1. Integrating the Osteopathic Structural Exam into the Physical Diagnosis Practical Aubrey M. Olson, D.O., M.S.Ed. Rebecca Moore, D.O. Danielle Cooley, D.O.

2. Objectives
Discuss the importance of incorporating the Osteopathic Structural exam into the general physical exam.
Describe the implementation of the Osteopathic structural exam into the general physical exam.
Examine the relevance for integrating the Osteopathic structural exam into the Physical Exam with regard to COMLEX PE and ACGME’s Osteopathic Neuromuscular Medicine Milestone Project in the unified pathway.

3. Background
The Osteopathic structural exam is often not included in physical examination training
Students struggle to incorporate both exams into patient care
Incorporation is critical for success in the Comlex PE

4. Why does this matter?
As per AACOM’s Osteopathic Core Competencies for Medical Students, which sets the guidelines for Osteopathic Medical education:
Under section III Patient Care, a medical student must:
3a. Perform a clinically appropriate standard physical examination, including evaluation of each of the body areas (i.e., head, neck, chest; abdomen; genitalia/groin/buttocks; back, including spine; upper and lower extremities) and organ systems (constitutional; cardiovascular; ears, nose, mouth and throat; eyes; genitourinary (female and male); hematologic/lymphatic/immunological; musculoskeletal; neurological; psychiatric; respiratory; skin).
3b. Perform an osteopathic structural examination and osteopathic manipulative therapy as appropriate.

5. Why this matters (continued)
The National Board of Medical Examiners-- Fundamental Osteopathic Medical Competency Domains: Guidelines for Osteopathic Medical Licensure and the Practice of Osteopathic Medicine
Osteopathic medical students are required to integrate all aspects of the physical exam, including the Osteopathic structural exam, into patient care
Students are at a distinct disadvantage when taught separately

6. Our Goal
Integrate the Osteopathic structural exam into physical diagnosis
Utilize educators from both the Osteosciences Department and the Family Medicine Departments
Interdisciplinary approach to teach the incorporated examination in both courses
Parallel teaching to help with student facilitation and integration into the incorporated exam

7. The Challenges
The Osteosciences and Family Medicine Departments were isolated in teaching their own courses
Didactics follow systems-based general curriculum
Courses were taught independently of each other
Limited resources:
Class size of 168
Standardized patient laboratory with 10 examination rooms
9 hours exam sessions for practical exams
Student performance on CSCE (Mock COMLEX PE) and COMLEX PE were not reflective of student’s ability to integrate both components into a patient encounter

8. How we changed the discussion
On Doctoring (physical diagnosis):
All lecturers include a slide of Osteopathic Considerations
Laboratory sessions include osteopathic structural exam considerations and treatment
OMM: table trainers discuss where the structural exam fits into the patient encounter
Physical Diagnosis Practical: rubric now includes aspects of Osteopathic Structural Exam
OMM Practical: now includes professionalism and interpersonal communications

9. On Doctoring Documentation and Osteopathic Structural Exam Slide:
Review of Systems
including all pertinent ROS for the body system presented
Documentation of exam finding
Normal & abnormal
Osteopathic Structural Exam
Structural exam findings
Chapman’s points

10. Example Slide for Cardiology Module
Top Ten ROS for the Cardiac System:
Chest pain
Edema
Palpitations
Recent Weight Change
Dyspnea / Shortness of breath
Fatigue
Orthopnea
Headache / Dizziness
Paroxysmal Nocturnal Dyspnea
Abdominal Pain / GERD
Documentation for the Cardiac Exam:
Normal Exam: Cardio: RRR +S1S2, no M/R/R
Abnormal Exam: Cardio: irreg rate/rhythm +S1S2, no R/R, + 3/6 SEM best heard at 2nd intercostal space
Osteopathic Considerations / Exam:
Palpation of anterior chest wall including Pec Major and Minor
Assessment of OA for restriction and tenderness
Range of motion for thoracic spine
Rib assessment (first rib, upper ribs, middle ribs, lower ribs)
Diaphragm Assessment for passive motion and tenderness
Chapman’s Points for Heart:
Heart Anterior: Just below R2 at the sternocostal junction
Heart Posterior: T3 Paraspinals at the 2nd intercostal space

11. OMM Cardiopulm Diagnostic Exam Rubric

12. On Doctoring II Cardiac Exam
Inspection
Check PMI
Auscultation of the heart with the diaphragm and bell in the four points - Aortic, Pulmonic, Tricuspid, Mitral Areas
Auscultate the carotid arteries
Check for JVD with measurements (head of table at degrees)
Arterial Pulse Assessment - Radial, Ulnar, Brachioradialis, Aortic, Femoral, Pretibial, Dorsalis pedis
Stands on right side of patient for exam
Palpate anterior chest wall including pec minor and major and ask about tenderness
Assess OA for restriction and ask about tenderness
Active and passive ROM for thoracic spine
Rib assessment (first rib, upper ribs, middle ribs, lower ribs)
Diaphragm Assessment for passive motion and tenderness
Passive assessment of sternum

