功能医学与情绪系列之肾上腺疲劳案例分析（上）---功能医学医生专业分享
五花大绑的意思编者按
Adrenal Fatigue
In primary care, fatigue is a complaint in more than 20% of all patient contacts, and accounts for more than 18 million physician visits in the United States annually. In unpublished data from the US General Social Survey, at least one fatigue-associated symptom was found in 78% of all women and in 73% of all men. Many cas elude diagnosis, and patients frequently do not pursue follow-up care, although at least half of all cas demonstrate unfavorable outcomes. Adrenal fatigue (stress-induced subclinical adrenal insufficiency) is a well-recognized cau of fatigue in integrative medicine, but its diagnostic validity is challenged by the conventional medical community, who consider frank adrenal insufficiency (the most common cau being exogenous steroid withdrawals) to be the recognized clinical entity. Rearch, however, supports the occurrence of chronic stress-induced hypocortisolemic states. Furthermore, a remarkable 75% to 90% of all prima
ry care visits are reported to be related to stress. Taken together, the facts suggest that adrenal fatigue may be a common cau of idiopathic fatigue.
肾上腺疲劳
我是妈妈的主人在美国普通门诊的访问量每年超过1800万，其中超过百分之二十的人群有疲劳主诉。未公开的美国综合社会调查数据表明，至少有78%的女性和73%的男性有疲劳的症状。在大多数情况下，许多病例没有明确诊断，患者通常不追求后续治疗，但所有病例中至少有一半表现出不良后果。肾上腺疲劳（压力介导的亚临床型肾上腺功能不全）在整体医学中被认为是疲劳的主要原因，但是其诊断的有效性却未被传统医学界所认可，而传统医学界认为肾上腺功能不全（其最常见的原因是外源性类固醇缺乏）是一种临床阶段，但也有研究支持是慢性应激诱导低皮质醇状态的发生。此外，在所有普通门诊中多达75-90%的病人症状都与疲劳有关。综合以上，这些数据表明了肾上腺疲劳可能就是原发性疲劳最常见的原因。
CASE HISTORY
桂鱼做法
危行言逊TJ was 29 years old when she prented with longstanding fatigue. She stated that the fatigue she had felt throughout college had recently worned. The incread fatigue correlated with the completion of graduate school, which was followed by a move to a new city and the start of a new job. She described her fatigue as being wor in the evening, rating her energy level at 3 out of 10 (0 as lowest energy possible, 10 as highest energy possible). She tended to avoid late night parties, and rested most weekends. She slept well and awoke rested. TJ felt her best in the morning and ud this time to maintain a regular exerci schedule of aerobic and anaerobic activities. She u some caffeine as a stimulant but tried to avoid excessive intake. She gained weight easily in her thighs, buttocks, and abdomen. Although she tended to gain it when she was feeling very stresd, she was not a binge eater. She craved salt. She occasionally had vere constipation. In spite of the fact that an elimination diet undertaken while in college revealed dairy, eggs, and soy as constipation triggers, she continued to consume forms of dairy. Her menstrual cycle was regular, with minimal PMS. She denied having had fever or myalgia. Her physical exam was unremarkable, with no fever or lymphadenopathy. Her blood pressure was low normal at 100/60 LAS.
病史
TJ ，女性，29岁，有长期疲劳症状。她说，在大学期间发现自己有疲劳症状，而且最近越来越严重，这些是和到了一座新城市，找了一份新工作以及接踵而来非常复杂的研究生院工作有关。疲劳程度在晚上尤为严重。能量水平评价仅有3 （0代表最低能量水平，10代表最高能量水平）。她尽量避免参加各种晚会，并在周末多休息，睡眠质量还算不错。她觉得自己最好的精神状态是在早晨，并充分利用这段时间有规律地做有氧和无氧运动。偶尔饮用一些咖啡，但尽量避免过多的摄入。由于她的大腿、臀部和腹部容易发胖，所以在她觉得非常疲惫而且想吃东西时，也尽量控制饮食。她喜欢偏咸的食物，经常出现便秘。她在大学期间采取了排除饮食（不含过敏性食物），避免食用乳制品、蛋类、豆制品以及容易引起便秘的食物，但坚持喝牛奶。月经周期正常，轻度经前症候群，无发热或者肌痛。身体检查未见明显异常，无发热或淋巴结肿大。血压正常（100/60mmHg）。
Laboratory tests ordered and rationale:
1.Four point-measurement of salivary cortisol: Evaluate etiology of stress-induced fatigue
2.Thyroid panel: Rule out hypothyroidism, a common cau of fatigue
3.Fasting insulin and blood sugar: Rule out dysinsulinemia, a common imbalance with fatigue and weight gain
4.Iron panel: Rule out iron deficiency, a common cau of fatigue
5.Blood chemistries: Rule out general metabolic dysfunctions, infection, macro-or microcytic anemia. All may be a cau of or associated with fatigue
实验室检查
1.四点法测量唾液皮质醇：评估应激性疲劳的病因。
2.甲状腺评估：排除甲状腺功能减退（疲劳症状的常见病因）。
3.空腹胰岛素和血糖监测：排除胰岛素异常（可引起疲劳和体重增加）。
4.铁测量：排除缺铁情况，缺铁可引起疲劳。
5.血生化：排除一般代谢功能障碍、感染、大小红细胞性贫血（都是与疲劳有关的原因）。
员工入职图1：唾液皮质醇检测结果
Initial Plan
Adrenal glandular formula (with B vitamins)
Adrenal botanical formula (Cordyceps mycelium, Panax ginng, and Rhodiola roa)
Vitamin C,1-3 grams/day
Multivitamin mineral formula
Re-evaluate adrenal and thyroid function in four months
Stress-reduction techniques discusd
Recommend continued exerci to tolerance
Recommend complete dairy elimination with reduction in simple carbohydrates including grains, starchy vegetables, and high-sugar fruits
Recommend minimize or discontinue coffee
Recommend fiber formula with added prune extract
初步计划
▷ 肾上腺支持配方（添加B族维生素）
▷ 肾上腺植物性配方（冬虫夏草、人参、红景天）
▷ 维生素C 1~3g/天
▷ 多种维生素矿物质配方
▷ 四个月后重新评估肾上腺和甲状腺功能
▷ 讨论如何减压
▷ 继续运动耐受练习
▷网上年货节 避免食用奶制品并减少食用碳水化合物，包括谷物、含淀粉类蔬菜和高糖水果抚尺
▷ 减少或避免饮用咖啡
▷ 建议搭配大枣萃取液和粗纤维食物一起服用
Treatment plan rationale:
雷超武Nutrient and botanical preparations associated with adrenal function were initiated. Adrenal gland extract void of active hormone has a long been ud as a supportive intervention for hypoadrenalism. Cordyceps mycelium, Panax ginng, and Rhodiola roa have demonstrated favorable modulation of adrenal function, stress and fatigue. Vitamins C and B complex have also been shown to be helpful in normalizing adrenal function. Stress reduction techniques were taught and exerci was encouraged. It was recommended that the coffee be discontinued, becau of its well-recognized potentiation of the stress respon. A low glycemic, low simple carbohydrate diet was started to assist in improving insulin nsitivity. For constipation, fiber with prune extract was started and complete dietary elimination of dairy products was suggested.
