Osteopathic Manipulative Medicine

Arizona College of Osteopathic Medicine

MS-II Lab
Dr. Gary Gailius DO
04-05-2017

Clinical Cases Lab

OBJECTIVES:

Upon completion of this lab, the student will be able to:

1. Integrate using an osteopathic structural examination into their physical
examination.
2. Complete a SOAP note with proper documentation of osteopathic history,
objective findings on examination, developing an assessment and formulating a plan.
3. Assess all components of an abdominal pain case including physical examination,
osteopathic structural examination, differential diagnosis, and appropriate treatment plan.
4. Assess all components of a headache case including neurological examination,
musculoskeletal examination, and headache red flag screening.
5. Perform OMT on abdominal and headache pain cases.
6. Succeed in performing an integrated history, physical examination and
completion of a SOAP note in a timed setting.

Instructions for the Lab:

For each of the 2 clinical cases, one student will be the physician and perform the history
and physical and the other student with be the standardized patient, and then you will
switch roles. Start with Clinical Case Scenario #1: Heart Burn. Follow along with the
instructor who will keep track of the timing, and ask questions from your table trainers if
you get lost! It is important to keep up with the pace of the class!

Clinical Case Scenarios #1

CC: Heart Burn

Subjective:

Contains chief complaint, age, gender, the history of the present illness (HPI), aggravating or
alleviating factors pertinent to the HPI, past medical history, current medications, allergies,
family history, social history, occupation, recent or past injuries, and any past OMT. Review of
systems includes pertinent positives and pertinent negatives.

Case/Script: A 48 year old female presents to your office with worsening epigastric pain for the
past 4 weeks. She thinks it is heart burn described as a burning sensation that radiates to her
midback which has increased from a 3/10 to now 6/10. She reports decreased appetite and pain
causes her to wake up at night. Nothing in particular brought on the symptoms. She has nausea
but no vomiting. She denies rectal bleeding or black tarry stools.

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She denies coughing up blood, fever or cold/flu symptoms. She takes 8-10 ibuprofen tablets
each day to ease her tension headaches. She has lost 2# in 4 weeks.

All other review of systems negative.

Past Medical History (PMH): Uterine fibroids, tension headaches

Past Surgical History (PSH): Tonsillectomy, total abdominal hysterectomy.
Current Medications: ibuprofen daily
Allergies: Penicillin (causes swelling)
Family History: Father died at 43 of M.I., mother has high blood pressure.
Social History: Smokes cigarettes, 1ppd since 20y.o. social drinker-2-3 drinks /week. She is
sexually active in a monogamous relationship.
Occupation: News reporter

STOP: Now students examine their partners. Give vitals only at this
point.
BP 100/68 Pulse 96 Resp. 20 Temp. 99F Wt. 142# Ht. 56
Students should only document physical findings of their own partner on the
SOAP note.

Discussion of Objective:
Contains physical exam, general description of patients appearance and demeanor. Vital signs,
pertinent systems exam findings (both positives and negatives). Must include OMM exam
findings, other lab such as EKG, x-ray, blood work (if appropriate).

Abdominal Pain Red flags:

1. Severe pain
2. Signs of shock (i.e. tachycardia, hypotension, diaphoresis, confusion)
3. Signs of peritonitis
4. Abdominal distention
Especially when surgical scars, tympani to percussion, and high-pitched
peristalsis or borborygmi in rushes are present, strongly suggests bowel
obstruction.
5. Severe pain in a patient with a silent abdomen who is lying as still as possible suggests
peritonitis
6. Back pain with shock suggests ruptured abdominal aortic aneurysm (AAA), particularly
if there is a tender, pulsatile mass.
7. Shock and vaginal bleeding in a pregnant woman suggest ruptured ectopic pregnancy.
8. Ecchymoses of the costovertebral angles (Grey Turner's sign) or around the umbilicus
(Cullen's sign) suggest hemorrhagic pancreatitis.

