Acid reflux

This is 58-year-old male patient, who presents to the Center today for ALCAT testing. He is complaining of pain in the right side of his paraspinous muscles and in the rhomboid muscles of the scapula. Onset of pain is on right thumb with locking of the thumb intermittently. He has been having issues with sinus allergies, congestion, runny nose, sneezing with new onset. He has joint pain in multiple joints intermittently.

He complains of acid reflux every morning. He has gas and bloating associated with food and constipation intermittently. He has some food cravings and inability to lose weight and headaches. He has ringing in his ears on consistent basis.

He also has issues with insomnia frequently, restlessness, hyperactivity, and poor concentration.

DIAGNOSES:
Myofascial pain.
Allergy.
Gas and bloating.
Acid reflux.
Constipation.

RECOMMENDATIONS:
We will recommend comprehensive ALCAT testing to evaluate the patient for any food intolerances that may be continuing factors in his symptoms and problems. I also recommend physical therapy for some of his myofascial pain and acupuncture as they could be helpful as well. We will schedule for PT evaluation and reevaluate the patient after he has four weeks of physical therapy three times per week.

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