PPC/OMM Exam 1

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1

Hippocratic Philosophy

centered on "holistic patient oriented care"

2

Cnidian Philosophy

centered on "disease" or symptoms

3

Bone Setters

Celtic healing practitioners who used manual therapy as an integral part of their care

(royal family down to smallest hamlet used bone setters"

ex. the Sweet family of New England 1830s in the Northeast emigrated in the 1850s to the West

4

Andrew Taylor Still

Born 1828, Died 1917

Researched for 10 years, 1874 osteopathy officially began

Founded the first American school of Osteopathy in 1892

5

First school of osteopathy was titled? where? and in what year?

American School of Osteopathy in Kirksville (ASO)

Kirksville, Missouri

1892

6

Roots of the word Osteopathy

Osteon- bone

Pathos (or) pathine- to suffer

7

Official Osteopathic Emblem

The Staff of Asclepius

(more associated with healing than the Magical Staff of Hermes

8

John Martin Littlejohn

Both a DO and MD

Treated by AT Still in 1897

Founded Chicago School of Osteopathy in 1900

Began ASO training in 1898 and graduated in 1900

Moved to England in 1913 and began the BSO in 1917

9

D.D. Palmer

Founder of Chiropractic (opened his first school in Davenport, Iowa in 1897)

1895 received first adjustment, visited Kirksville prior to opening his first school

10

Homeostasis

Maintenance of static or constant conditions in the internal environment

The level of well-being of an individual maintained by internal physiologic harmony that is the result of a relatively stable state of equilibrium among the interdependent body functions

11

Allostasis

Remaining stable by being variable

12

Allostatic Load

Coined by McEwen and Stellar in 1993

The physiological costs of chronic exposure to fluctuating or heightened neural or neuroendocrine response that results from repeated or chronic stress.

(It is used to explain how frequent activation of the body's stress response, essential for managing acute threats, can damage the body in the long run)

13

4 Tenets of Osteopathic Philosophy

1. The body is a unit

2. The body possesses self-regulatory, self-healing,
and health maintenance mechanisms

3. Structure and function are reciprocally interrelated.

4. Rational therapy is based on an understanding of body unity, self-regulatory mechanisms, and the interrelationship of structure and function.

14

Osteopathic Philosophy and Principles (where they derived the 4 tenets from)

  • Man is Triune in nature consisting of body, mind and spirit.
  • The body is a unit.
  • Structure & Function are reciprocally interrelated.
  • The body possesses self-regulatory mechanisms.
  • The body has the inherent capacity to defend and repair itself.
  • When normal adaptability is disrupted, or when environmental changes overcome the body’s capacity for self-maintenance, disease may ensue.
  • Movement of body fluids is essential to the maintenance of health.
  • The nerves play a crucial part in controlling the fluids of the body.
  • There are somatic components to disease that are not only manifestations of disease but also are factors that contribute to maintenance of the diseased state.
15

Somatic Dysfunction

There are somatic components to disease that are not only manifestations of disease but also are factors that contribute to maintenance of the diseased state.

The somatic components which Osteopathic physicians look for and treat are called somatic dysfunction

16

Rational Treatment

Host + Disease = Illness

17

Allopathic Care focuses on (in reference to rational treatment)...

Disease

18

Osteopathic Care focuses on (in reference to rational treatment)...

Host

19

Somatic Dysfunction

What we look for AND treat

Impaired or altered function of related components of the somatic system (body framework) : skeletal, arthroidal, and myofascial structures, and related vascular, lymphatic and neural elements (somatic components of disease that are manifestations of the disease but also lead to maintenance of the disease state)

Appear to be based on neurophysiologic phenomenon

20

Diagnostic Criteria for Somatic Dysfunction

TART

21

TART

Tissue texture changes

Asymmetry of structure

Restriction of motion

tenderness to palpation (least noteworthy)

22

First question to ask yourself when figuring out what to treat

Does the patient have a significant musculoskeletal component to their problem?