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Viscerosomatic points
Esophagus: T2-8 (more specifically T3R)
Foregut (stomach, liver, GB, spleen, pancreas, 1-2nd part of duodenum): T5-9
Stomach T5L, Pancreas T6-8 bil, Liver T5-9 R, Duodenum T7R, Gallbladder T9R
(more specifically)

Chapmans Reflexes
Stomach, liver, gallbladder:
Anterior: 5-6th intercostal space at the mid clavicular line
Posterior: stomach: 5th thoracic intertransverse space on left, liver and
gallbladder 6th thoracic intertransverse space on right.

General: What is the patients body habitus, level of overall condition, distress?

HEENT: Pupils equal round and reactive, conjunctiva pale (anemia), ears clear, nose clear,
pharynx clear, mucosa pale (anemia), any oral lesions??

Heart: Tachycardia, murmurs, irregular rhythm?

Chest: Anterior chest wall tender to palpation diffusely?

Lungs: Scattered expiratory wheezes at bases may indicate tobacco exposure- possible early
COPD vs acute infection?

Abdomen: CVA tenderness, Murphys, McBurneys, and examination for Pyelonephritis,

Hepatitis, Pancreatitis, Appendicitis, etc?

Musculoskeletal: Cervical: ROM, TART

Thoracic: ROM, TART, if the patient has intolerance to flexion and extension of thoracics- why
is this important?
Are there any Viscerosomatic Reflexes? Tenderness to palpation T5-L1
Where are the Chapmans reflexes?
Are there any Trigger points in the L anterior external oblique under the costophrenic angle?

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 Trigger vs Chapmans Points
Myofascial Trigger Pts
Tender to deep palpation
Palpably, small, circumscribed,
myofascial thickenings within
skeletal muscle
Pain refers in typical pattern upon
touch trigger
Treatments injection, cooling,
various OMT techniques
Chapmans Pts
Tender to superficial palpation
Palpably small, circumscribed
deep to skin/subcutaneous fat and
fascia
Nonradiating
Paired dorsal/ventral sides of
body
Usually diagnostic
Treatment with direct pressure

Assessment:
Differential diagnosis must include at least 3, ranked in order of
1. Peptic Ulcer
2. GERD
3. Gastritis
4. Hiatial Hernia
5. Angina
6. Gall bladder disease
7. Somatic Dysfunction Thoracic spine-viscero-somatic dysfunction
8. Tobacco Abuse
9. Excessive NSAID use

10. Gastritis
Ulcer symptoms can be confused with dyspepsia or gastroesophageal reflux disease (GERD).
11. Angina
Common ulcer symptoms include:
12. Gall bladder disease
13. Somatic
A burning, Dysfunction
aching pain-or a Thoracic spine-viscero-somatic
pain that feels like hunger-betweendysfunction
the navel and sternum. The pain may extend to the
14. Tobacco Abuse
back. Belly pain that can last from a few minutes to a few hours and usually goes away for a while after taking an
15. Elevated
antacid or acidBlood Pressure
reducer. Pain from a gastric ulcer may occur shortly after eating (when food is still in the stomach).

Weeks of pain that comes and goes and may alternate with pain-free periods. Loss of appetite and weight loss.
Bloating or nausea after eating.

Less common but more serious symptoms of ulcers include:

Vomiting after meals. Vomiting blood and/or material that looks like coffee grounds. Black stools that look like tar,
or stools that contain dark red blood.

Symptoms of ulcers in the upper small intestine (duodenal ulcers) and in the stomach (gastric ulcers) are similar,
except for when pain occurs. Pain from a duodenal ulcer may occur several hours after eating (when4the stomach
is empty) and may improve after eating. Pain also may wake you frequently in the middle of the night.
 Plan:
Includes testing, treatment plan (including pharmaceuticals and non-pharmaceuticals such as
life style changes, physical therapy, OMT.) Imaging studies such as x-ray, MRI or other
diagnostic studies should be mentioned but need not be too specific. Must include plan for
follow-up.

