Rural and Medically Underserved Population Primary Care

OMS III CLINICAL ROTATION

MODULE 3

It is anticipated that completing this Case (along with what you are learning clinically we expect that
completing this module will take at least three days).

Cases:
1) Sinusitis
2) Pneumonia

Assigned Reading and other evidence-based resources:

Rakel Textbook of Family Medicine, Chapter 18, pages 329-336
Somatic Dysfunction in Osteopathic Family Medicine (2nd ed.) Chapter 24, pages 258-273
Learning Objectives:

Sinusitis
a. Recall the normal anatomy of the upper respiratory tract including sinuses
b. Apply the osteopathic evaluation and work up for a patient with suspected
sinusitis
c. Identify the etiology of sinus infections
d. Recognize the main risk factors for the development of sinusitis
e. Identify improper use of nasal decongestant sprays leading to rhinitis
medicamentosa
f. Discriminate when antibiotics are appropriate for acute bacterial sinusitis
g. Identify pharmacologic treatments of sinusitis
h. Recall all non-medication treatment options for sinusitis
i. Recall the potential interactions of common decongestants in patients with
hypertension or coronary artery disease
j. Predict potential complications of sinus infections and indications for referral
k. Apply facial effleurage, mandibular drainage, suboccipital release and trigeminal
nerve stimulation to improve symptoms of sinusitis
l. Develop patient education on the complications of overuse of antibiotics in non-
bacterial sinusitis and treatment options at home for prevention of sinusitis

Rakel Textbook of Family Medicine, Chapter 15, pages 183-235

Somatic Dysfunction in Osteopathic Family Medicine, Chapter 25, pages 274-286
Learning Objectives

Pneumonia
a. Generate a thorough history and perform an appropriate physical exam in the
setting of an acute respiratory illness
b. Contrast clinical symptoms of upper respiratory infections verses pneumonia
c. Identify the common positive findings on physical exam for pneumonia and acute
respiratory infection
 d. Select the appropriate diagnostic studies to confirm the diagnosis in the setting of
respiratory infections
e. Predict the severity of illness and potential complications in a patient presenting
with suspected influenza
f. Identify the risk factors for various types of pneumonia according to age, lifestyle,
and exposures
g. Choose appropriate antibiotic coverage for different presentations of pneumonia
h. Identify potential contraindications to first line antibiotic treatments for
pneumonia
i. Recall the most important way to stop the spread of respiratory illness in health
care settings
j. Identify osteopathic treatment options for a patient with pneumonia

Case:
A 24-year-old female, presents to the office complaining for upper respiratory cold symptoms for almost
5 days now. She has used over-the-counter medication without significant benefit. She lists her specific
symptoms as runny nose, worsening nasal congestion, mildly productive cough, sore throat, headache,
subjective fever and chills, decreased appetite, and overall malaise.

Discussion/Questions:

1. List the differential diagnosis for the complaints above.

2. What history and review of system questions are indicated at this time?
3. Describe the physical examination you believe should be completed for this patient?

Back to the Case:

Review of Systems (ROS)

HEENT: Denies severe headache, diplopia or visual loss, mental status change, dental pain, neck pain,
epistaxis

Reports purulent nasal discharge and right-sided facial pain

Respiratory: Denies hemoptysis, purulent sputum production, dyspnea

CV: Denies chest pain

GI: Denies abdominal pain, nausea, vomiting, and diarrhea

GU: Denies change in urinary pattern or hematuria

Skin: Denies rash

General: Denies weight loss or night sweats

Reports mild loss of appetite since illness began

Past Medical History (PMH)

Denies diabetes mellitus, asthma, allergic rhinitis, HIV, liver or renal disease, or recurrent
infections

Surgical History (SxH)

Denies any previous surgery

Family History (FH)

No diabetes, heart disease, asthma, immune deficiencies, or similar symptoms.

Social History (SH)

Denies cocaine use. Denies IV drug use. Occasional alcohol and marijuana. Smokes 1 PPD x 6
years. Lives with family. Medical student. Heterosexual.
Physical Exam (PE)
Temp: 99.5°F Pulse: 88 bpm BP: 125/78 mmHg Resp: 18 breaths/min

GENERAL: mild distress. Alert and oriented. Cooperative with fluent speech.

HEENT: NCAT, External ocular muscles intact. Pupils equal round and reactive to light. TM’s
intact c clear fluid. No erythema or exudates noted. Nasal mucosa swollen and erythematous
with thick yellow discharge. No polyps noted. There is right maxillary and frontal sinus
tenderness to palpation. Posterior oropharynx without exudates. Mild erythema noted.

NECK: supple with scattered mildly tender anterior cervical lymphadenopathy, no thyromegaly,
bruits, or mass present. Full range of motion.

CHEST: clear to auscultation bilaterally without crackles, rhonchi, or wheeze.

