PPC/OMM Exam 1

Hippocratic Philosophy

centered on "holistic patient oriented care

Cnidian Philosophy

centered on "disease" or symptoms

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

Andrew Taylor Still

Born 1828, Died 1917
Researched for 10 years, 1874 osteopathy officially began
Founded the first American school of Osteopathy in 1892

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

American School of Osteopathy in Kirksville (ASO)
Kirksville, Missouri
1892

Roots of the word Osteopathy

Osteon- bone
Pathos (or) pathine- to suffer

Official Osteopathic Emblem

The Staff of Asclepius
(more associated with healing than the Magical Staff of Hermes

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

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

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

Allostasis

Remaining stable by being variable

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)

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.

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.

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

Rational Treatment

Host + Disease = Illness

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

Disease

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

Host

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

Diagnostic Criteria for Somatic Dysfunction

TART

TART


Tissue texture changes

Asymmetry of structure

Restriction of motion

tenderness to palpation (least noteworthy)

First question to ask yourself when figuring out what to treat

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

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

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

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

Asymmetry of Structure

Visual
Palpatory

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

Tenderness to Palpation

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

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)

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

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

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

Motion Barrier

The limit to motion (bind vs. ease)
Bind-Restriction in one direction
Ease-Freer motion in other direction

Physiologic Barrier

End point of normal physiologic motion
The range of normal active motion occurs between the physiologic barriers

Anatomic Barrier

End point of permitted passive motion
Motion beyond the anatomic barrier damages anatomic structures

Restrictive Barrier

End point of permitted motion in somatic dysfunction
Also known as pathologic barrier
Movement toward the restrictive barrier exhibits bind

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.

OMT

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

Direct Technique

Positioning in the direction of the restrictive barrier
Activating force is applied
Movement through restrictive barrier
eg. drawer analogy/yanking the drawer

Indirect Technique

Positioning away from restrictive barrier
Move tissues in a direction that is freer
Release by inherent forces

Components of a General History

CC
HPI
PMHx
PSHx
PFHx
Social Hx
Medications
Allergies
ROS

CC

Main/Primary Complaint
Subjective, ok to use quotation marks
One liner

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!!!

PMHx

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

Where do secondary dx typically come from

PMHx

PSHx

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

PFHx

Mom, dad, sister, brother, children
Ages (and ages at time of death)
Include genetic testing here

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

Medications

Name, dose, compliance
OTC and herbals
orals, injectables, transdermals,

Allergies

Allergy AND rx

ROS

APPROPRIATE INFO FROM EACH SYSTEM

Average Life Expectancy

US 79.38 (ranked #53)
Nambia 50.89
Monaco 89.32

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

Prevention Hx

Age appropriate screenings
blood pressure diabetes lipids
colon cancer depression weight problems
sexually transmitted infections (STIs)
Immunizations
and incorporate into the plan

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.

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

Subjective

CC, HPI, ROS

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

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

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.)

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

Layers

Epidermis
Dermis
SubQ

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)

2 Layers of the Dermis

Papillary
Reticulary

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

Primary Lesion

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

Secondary Lesion

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

Macule

Circumscribed flat lesion
Less than 10mm diameter

Patch

Flat and non-palpable
10mm or greater diameter

Papule

Elevated, circumscribed, solid palpable lesion
Less than 10mm diameter

Vesicle

Elevated, superficial lesion containing serous (clear) fluid
Less than 10mm in diameter

Bulla

Circumscribed and elevated lesion containing serous (clear) fluid
10mm or greater in diameter

Pustule

Superficial and elevated lesion containing purulent fluid

Nodule

Firm, elevated, circumscribed
Different books vary in what size defines this lesion
Usually 0.5 or 1 cm � 2cm

Tumor

Solid and elevated lesion
Diameter greater than 2cm

Plaque

Elevated and circumscribed lesion with flat top surface
10mm or greater diameter

Wheals

Transient firm plaque caused by fluid infiltration into dermis
Size can vary

Scale

Excess of dead epidermal cells

Crust

Dried cellular debris and serum

Erosion

Focal area of epidermal skin loss

Ulcer

Focal area of epidermal and dermal skin loss

Fissure

Sharply defined loss of epidermis and dermis in linear fashion

Annular

Ring shaped
erythematous periphery with central clearing to some extent

Serpiginous

Snake-like

Reticulated

Lacey

Ephelides

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

Solar Lentigo

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

Nevi

moles

Angiomas

Scattered red papules with even and well-defined border

Acrocordon

Discrete soft tan pedunculated papules

ABCDEs of Melanoma

A- asymmetry
B- borders
C- color
D- diameter
E- evolve

Punch Biopsy

Takes a column down to the subq layer

Shave Biopsy

...

Excisional Biopsy and Excision Removal

...

Electrodessication and Curettage

...

Cryosurgery

Usually destroy warts, the OTC doesn�t work as well because it
doesn�t get the skin cold enough, fast enough
Use cold

Sense

Sight
Hearing
Smell
Taste
Touch

Equilibrioception

Balance

Proprioception

Position

Thermoception

Temperature

Nociception

Pain

Interoception

Sensitivity to sensations originating inside the body

Detection

Feeling
Feeling through the development of psychomotor skills

Internal Amplification

Seeing
See the structures that you are palpating by having a thorough
knowledge of the anatomy
Create a visual mind-image

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

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

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

Dorsum of the hand

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

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

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)

Meissner's Corpuscles

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

Merkels Disc

Mechanoreceptor
sensitive to vibration (slow adapting)
Receptive to sustained response to pressure

Ruffini Terminals

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

Krause End Bulbs

Receptor for vibration

Anatomical Layers

Dermis
Fascial layers
Musculoskeletal
Viscera

Turgor

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

Passive Motion

brought about by the D.O.
movement done to the subject

Active Motion

performed by the subject
deliberate, conscious, muscular activity

Inherent Motion

activity unconsciously generated within the body
can be perceived at 1 micron!
ex: respiration, circulatory or electrical patterns