1. EKG, lab work, H. pylori (stool or breath test)

2. Proton Pump Inhibitor or H2 blocker
3. Abdominal US (rule out gall bladder disease)
4. CXR
5. OMT to thoracic spine
a. Treatment of Viscerosomatic Reflexes:
i. SNS innervations
1. Celiac Ganglion (T5-9)
a. Stomach, liver, gallbladder, pancreas (digestion)
2. Superior Mesenteric Ganglion (T10-L1)
a. Small intestine (absorption)
3. Inferior Mesenteric Ganglion (T12-L2)
a. Colon (elimination)
4. Heart
a. Right Cardiac Plexus- SA node
b. Left Cardiac Plexus- AV node
5. Lungs
a. T2-4 bilaterally
b. Upper thoracic and cervical chain ganglia
ii. PNS innervations
1. Upper GI: Vagus Nerve
2. Lower GI: Sacral Splanchnic nerves: S2-4
3. Heart
a. Right Vagus- SA node
b. Left Vagus- AV node
4. Lungs: Vagus nerve
iii. Viscerosomatic points
1. Esophagus: T2-8
a. T3R
2. Foregut (stomach, liver, GB, spleen, pancreas, 1-2nd part of
duodenum): T5-9
a. Stomach T5L
b. Pancreas T6-8 bil
c. Liver T5-9 R
d. Duodenum T7R
e. Gallbladder T9R
3. Midgut (3-4th parts of duodenum, jejunum, ileum, ascending colon,
proximal 2/3 transverse colon): T10-11

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 4. Hindgut (distal transverse colon, descending colon, sigmoid,
rectum): T12-L2
5. Appendix T12
6. Lungs T2-7 bilaterally
7. Heart T1-5
b. Treatment of Chapmans Reflexes
i. Stomach, liver, gallbladder
1. Anterior: 5-6th intercostal space at the mid clavicular line
2. Posterior: stomach: 5th thoracic intertransverse space on left, liver
and gallbladder 6th thoracic intertransverse space on right
ii. Pancreas
1. Anterior: lateral to costal cartilage of ribs 7-8 on right
2. Posterior: 7th thoracic intertransverse space on the right
iii. Appendix
1. Anterior: anterior to tip of rib 12 on right
2. Posterior: lateral aspect of the 11th intercostals space on the right
iv. Small Intestine
1. Anterior: 8-10th intercostal space at mid-axillary line bilaterally
2. Posterior: bilaterally between the spinous and transverse processes
of the 8-10 thoracic vertebrae
v. Colon Reflexes found along the femur (refer to OMM hospital lab picture)
All colon posterior points are located in the paraspinal musculature in a triangle connecting the
tips of the 2-4 lumbar transverse processes to the mid pain to f the iliac crest.

c. Myofascial release to anterior/posterior thorax/abdomen

d. Counterstrain to anterior/posterior thorax/abdomen
e. Abdominal ganglia release: Celiac, SMG, IMG
f. Thoracic inlet/outlet
g. Rib Raising, Dorsal Inhibition
h. Cervical Ganglia Release
i. Suboccipital and lumbosacral decompression- Vagus
j. Doming of diaphragm

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7
 Collateral Ganglia Inhibition
Chapmans Reflexes: Chapmans Reflexes:
GastroIntestinal Track Lower GI Track

LIVER (5) PYLORUS STOMACH 5-6 LIVER (5) PYLORUS STOMACH 5-6
GALL
(6) GALL
(6)

U
BLADDER BLADDER

PANCREAS PANCREAS

Descending
Ascending
Celiac SM Ganglion
SMALL
Ganglia Additional Findings INTESTINE
OM/OA/AA/C2 (+/-
(+/-) APPENDIX x
Fifth-
Fifth-Ninth Rib SD (tip 12th) IM Ganglion
HVLA T5-
T5-9 Rubbery

6. Stop smoking
7. GERD education: elevate head of bed, no stooping or bending forward after meals, limit
triggering food intake.
8. Follow-up 1 week
9. Referral to GI for Endoscopy: tobacco use, worsening GERD
10. For any worsening chest pain, change in vitals or vomiting up blood, go to the
Emergency Room.

