Justin is currently working with the in-patient internal medicine team and is completing morning rounds. His first patient of the day is Mr. Thompson, a 75-year-old man admitted 2 days ago for pneumonia. Justin begins by reviewing Mr. Thompson's vital signs, morning laboratory results, and current medications. Justin then goes to Mr. Thompson's room for further evaluation. He begins by asking him how he is feeling, if he has had improvement of his cough, and about associated symptoms, including if he has any pain or discomfort. Mr. Thompson notes that he is feeling a little better, but he is still coughing a lot and intermittently feels feverish. His appetite has not yet returned, and he has some mild lower rib pain on the right side that has been present since the coughing started.
Justin then proceeds with a physical examination, including a general evaluation, mental status evaluation, listening to lung fields, listening for heart sounds in all 4 positions, observing skin for color, checking capillary refill, and palpating proximal and distal pulses. He checks the cervical and axillary lymph nodes. Additionally, he palpates the T2-T6 thoracic region looking for somatic dysfunction representing a viscerosomatic reflex. He notes some hypertonicity in the thoracic paraspinal region as well as some segmental dysfunction. Justin examines the ribs and finds the right first rib elevated and the right ribs 4-6 exhaled. He also notes diaphragm restriction on the right, the cervicothoracic junction rotated right, as well as a tender Chapman point on the right between the first and second rib.
Justin reviews the patient encounter with Mr. Thompson with his attending physician. He appropriately organizes and presents the HPI and the physical examination under which he describes the somatic dysfunction found in the thoracic region, ribs, and diaphragm. In his assessment and plan he describes to his attending how treating these areas will help address viscerosomatic reflexes (thoracic spine), adequate respiration (ribs/diaphragm), and decreased pain by addressing rib motion, as well as adequate lymphatic and vascular flow by treating the diaphragm and thoracic inlet. Justin's attending asks if there is any research on using OMT in patients with pneumonia, and Justin states he knows of several published in the JAOA and can pull them up for review. Justin's attending is supportive of the use of OMT and would like him to perform it on the patient.
Justin and his attending return to the patients' room. He chooses to perform soft tissue and balanced ligamentous tension models of treatment after contemplating other technique choices, such as HVLA. He decides against HVLA because of Mr. Thompson's level of illness and age. Before beginning OMT, he discusses with Mr. Thompson what he has found on physical examination and how he believes OMT may help. He outlines risks and benefits of the procedure and asks if Mr. Thompson would like to consent to treatment. Mr. Thompson consents, and Justin performs OMT to address the somatic dysfunction. When he is finished he checks in with Mr. Thompson to see how he is feeling and counsels him on what to expect after treatment. He then discusses the physical examination and laboratory findings and what they indicate for Mr. Thompson.
Justin returns to the medical record and documents his note, including the following somatic dysfunction: THORAX: T3ERSr, T5ERSl, hypertonic paraspinals bilaterally T2-6, right diaphragm restriction, right respiratory Chapman point, cervicothoracic junction rotated right; RIBS: right rib 1 elevated, right ribs 4-6 exhaled, T/L junction rotated right. He finishes his assessment and plan with a procedure note including consent, reason for treatment, type of treatment, body areas treated, patient response, and posttreatment follow-up.