Sunday, September 21, 2008

Case: Osteopathic Structural Exam on an ICU patient

I wanted to share a brief, informal case from my current internal medicine rotation:

My patient was a 61-year-old Hispanic female who I met in the ICU for a workup of CHF vs. COPD exacerbation.  She had a past medical history of hypertension, gastroesophageal reflux disease, hyperlipidemia, and gout.  My team got the page that her sugars were soaring in the 500’s.  We hooked her up to a rhythm monitor, ordered a chest x-ray, and turned on the pulse oximetry. The resident and I put her on Lantus, an insulin sliding scale, Lasix, Protonix, and an albuterol nebulizer.  

On exam, the patient was seated in a chair, rebreather mask strapped to her face, and the “usual crowd” at the bedside.  She had shortness of breath with exertion, and she complained of a vague epigastric pain.  My team was ready to move on, but something didn’t add up.  I looked at her back, and before I even untied the top of her gown, it looked like T3-T5 were jumping out on the left.  She had fine, purple, almost telangiectasic streaks extending from these segments down towards the angle of her left scapula.  On the other side, ribs 6-10 were inhaled, and the ipsilateral diaphragm was in a relentless spasm.  I suggested ordering cardiac enzymes and running a 12-lead EKG.

Her CK-MB came back as 80 (normal is less than 6).  Troponin-I was 8.1 ng/ml (normal is less than 0.4 ng/ml), and her total CK was over 1000.  The EKG showed S-T elevation in leads V4-V6 and inverted T waves.  I called my resident with the results, and there was silence on the end of the line.  We immediately paged the cardiologist and started her on Plavix and Heparin.  

I had diagnosed a MI in this woman, which would have been completely missed if not for my osteopathic structural exam.  Our early, suppportive intervention may have helped save much of this patient's heart, if not her life.

The instructors in medical school had told us to "keep an eye out" for this sort of thing, but it was pretty mind-blowing to experience it firsthand.  


OD Lady said...

i'm was about to begin studying right now for my osteo test on tuesday.. let me just say that this blog just totally motivated me to stop procrastinating on it! Thanks for sharing that awesome story!

Kelly said...

Jonathan, you never cease to be an inspiration! I am also reminded of our recent experience together in a different ICU.

We used rib raising and myofascial release to reduce a ventilator dependent patient's respiratory rate (he was breathing over the vent at a rate of 40). This allowed his body to properly compensate for his underlying metabolic alkalosis with more appropriate respiratory patterns, as he had developed a combined alkalosis secondary to his tachypnea from sympathetic overload. By rebalancing his autonomics, we were able to achieve results that adjustments of vent settings and CV medications could not.

Our attending physician, a brilliant allopath with a fair amount of scepticism with regard to OMT, was taken aback. In fact, our treatment success blew him and the team of respiratory therapists away and allowed us the opportunity to explain the physiological and anatomical underpinings of Osteopathy. I hope they all learned to approach patients a bit more holistically!

osteopath from chatswood said...

I just looking forward to get such type of information about the Osteopathic Structural Exam on an ICU patient which you have posted here. That is cool info to me and I am thankful for sharing it here.

SwellNoMore said...

Really I read out this history of hypertension, gastroesophageal reflux disease. And really so pleased to read out your concept which is helpful and awesome to me. Thanks a lot for sharing this valuable information indeed. Take it up and inform like this.
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