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CLINICAL CASE #1

Student Name: Patient Name:

Please write ONLY in the space provided for each section. List at least 4 items in the assessment and the plan
sections

CC: Stomach Pain Vitals: 100/68 HR 96 RR 20 T 99 Wt 142 Ht

56 48 yo F

ASSESSMENT PLAN

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 Clinical Case Scenarios #2

CC: Headache
Subjective:
Contains chief complaint, age, gender, the history of the present illness (HPI), aggravating or
alleviating factors pertinent to the HPI, past medical history, current medications, allergies,
family history, social history, occupation, recent or past injuries, and any past OMT. Review of
systems includes pertinent positives and pertinent negatives.

Case/Script: A 35 year old female presents with headaches on and off for 3 weeks. She has a
history of migraines in the past, but these headaches are different. They occur 1-2 times per
week, starting at the back of her head in the occipital area bilaterally and radiate forward. The
headaches last 1-3 hours, no photosensitivity, no nausea, and no aura. She takes IBU 600 mg
with 50% relief. Today her pain is present 4/10. Exercise does not make it worse. She works as
a daycare provider in a busy infant nursery. This is not the worst headache of her life.

She denies any form of trauma. There is no numbness, weakness or tingling. She also has some
neck pain on the right lower cervical area that radiates into her shoulder.

She denies any other back pain. She denies mental status changes or emotional changes. She
denies any visual changes, speech problems, no sore throat, cough or runny nose. She denies
fever, nausea, vomiting or diarrhea. She denies any changes in bowel or bladder habits. She is
right hand dominant.

All other review of systems are normal. Last menstrual period was 4 weeks ago.

Past Medical History (PMH): Hypothyroidism, seasonal allergies- controlled

Past Surgical History (PSH): gall bladder removal, bilateral tubal ligation, C-Sections x 2
Current Medications: Synthroid, Tylenol
Allergies: Denies
Family History: Father has HTN and diabetes. Mother has hypothyroidism.
Social History: Denies smoking, alcohol use, and illicit drugs. She is married and sexually
active with one partner.
She was pregnant three times and has three healthy children
Occupation: daycare worker

STOP: Now students examine their partners. Give vitals only at this
point.
BP 130/80 Pulse 64 Resp. 18 Temp. 99.7F Wt. 160# Ht. 55
Students should only document physical findings of their own partner on the
SOAP note.

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 Discussion of Objective:
Contains physical exam, general description of patients appearance and demeanor. Vital signs,
pertinent systems exam findings (both positives and negatives). Must include OMM exam
findings, other lab such as EKG, x-ray, blood work (if appropriate).

Headache Red Flags:

1. Sudden onset- bleed
2. Worsening- mass or bleed
3. Headache with systemic illness (fever, neck stiffness, rash) - infection, collagen vascular dz,
arteritis
4. Focal neurological signs or symptoms other than typical visual or sensory aura- mass, AVM,
collagen vascular disease
5. Papilledema- mass, pseudotumor, encephalitis, meningitis
6. Triggered by cough, exertion, or valsalva- SAH, mass
7. Headache during pregnancy- pituitary apoplexy, carotid dissection, pre eclampsia
8. New headache in a pt with cancer, lyme disease, or HIV- metastasis, meningoencephalitis,
opportunistic infection.

International Headache Society Diagnosis Criteria for Migraine -5-4-3-2-1 DX

PNEUMONIC

5 or more attacks. [For migraine with aura, only two attacks are sufficient for
diagnosis]
4 hours to 3 days in duration.
2 or more of the following:
o Unilateral (affecting half the head)
o Pulsating
o "Moderate or severe pain intensity"
o "Aggravation by or causing avoidance of routine physical activity".
1 or more of the following:
o "Nausea and/or vomiting"
o Sensitivity to both light (photophobia) and sound (phonophobia).