23

How to answer the question of "what to treat"

Need data from a musculoskeletal eval and assess data in relation to the patients problem

If you identify musculoskeletal/somatic dysfunction (remember TART) and relate it to the pt.'s problem, you have indication for OMT

24

Classification of Somatic Dysfunction

Duration: Acute vs. Chronic

Etiology Primary (usually traumatic) vs. Secondary (compensation for primary or MSK problem)

Motion name the dysfunction by what motion remains, or what direction the structure can still move towards

Location Single Component- single vertebral unit (i.e. rib, fibular head, inominate at SI joint), Multiple Component- several vertebrae in a group (i.e. tarsal bones, pelvic girdle), Abdominal/Pulmonary

25

Tissue Texture Change

Palpable evidence of physiologic dysfunction

Reflects disturbance in local tissues, related organs, or entire system

Found in skin ,fascia, muscles

May reflect physiologic dysfunction of specific spinal segments

Acute vs. Chronic

See chart in ppt for more details

26

Asymmetry of Structure

Visual

Palpatory

27

Restriction of Motion

Asymmetry and restricted range of motion occur as a result of somatic dysfunction that creates a restrictive barrier

Motion loss is maintained by the restrictive barrier

Passive vs Active motion

Quantitative-How much does it move

Qualitative-How well does it move?

The Barrier Concept applies

28

Tenderness to Palpation

Subjective, not always reliable and doesnt need to be present for somatic dysfunction diagnosis.

29

Acute Tissue Changes

Articular mobility-sluggish, guarded motion, range restricted

Myofascial-flaccidity then contraction

Vascular-heat, erythema and/or edema

Lymphatic-edema, congestion

Neural-skeletal pain, (visceral irritation)

30

Chronic Tissue Changes

Mobility-limited range, quality good

Myofascial-fibrosis

Vascular-constriction (cool, dry, blanched)

Lymphatic-edema, congestion

Neural-tenderness, paresthesia , itching, sympathicotonia , visceral effects

31

The Barriers Concept

Limitation of motion described in a joint or in tissue in 1 plane

A neutral point exists along with barriers

The presence of somatic dysfunction will alter normal barriers and produce a pathologic neutral point

32

Normal Motion

The range of normal active motion occurs between the physiologic barriers

A normal joint has a midline or neutral point within its range of motion

33

Motion Barrier

The limit to motion (bind vs. ease)

Bind-Restriction in one direction

Ease-Freer motion in other direction

34

Physiologic Barrier

End point of normal physiologic motion

The range of normal active motion occurs between the physiologic barriers

35

Anatomic Barrier

End point of permitted passive motion

Motion beyond the anatomic barrier damages anatomic structures

36

Restrictive Barrier

End point of permitted motion in somatic dysfunction

Also known as pathologic barrier

Movement toward the restrictive barrier exhibits bind

37

Goal of OMT

Is to restore homeostasis utilizing concepts of the unity of the living organism’s structure (Anatomy), and function (Physiology) and using the art of medicine and surgery in all of its branches & specialties.

38

OMT

The therapeutic application of manually guided forces by an Osteopathic Physician to improve physiologic function and /or support homeostasis.

39

Direct Technique

Positioning in the direction of the restrictive barrier

Activating force is applied

Movement through restrictive barrier

eg. drawer analogy/yanking the drawer

40

Indirect Technique

Positioning away from restrictive barrier

Move tissues in a direction that is freer

Release by inherent forces

41

Components of a General History

CC

HPI

PMHx

PSHx

PFHx

Social Hx

Medications

Allergies

ROS

42

CC

Main/Primary Complaint

Subjective, ok to use quotation marks

One liner

43

HPI

OLD CARTS (if pain complaint)

O- onset

L- location

D- duration

C- character/characteristics, how they describe the pain

A- aggravating/alleviating factors

R- radiating/relevant lab value

T- tx tried

S- severity 1-10 scale, intermittent vs. chronic

Associated information- was there an injury? has this happened before? if so, what was done for you? was it effective?

Immediately relevant ROS in HPI

use 8 attributes of a symptom!!!