HEART: S1, S2 without murmur, gallop, rub, or click. Regular rate of 88.

ABDOMEN: soft, nontender, nondistended. No organomegaly.

EXTREMITIES: pulses full and equal. Full range of motion.

SKIN: No rash or erythema noted.

Discussion/Questions:

4. Recall the normal anatomy of the upper respiratory tract including sinuses.
5. List the common causes of acute sinusitis/rhinosinusitis below?
Microbial etiology Specific infectious agent/organism

Viral

Bacterial

Fungal

6. List risk factors for the development of sinusitis below.

7. List appropriate treatment recommendations and their contraindication for a patient with
rhinosinusitis?

Pharmacologic Management Non-pharmacologic management

including OMT
Option: Option:
Contraindication: Contraindication:

Option: Option:
Contraindication: Contraindication:

Option: Option:
Contraindication: Contraindication:

Option: Option:
Contraindication: Contraindication:

Option: Option:
Contraindication: Contraindication:
8. When is treatment with an antibiotic recommended?

9. Which antibiotics are used to treat rhinosinusitis and what specific organism is targeted with these
choices?

10. List potential complications associated with sinusitis?

11. When is an ENT referral indicated for treatment of sinusitis?

12. Define rhinitis medicamentosa. How is this disorder treated?

Back to the Case:

After performing OMT and discussing options for supportive care at home, the patient leaves
the office with recommendation to return if her symptoms worsen or persist.

Five days later, the patient returns reporting that the sinus pressure has improved however, her
cough has significantly worsened. She also complains of fatigue, myalgia, arthralgia, chills, and
a fever of up to 104°F last night. Her appetite has been poor but she is forcing herself to eat a
small amount of soup. She denies nausea or vomiting but had a loose stool this morning.

13. Contrast clinical symptoms of upper respiratory infections verses pneumonia.

Upper respiratory tract Pneumonia
infection
History

Physical exam findings

14. What physical exam and diagnostic studies are indicated at this time?

Back to the Case:

Physical Exam (PE)

Temp: 103°F Pulse: 99 bpm BP: 122/72 mmHg Resp: 20 breaths/min
Pulse Ox 95% on room air

GENERAL: mild distress. Alert and oriented. Cooperative with fluent speech.

HEENT: NCAT. External ocular muscles intact. Pupils equal round and reactive to light. TM’s
intact c clear fluid. No erythema or exudates noted. Nasal mucosa swollen and erythematous
with thick yellow discharge. No polyps noted. Examination of the facial bones was normal with no
tenderness. Throat: Mild erythema of posterior pharynx present.

NECK: supple with scattered mildly tender anterior cervical lymphadenopathy, no thyromegaly,
bruits, or mass present. Full range of motion.

CHEST: rhonchi and rales present in right lower lung field, no wheezing.

HEART: S1, S2 without murmur, gallop, rub, or click.

ABDOMEN: soft, nontender, nondistended. No organomegaly.

EXTREMITIES: pulses full and equal. Full range of motion.

SKIN: No rash or erythema noted.

OMM: TART findings- hypertonicity of para-spinal musculature at T1-T5.

Discussion/Questions:

15. Recognize the correlation of risk factors for various types of pneumonia according to age, lifestyle,
and exposures and the microorganism responsible
Risk Factor Suggested Etiology
Sudden onset
Gradual onset
Respiratory illness in the family/ recent exposure
to small children
Chronic bronchitis or COPD
Nursing home resident
Altered mental status, seizure, alcoholism, recent
dental procedure
Homelessness or incarceration
Injection drug use
Recent influenza infection
Exposure to contaminated aerosols (showers, air
coolers, water supplies), hotel or cruise ship stay in
the previous 2 weeks
Cystic fibrosis
Sickle cell anemia
Exposure to birds
Exposure to cows, sheep, goats, or parturient cats
Exposure to tissues or body fluids of rabbits, foxes,
or squirrels
Exposure to raw wool, goat hair, animal hides,
cattle, pigs, or horses
Exposure to rodent droppings, urine, or saliva,
visiting the “four corners “ of the United States
Associated weight loss
HIV early
HIV late disease

Back to the Case:

Chest X-ray

Airspace opacity with air

bronchograms obscuring the right
hemidiaphragm in keeping with right
lower lobe pnuemonia

CBC Hematology
  WBC RBC Hgb Hct Plt
Result 12.3 4.8 14 40 350
Normal Value 3.7-9.7 4.54-5.78 13.3-17.2 38.9-50.9 179-373
Units x 109/L  x 106/µL % % µL

Discussion/Questions:
16. What are treatment options for patient and most appropriate treatment choice at this time? Please
include medication dosage instructions.

17. Describe OMT options that may be helpful for this patient.
Specific Treatment Goal of this Contraindication Describe the
Technique Technique treatment position