A thorough Neurological exam including: gait, CN, DTR, sensation, and motor should
be performed prior to any OMT. Manipulation can be performed prior to MRI if red
flags are absent.

A thorough musculoskeletal exam for headaches includes (but is not limited to): ROM and
TART findings in the cranium, cervical spine, thoracic spine, UE, lumbar spine, and sacrum.
General: What is the patients body habitus, level of overall condition, distress?

HEENT: Is it important to examine this area? Ophthalmoscope exam?

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 Document any facial or cranial tenderness, any tenderness over the temporal artery, eyes
equal round and reactive, ears clear, nose clear, pharynx clear?

Heart: Tachycardia, murmurs, irregular rhythm?

Lungs: Rales, rhonchi, wheezing?

Musculoskeletal: Standing posture exam, gait.

Cervical spine: ROM, nuchal rigidity, TART, hypertonicity
Thoracic spine: ROM, TART, hypertonicity
UE: ROM, TART, hypertonicity
Any leg length discrepancy

Neuro: Key exam components: This needs to be done before any manipulation is performed.
Cranial nerves, cerebellar function, motor, sensation, DTRs?

Assessment:

Differential diagnosis must include at least 3, ranked in order of likelihood

1. Tension Headache- typically affects both sides of the head, steady rather than throbbing,
triggered in response to stress. Divided into frequent and infrequent, episodic, and
chronic. Timing can be from 30 min to 7 days. Typically not associated with nausea.
Pain does not worsen with physical activity. Photo or phonophobia may be present.
Tenderness can be palpated in the cranium and surrounding muscle of the cervical spine.
Frequent episodic tension HA often coexist with migraines. HA diary may help to
distinguish between the two.

2. Migraine Headache- recurrent one- sided, pulsating or throbbing. Moderate to severe

pain that prevents activity, worsens with activity. Nausea, photo or phonophobia are
usually present. Classified as migraine with aura, migraine without aura.

3. Somatic Dysfunction of Cervical Spine

4. Cervical root impingement
5. Meningitis
6. Sinusitis, otitis media
7. Seasonal allergies, allergic rhinitis
8. Hypothyroidism
9. Thoracic outlet syndrome
10. Mass/cancer

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 Plan:

Includes testing, treatment plan (including pharmaceuticals and non pharmaceuticals such as
life style changes, physical therapy, OMT.) Imaging studies such as x-ray, MRI or other
diagnostic studies should be mentioned but need not be too specific. Must include plan for
follow-up.

1. Consider MRI brain for any change in headache pattern or RED FLAGS
2. OMT
a. Treatments include:
i. Suboccipital Release or HVLA (not used for acute migraine phase) -
treating the OA, C1 and C2
ii. Condylar decompression- treating the Vagus for any nausea (for migraine)
iii. ME Cervical Spine
iv. Counterstrain cervical spine, levator scapula
v. ME scalenes- remember insertion on the Ribs 1-2, SCM
vi. Myofascial release Cervical, Thoracic, UE
vii. Temporal bone release- trigeminal nerve and ganglion
3. Optional blood tests (CBC, CMP, TSH, SED rate)
4. Avoid triggers if possible
5. Home stretching exercises
6. NSAIDs, discuss SE of meds with patient
7. Follow-up 2 weeks
8. For any worsening pain go to the emergency room

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CLINICAL CASE #2

Student Name: Patient Name:

Please write ONLY in the space provided for each section. List at least 4 items in the assessment and the plan
sections

CC: Headache Vitals: 130/80 HR 64 RR 18 T 99.7 Wt 160 Ht

55 35 yo F

ASSESSMENT PLAN

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Further Reading:
Comlex Level 2-PE Review Guide, Kauffman
Foundations of Osteopathic Medicine: Third edition 698 to 727
An Osteopathic Approach to Diagnosis and Treatment: Third edition 95-102
Grays Anatomy: Fortieth edition, Susan Standring, 2008.
Netter.
Thank you to Shannon Scott, DO.

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