44

PMHx

medical conditions (with onset if known), hospitalizations, immunizations, and preventative health

45

Where do secondary dx typically come from

PMHx

46

PSHx

Who, what, when, where, why, what is relevant

47

PFHx

Mom, dad, sister, brother, children

Ages (and ages at time of death)

Include genetic testing here

48

Social Hx

FED TACOS (food, exercise, drugs, tobacco, alcohol, caffeine, occupation, sexual hx)

illicit drugs*, tobacco*,alcohol consumption*,occupation*

Not always relevant: diet, exercise, caffeine, sexual hx, travel hx

49

Medications

Name, dose, compliance

OTC and herbals

orals, injectables, transdermals,

50

Allergies

Allergy AND rx

51

ROS

APPROPRIATE INFO FROM EACH SYSTEM

52

Average Life Expectancy

US 79.38 (ranked #53)

Nambia 50.89

Monaco 89.32

53

Leading Causes of Death

Preventable Causes of Death

Heart Disease Tobacco

Cancer Obesity

Stroke Alcohol

Respiratory Diseases Infectious Diseases

Injuries Toxins

Diabetes Car Accidents

Alzheimer’s Disease

Pneumonia/Flu

Kidney Disease

Septicemia

54

Prevention Hx

Age appropriate screenings

  • blood pressure
  • diabetes
  • lipids
  • colon cancer
  • depression
  • weight problems
  • sexually transmitted infections (STIs)

Immunizations

and incorporate into the plan

55

Economic Importance of Prevention

Every $1 spent on immunization saves $16.50 in medical costs and indirect costs, such as disability.

´Every $10 bike helmet generates $570 in benefits to society.

56

Preventative Screenings

Hearing-birth

Visual acuity-as early as age 3

Colon cancer-age 50 or sooner depending on family history

Pap-beginning at age 21 and ending at age 65

AAA (abdominal aortic aneurysm)-age 65 for men

´Prostate cancer?- age 55-69...present info and let pt. choose

57

Subjective

CC, HPI, ROS

58

Objective

Physical Exam (list general survey WD/WN/NAD and exams you have done/deferred): general appearance, vital signs; system headings, osteopathic findings, labs and diagnostic testing

59

Assessment

Differential Dx in order of likelihood; Most likely to least likely (minimum of 3 possible dx that directly relate to the chief complaint; more is better)

Secondary Dx: tobacco or alcohol abuse, other chronic medical problems not related to the visit, health maintenance risk factors/counseling on them

60

Plan

Theraputic Plan

What you need to find out: Labs, X-rays or other tests.

What you need to do:

1. Medications-name dose, frequency, etc.

2. Procedures (including OMT with type of technique performed or planned). Procedure notes go here for procedures done during visit.

3. Referrals

4. Patient education (e.g. pathophysiology of condition, health counseling)

What they need to do:

1. Return (follow-up)

2. Understand/Humanism (e.g. Patient voices understanding and agreement with above plan. Patient has insurance to help with costs and good support system. Work accommodations/note/etc.)

61

Functions of Skin

Protects against penetration of external microbes and/or foreign substances

Helps regulate body fluid loss

Helps regulate body temperature

Contains nerve endings and sensory receptors

Affects vitamin D conversion

62

Layers

Epidermis

Dermis

SubQ

63

5 Layers of the Edermis

4-5 layers depending on where the skin is found (thick skin vs. thin skin)

Stratum corneum (top)

Stratum lucidum (thick vs. thin)

Stratum granulosum

Stratum spinosum

Stratum basale (bottom)

(Acronym: Come, Let's Get Some Bitches)

64

2 Layers of the Dermis

Papillary

Reticulary

65

Indications for Total Body Skin Exam

Personal history of skin cancer

Increased risk for melanoma

Changing or concerning skin lesions

New rash

Undiagnosed skin condition in a new patient

Follow-up for patient’s who have extensive skin conditions

66

Primary Lesion

Describe the size, shape, color, border, arrangement, and distribution

67

Secondary Lesion

Develop as the primary skin lesion(s) evolves (i.e. scale, crust, erosion, ulcer, fissure, atrophy)

