+
The Patient presents.
+
HPI continued
+
History continue
PMHx
PSHx
Tracheostomy (1956)
Tonsillectomy (1971)
Laparoscopic removal of
endometriosis from fallopian
tubes and posterior uterus (1977)
Hymenectomy (1985) resulted in
increased scar tissue constricting
vaginal wall
Spinal fusion surgery due to C4/5
and C5/6 disc herniation (2007)
Lap-band (2009) resulted in chest
fascial tightening, scar tissue
around the port, and intraabdominal hernia
Hysterectomy due to fibroids
(2011)
+
History continue
Trauma Hx
FamHx
+
History continued.
Meds & Allergies
Meds:
Ambien 12mg PO 1 tab qhs.
Cymbalta 120mg PO 1 tab qhs.
Elavil qhs, unknown dose and
frequency.
Ativan unknown dose PO 1 tab
qhs prn.
Alg:
Penicillin causes erythema and
high fever.
Sulfa-drugs causes upset
stomach with nausea and
vomiting.
Paxil causes hallucinations
SocHx
Follows Metagenics diet,
which helps her lose
weight, but then regains it
due to her sugar addiction
Denies smoking
Occasional cocktail
+
ROS
+
ROS
+
Physical Exam
Vitals:
Gen:
Derm:
HEENT:
Neck:
Lungs:
Abd:
CTA bilaterally.
+
Physical Exam
+
Osteopathic exam
C2-C3 FRRSR, AA RL
R 2-7 ISD on L
Diaphragm restricted to L
+
Diagnosis and Differential
Working Diagnosis
Osteoarthritis of R knee
Sciatic neuritis
Somatic Dysfunction
Differential Diagnosis
Rheumatoid Arthritis
Scleroderma
Sjogrens Syndrome
Dermatomyositis/polymyositis
+
Rheumatoid Arthritis
+
Rheumatoid Arthritis
Clinical findings:
Eyes: Iritis
+
Rheumatoid Arthritis
Lab findings
ACPA
Serum RF
Elevated ESR
Imaging
Bony erosions
+
Systemic Lupus Erythematous
Pathogenesis:
Diagnosis:
Serum ANA
+
Systemic Lupus Erythematous
Clinical findings:
Generalized LAD
Fibrous pericarditis
Headaches
+
Scleroderma
Pathogenesis:
+
Scleroderma
Clinical findings:
Fatigue
Stiff joints, joint pain and contractures due to fibrosis around tendons
Raynauds phenomenon
Skin thickening
Esophageal hypomotility
Pericarditis
Neuropathies
Sexual dysfunction due to constriction of vaginal introitus
Diagnosis
+
Sjorens Syndrome
Clinical findings:
RA
Xerosis: dry, scaly pruritic skin affecting the LE and axillary creases
Depression
Painful neuropathies
Fibromyalgia
+
Sjorens Syndrome
Lab findings
Serum ANA
Serum RF
Diagnostic testing
+
Dermatomyositis/Polymyositis
Pathogenesis:
+
Dermatomyositis/Polymyositis
Clinical findings
Diagnosis
+
UCTD
+
Treatment of Arthritic Pain
Goals:
Control
of pain
Improvement of function and quality
of life with minimal toxic effects from
therapy
+
Pharmacologic modalities
Anti-inflammatory
Topical analgesics
Adjunctive modes of therapy for pt who cannot take systemic antiinflammatory therapy
Capsaicin cream
Opiate Analgesics
Glucosamine chondrotin
+
Non-pharmacologic modalities
Surgical
Procedural
Intra-articular
steroid injections
Relief lasting for months, but possibly increase the
progression of OA
Hyaluronic acid replacement by injecting HA into
painful joint to provide lubrication
Patient education
Weight loss
Aerobic exercise: swimming pool exercises
Physical therapy
Occupational therapy
Assistive devices for ADL
OMT!
Muscle Energy
Myofascial Release
+
Resources
UptoDate
Medscape
OMT manual