
Xenobiotics Micro-organismsRadiation
Physical ExerciseTrauma
Diet, Nutrients, Air/Water
Psycho-social
Environmental Inputs