68

Macule

Circumscribed flat lesion

Less than 10mm diameter

69

Patch

Flat and non-palpable

10mm or greater diameter

70

Papule

Elevated, circumscribed, solid palpable lesion

Less than 10mm diameter

71

Vesicle

Elevated, superficial lesion containing serous (clear) fluid

Less than 10mm in diameter

72

Bulla

Circumscribed and elevated lesion containing serous (clear) fluid

10mm or greater in diameter

73

Pustule

Superficial and elevated lesion containing purulent fluid

74

Nodule

Firm, elevated, circumscribed

Different books vary in what size defines this lesion

Usually 0.5 or 1 cm – 2cm

75

Tumor

Solid and elevated lesion

Diameter greater than 2cm

76

Plaque

Elevated and circumscribed lesion with flat top surface

10mm or greater diameter

77

Wheals

Transient firm plaque caused by fluid infiltration into dermis

Size can vary

78

Scale

Excess of dead epidermal cells

79

Crust

Dried cellular debris and serum

80

Erosion

Focal area of epidermal skin loss

81

Ulcer

Focal area of epidermal and dermal skin loss

82

Fissure

Sharply defined loss of epidermis and dermis in linear fashion

83

Annular

Ring shaped

erythematous periphery with central clearing to some extent

84

Serpiginous

Snake-like

85

Reticulated

Lacey

86

Ephelides

Freckles

Widespread 2-3mm evenly pigmented tan/brown macules w/irregular but well-defined borders

87

Solar Lentigo

Sun spots

Brown evenly pigmented annular macule (or patch if >10mm) with irregular but well defined borders

88

Nevi

moles

89

Angiomas

Scattered red papules with even and well-defined border

90

Acrocordon

Discrete soft tan pedunculated papules

91

ABCDEs of Melanoma

A- asymmetry

B- borders

C- color

D- diameter

E- evolve

92

Punch Biopsy

Takes a column down to the subq layer

93

Shave Biopsy

...

94

Excisional Biopsy and Excision Removal

...

95

Electrodessication and Curettage

...

96

Cryosurgery

Usually destroy warts, the OTC doesn’t work as well because it doesn’t get the skin cold enough, fast enough

Use cold

97

Sense

Sight

Hearing

Smell

Taste

Touch

98

Equilibrioception

Balance

99

Proprioception

Position

100

Thermoception

Temperature

101

Nociception

Pain

102

Interoception

Sensitivity to sensations originating inside the body

103

Detection

Feeling

Feeling through the development of psychomotor skills

104

Internal Amplification

Seeing

See the structures that you are palpating by having a thorough knowledge of the anatomy

Create a visual mind-image

105

Analysis and Interpretation

Thinking and Knowing

Must be correlated with a knowledge of functional anatomy, physiology, and pathophysiology.

Practice to know the difference between normal and abnormal

106

Palpation

The application of fingers to the surface of the skin or other tissues, using varying amounts of pressure, to selectively determine the condition of the parts beneath

107

Which part of the body is best/most sensitive to skin and temperature

Dorsum of the hand

108

Which part of the body is best/most sensitive for palpation

Pads of the fingers (thumb and first 2 fingers most sensitive)

109

Pacinian Corpuscles

Mechanoreceptor

Sensitive to pressure and vibration

Textures smaller than 200um can be sensed on the finger tips due to these (rapidly adapting –Phasic)

110

Meissner's Corpuscles

Mechanoreceptor

Sensitive to light touch and very sensitive to vibration (rapidly adapting)

111

Merkels Disc

Mechanoreceptor

sensitive to vibration (slow adapting)

Receptive to sustained response to pressure

112

Ruffini Terminals

Sensitive to stretch

Register degree changes in joint position,and register thermal changes and can register for prolonged periods of time

113

Krause End Bulbs

Receptor for vibration

114

Anatomical Layers

Dermis

Fascial layers

Musculoskeletal

Viscera

115

Turgor

Resitance to deformation (i.e. hydrated-returns to normal position almost immediately vs. dehydrated- “tents”-keeps deformed shape longer than expected.)

116

Passive Motion

brought about by the D.O.

movement done to the subject

117

Active Motion

performed by the subject

deliberate, conscious, muscular activity

118

Inherent Motion

activity unconsciously generated within the body

can be perceived at 1 micron!

ex: respiration, circulatory or electrical patterns