Complex Case Study: A Multisystem Presentation Managed Across Disciplines

The final case studies in this library have focused on reasoning within one practitioner’s consultations. This case focuses on something different: coordination. It follows a patient whose care was delivered by many capable practitioners working in parallel, and shows how integration turned that care into a single, coherent plan. It is an illustrative composite.

Presentation

A 64 year old retired bank manager has rheumatoid arthritis, atrial fibrillation treated with warfarin, osteoporosis diagnosed after a wrist fracture, depression and knee osteoarthritis. She comes to a clinical nutritionist trained in Integrated Functional Medicine because she feels exhausted, her INR has been unstable and she is “confused by everyone’s advice”.

The inventory of care

No single practitioner knew about all of these. Several had never communicated with each other.

Identifying conflicts and risks

The anticoagulation interactions required prompt action. With her consent, the nutritionist wrote to her doctor and anticoagulation clinic the same day, listing all supplements and the recent dietary change, and advised her not to take further ibuprofen until reviewed.

The case conference

Her doctor agreed to convene a brief virtual case conference with the rheumatologist’s nurse specialist, the physiotherapist and the nutritionist, with the patient present. Her Ayurvedic practitioner and yoga teacher were informed and invited to comment in writing. The agenda:

1. The patient’s priorities: less fatigue, stable INR, no more fractures, being able to garden.
2. Safety: anticoagulation interactions; NSAIDs; osteoporosis.
3. Rheumatoid disease control and steroid use.
4. Fatigue assessment.
5. Activity and exercise safety.
6. Nutrition.
7. Who does what, and how communication will continue.

Decisions

• Anticoagulation: ginkgo and high dose fish oil stopped; the turmeric formulation paused, with the Ayurvedic practitioner’s agreement, while alternatives were considered; ibuprofen avoided; green vegetables kept consistent rather than eliminated. Her cardiologist discussed whether a different anticoagulant, with fewer food interactions, might be suitable.
• Rheumatoid arthritis: disease activity was higher than recognised; the rheumatologist adjusted her disease modifying treatment to reduce the need for steroid courses.
• Osteoporosis: her doctor started a bone protective medicine, with vitamin D and dietary calcium.
• Fatigue: blood tests found iron deficiency, treated; her antidepressant was reviewed; poor sleep from night pain was addressed.
• Exercise: the physiotherapist and yoga teacher agreed an adapted practice avoiding deep spinal flexion and twisting, adding balance and strength work.
• Nutrition: a Mediterranean style pattern with consistent vitamin K intake; calcium from dairy or fortified alternatives, discussed respectfully with her Ayurvedic practitioner, who suggested warm spiced milk as an acceptable form; adequate protein for bone and muscle.

The shared care plan

6 months later

Her INR has been stable, she has had no steroid courses, her iron and energy have improved, her mood is better and she is gardening again. She keeps a copy of her shared care plan and brings it to every appointment. She says that for the first time she feels that her practitioners are working together.

Reasoning notes

• No one had the whole picture until an inventory was compiled.
• The most dangerous issues were interactions between practitioners’ recommendations, not failings of any one.
• Urgent issues were acted on immediately; others waited for the case conference.
• Every practitioner’s contribution was respected, including traditional care, while safety was non negotiable.
• A shared plan with named responsibilities sustained coordination beyond a single meeting.

Integration made visible

This case captures what Integrated Functional Medicine adds to healthcare: someone who sees all the care a patient receives, recognises where it conflicts, brings practitioners together and keeps one plan at the centre. Each practitioner was competent; together, coordinated, they became effective.