13. Cardiology Practical Exam Rubric

14. On Doctoring II Pulmonary Exam
Inspection anterior and posterior
Palpation of inspiration anterior and posterior
Percussion posterior – 8 points
Tactile Fremitus posterior - 8 points
Ausculatation with Diaphragm and bell, anterior and posterior - 8 points
Bronchophony posterior -- 8 points
Whispered pectoriloquy posterior -- 8 points
Egophony posterior - 8 points
Stands on right side of patient for exam
Assessment of OA for restriction and tenderness
Active and passive range of motion for thoracic spine
Rib assessment (first rib, upper ribs, middle ribs, lower ribs)
Diaphragm Assessment for passive motion and tenderness
Passive motion of clavicle (abd, add, flex, ext, int rot, ext rot)

15. Pulmonology Practical Exam Rubric

16. Gastrointestinal Focused Structural Exam
2nd year OMM Practical Exam Date ____________ Student Name ___________________________
Gastrointestinal Focused Structural Exam
­­­­___/3
Demonstrates Humanism
___/3
Evaluates OA motion
Evaluates cervical spine for flexion/extension, rotation, sidebending. Active motion Passive motion
Evaluates thoracic spine for flexion/ extension, rotation, sidebending Active motion Passive motion
Evaluates lumbar spine for flexion/ extension, rotation, sidebending Active motion Passive motion
Palpates cervical spine evaluating for TART (should ask patient if there is tenderness)
Palpates thoracic spine evaluating for TART (should ask patient if there is tenderness)
Palpates lumbar spine evaluating for TART (should ask patient if there is tenderness)
Evaluates Sacrum Performs Seated flexion test Palpates sacral bases and ILAs
Evaluates Innominates Performs ASIS Compression or standing flexion test Palpates ASIS and PSIS
Palpates iliotibial band for Tenderness (should ask patient if there is tenderness) Tissue texture changes
____/3
Palpates preverterbral ganglia for Tenderness (should ask patient if there is tenderness) Tissue texture changes
Palpates diaphragm for
Tenderness (should ask patient if there is tenderness)
Tissue texture changes
Diagnosis
_____/2
Nomenclature
Biomechanical exam documentation (Please document somatic dysfunction diagnoses for 3 of the following body regions)
Head _____________________________________________
Cervical _____________________________________________
Thoracic_____________________________________________
Lumbar_____________________________________________
Pelvis/Innominates _____________________________________________
Abdomen _____________________________________________
Sacrum ___________________________________________
Lower Extremity/Chapmans________________________________________
Subtotal
______/12
Total ______/38

17. On Doctoring Abdominal Exam
Inspect
Specials tests:
Auscultate all four quadrants with diaphragm
Murphy’s test
Lloyd’s test
Auscultate abdominal aorta artery
Psoas sign
Rosvings sign
Percuss all four quadrants
Obturator sign
Palpate all four quadrants
Assess diaphragm
Pay particular attention to liver,
Assess prevertebral ganglia
spleen, aorta
Lumbar – palpate lumbar spine for TART, ask about pain/tenderness
Check for ascites
Either shifting dullness OR fluid wave
Assess Iliotibial band for tenderness
Rebound tenderness at McBurneys point
Seated flexion test
Palpation of sacral sulci and ILAs 

18. Why is this important?
Unified ACGME pathway Osteopathic Neuromuscular Medicine Milestone Project
“The Milestones provide a framework for assessment of the development of the resident in key dimensions of the elements of physician competency in a specialty or subspecialty.”
Weights the knowledge of the interrelationship of physical diagnosis findings and osteopathic structural findings as an integral skill
These skills start in pre-clerkship years when students are first taught diagnostic skills. They are built upon in clerkship and residency.

20. In Conclusion
Students need to be able to integrate both skill sets for the COMLEX PE
Lack of the Osteopathic structural exam integration may result in physicians who are unsure of their Osteopathic skills
Incorporation is of both skill sets is necessary

21. References
ACGME. The Osteopathic Neuromusculoskeletal Medicine Milestone Project. The Accreditation Council for Graduate Medical Education. December, Accessed via the internet at:
AACOM. Osteopathic Core Competencies for Medical Students. American Association of Colleges of Osteopathic Medicine. August, Accessed via the internet at:
NBOME. Fundamental Osteopathic Medical Competency Domains: Guidelines for Osteopathic Medical Licensure and the Practice of Osteopathic Medicine. National Board of Osteopathic Medical Examiners. June, Accessed via the internet at:
Brian F. Degenhardt, DO. “Osteopathic Manipulative Medicine: Optimizing Patient-focused Health Care.” The Advisor, Vol. 21, #1 (Dec 2000)
Amy W. Johnson, DO; Jay H. Shubrook, Jr, DO. “Role of Osteopathic Structural Diagnosis and Osteopathic Manipulative Treatment for Diabetes Mellitus and Its Complications.” The Journal of the American Osteopathic Association, November 2013, Vol. 113, doi: /jaoa
A special thank you to Brittany Lipsett, Kathleen Maguire, Sima Bennett, and Kathy Roderique, for their invaluable help in this endeavor.