Michael Zhitnitsky

Group C7
1/24/2021
Pt Name: Monica Stone Age: 35

Subjective:
CC: “My stomach hurts”

HPI: A 35 YO female with a PMHx of chronic constipation and increased stress presents to the
clinic with chronic colicky LLQ/diffuse abdominal cramping for the last 2 years. Pt describes that
the pain is slightly better after bowel movements and when taking stool softeners/prunes, and
worse when not having a BM at all. Pt denies any recent illness and infections and is currently in
4-8/10 pain. Pt feels slightly nauseated but has not vomited. Pt has had chronic constipation for
4 years, describes having a BM 2-3x/wk and stool being hard, but normal in color. Blood in stool
is seen if pt strains too hard. Pt denies SOB, cough, color changes in vomit/stool, diarrhea,
changes in urine, joint pain, any recent travel, but does feel bloated. Pt is also experiencing
increased stress and currently eats fast food 3-4 times/week.

PMH: None
Trauma Hx: None
Hospitalizations: None
PSH: None
SH: Pt has a couple of glasses of wine/ month. No tobacco or drugs. Pt is extremely stressed
with work and family life (stays home from work when bloating gets really bad). Diet consists of
poor fiber intake, and fast food 3-4x/wk.
FH: None
Meds: Birth control pills, no name or dosage
Allergies: None
Immunizations: Up to date

Objective:
Physical Exam:
General: Pt is in NAD, AOx3.
HEENT: All normal. Normal mucus membranes and conjunctiva are clear.
CV/Resp: RRR without murmur, ectopy and gallops. Lungs are clear to auscultation in all fields.
Abd: Abdomen is flat, symmetrical without skin lesions. Bowel sounds are hypoactive, and all 4
quadrants are tympanic. Liver is not enlarged and no organomegaly was found. LLQ and entire
abdomen are tender to light and deep palpation. No rebound tenderness, and no shifting
dullness/fluid wave. Negative murphy’s sign.
OSE/MSK: Prolonged erythema T12-L2, with hypertonicity. Tenderness at T12-L2 with
palpation.
Neuro: DTR 2+/4 bilaterally. Strength 5/5 LE bilat. UE pulse 2+ brisk. Normal Cap refill

BP: 108/70
Pulse: 72
RR: 12/min
 Michael Zhitnitsky
Group C7
Temp: 98.8 F
Pain: 4-8/10
BMI: 19.2

Assessment and plan

1. Working Dx: Chronic constipation- Tender LLQ, low fiber, high salt/fat diet,
constipation for the last 4 years, and hypoactive bowel sounds. Hypertonicity and
prolonged erythema in T12-L2. Likely because pt is female and has increased family and
work stress.

DDx: IBS (constipation predominant)- Nausea, pain that is alleviated by bowel

movements, possible sigmoid colon tenderness, some mucorrhea, and onset in middle
age with stress. But pt has no excessive passing of gas or fever, and no feeling of
incomplete evacuation.

Small bowel obstruction- Hypoactive bowel sounds, mild abdominal distension, and
feeling bloated/ nauseated. No fever, Hx of surgery or malignancy, or early satiety.

Diverticulitis- LLQ abdominal pain, nausea, bloating, but no fever and pain does not
change with BM.

Plan:
Meds: Increase dietary fiber (beans, vegetables), increase fluid intake, stool softener
(colace), bulk-producing laxatives (psyllium)
Labs: CBC, ALT/AST, Alk Phos, Amylase/lipase, TSH/T3/T4 (rule out hypothyroidism)
Studies: CT scan to check for abscess, Barium study, upright chest radiograph
OMT: Chapman’s points (along lateral thigh), muscle energy of T12-L2.
Patient education: Bowel rest, and hydration. Discuss current diet and how high fat and
low fiber diet can increase likelihood for future events. Possible surgical
correction if large bowel obstruction or volvulus is found.
Follow up/referral: 1-2 wks follow up after labs or if ASAP if symptoms don’t improve.

2. Secondary Dx: Stress

Plan:
Meds: None
Labs: None
Studies: None
OMT: Soft Tissue for thoracic spine, and counterstrain for pain.
Pt Education: Explain possible ways to reduce stress, including exercise and
meditation. A balanced diet with increased fruits and vegetables could be
included with meal prepping.
F/U: 4-6 wks
 Michael Zhitnitsky
Group C7
Somatic Dysfunction: Prolonged erythema T12-L2, with hypertonicity. Tenderness at
T12-L2 with palpation.
Plan:
Meds: None
Labs: None
Studies: None
OMT: Same as above
Pt Education: Discuss the benefits of OMT and the possibility of soreness. Instruct
patient to drink plenty for water following the treatment.
F/U: 1-2 wks when results to labs return

ABCs:
Autonomics: Sympathetics to abdominal viscera: Thoracolumbar spine. Somatic
dysfunction in that area might decrease sympathetic tone and cause an unbalance in
response to stimuli. Parasympathetic: Sacral spine. Similar to the sympathetic balance,
relieving any congestion in the thoracic/ lumbar area with muscle energy will help the
patient better adjust to sympathetic or parasympathetic tone.
Biomechanics: Thoracic and ribs: these areas affect motion of breathing and overall
range of motion. Congestion in this area will result in overall tension and restriction in
breathing, lymph, and CSF flow.
Circulation: Restricted thoracic inlet and thoracoabdominal diaphragm stops lymphatic
movement, and results in congestion of sinuses and the venous system. Thoracic
release in this area will allow better lymph flow and better clearance of waste products.
Plan: Lymphatics for thoracic inlet and thoracoabdominal diaphragm, soft tissue and
muscle energy for hypertonic paraspinals

3. Screening:
Immunization boosters

The peer review was conducted with my partner.

Michael Zhitnitsky- 1/24/2021