Osteopath oral assessment prep

Knowledge: Back pain that does not vary with movement in an older man with a smoking history, hypertension and a family history of sudden death must make me consider abdominal aortic aneurysm, which can leak or rupture. Risk is higher in male smokers over 65. A palpable pulsatile abdominal mass may be absent, particularly in obese patients, so absence does not exclude an aneurysm, and I should not press deeply on a suspected one.

Management: I would take a full history including previous vascular disease, claudication and abdominal or groin pain, take his blood pressure, and perform a gentle abdominal inspection and light palpation. If I find a pulsatile expansile mass, or he has severe sudden pain, collapse or tachycardia, I would call 998 immediately and not treat. Even if the examination is unremarkable, because of the risk profile I would refer him the same week to his physician for an abdominal ultrasound and I would defer manual treatment of the lumbar spine until the result is available.

Ethics and communication: I would explain that I do not know that he has a problem, but that this pattern of pain and risk factors needs a scan before I treat him, and that waiting costs little while missing an aneurysm costs a great deal. I would respect that he may be reluctant to be sent for tests, but I would document my advice and his decision. I work within my scope as an osteopath, which includes recognising when a patient needs a physician, and I would send a letter to his doctor with my findings.

Reference: NICE Guideline NG156, Abdominal Aortic Aneurysm: Diagnosis and Management (2020) and Greenman's Principles of Manual Medicine (Lippincott Williams and Wilkins)

Knowledge: New headache in someone over 50 with scalp tenderness, jaw claudication, systemic symptoms and transient visual loss is giant cell arteritis until proven otherwise. Untreated, it can cause permanent visual loss, often within days, in one eye and then the other, and stroke. Diagnosis requires prompt medical assessment with inflammatory markers and usually early high-dose corticosteroids started before biopsy. A normal ESR does not completely exclude it.

Management: I would not perform cranial or any other manual technique. I would explain that I am concerned about an inflammatory condition of the blood vessels in her scalp that can threaten her sight, and she needs to be seen by a doctor today, in an emergency department or by an ophthalmologist or rheumatologist. I would arrange transport, telephone ahead and write a summary of the symptoms, including the visual episode. I would make sure that her daughter understands the urgency, and I would ask her to take any medicines she uses.

Ethics and communication: She and her daughter came for a particular treatment, and I should be honest that the treatment would not help and could delay urgent care. I would explain simply and respectfully, with an interpreter if needed, and not use alarming language that might frighten her, but be clear about the urgency. I would document the encounter and my advice. I should also be honest that the evidence for cranial osteopathy as a treatment for headache is limited.

Reference: Dasgupta et al., BSR and BHPR Guidelines for the Management of Giant Cell Arteritis (Rheumatology, 2010) and Chila (ed.), Foundations of Osteopathic Medicine (Lippincott Williams and Wilkins)

Knowledge: This picture suggests deformational (positional) plagiocephaly with congenital muscular torticollis. It must be separated from craniosynostosis (premature fusion of a suture), which gives a different head shape, for example a ridge along a suture, a parallelogram shape viewed from above with ear displacement and forehead asymmetry, and which can need surgery. Positional plagiocephaly usually improves with repositioning, tummy time and stretching of the neck muscles, and there is limited evidence that cranial manipulation changes head shape.

Management: I would examine head shape from above, the position of the ears and forehead, neck movement, hips and development, and refer him to a paediatrician for confirmation of the diagnosis and exclusion of craniosynostosis and developmental problems, particularly because of the neck mass. I would advise the parents on repositioning, supervised tummy time and sleeping on his back on a firm surface, and I could offer gentle, non-forceful soft-tissue and stretching advice for the neck, in line with the paediatrician's plan. I would not make a promise to reshape the skull.

Ethics and communication: I would explain honestly that the evidence for cranial osteopathy to reshape the skull is weak, that most positional flattening improves with simple measures, and that I do not want to delay a diagnosis that matters. Informed consent from the parents is essential and I would record it, explain what I will do in language they understand, and respect their decision if they choose a different path. I would not criticise the health visitor and would encourage the parents to follow the medical review.

Reference: Laughlin et al., Prevention and Management of Positional Skull Deformities in Infants (Pediatrics, 2011) and WHO Benchmarks for Training in Osteopathy (2010)

Knowledge: Pelvic girdle pain is common in late pregnancy and responds to education, exercise, support belts and gentle manual approaches, but a new frontal headache with swelling of the face and hands at 33 weeks may be pre-eclampsia, which can progress to eclampsia, placental abruption and HELLP syndrome. Other features include visual disturbance, epigastric pain, vomiting and reduced fetal movements. The diagnosis requires blood pressure and urine protein, so I cannot exclude it by history alone.

Management: I would measure her blood pressure now if my clinic has a validated device, ask about visual symptoms, epigastric pain and fetal movements, and defer treatment. If her blood pressure is raised, or she has severe headache, visual disturbance or abdominal pain, I would arrange immediate transfer to a maternity unit by ambulance, and call ahead. Even if the pressure is normal, I would insist on same-day assessment in the antenatal clinic or maternity triage given her symptoms and missed checks. After the obstetric review, I would be glad to treat her pelvic girdle pain with gentle articulation, soft-tissue work, exercise and support advice, avoiding any strong rotational or high-velocity technique.

Ethics and communication: I would explain clearly and calmly that my concern is for her and her baby, and that pelvic pain is a lesser worry today. I would ask whether she is comfortable with a male or female practitioner, offer a chaperone, and make sure she understands the plan. I would write a referral summary and record the blood pressure, her symptoms and her consent. I would also remind her she is entitled to routine antenatal checks and help her book one.

Reference: Vleeming et al., European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain (European Spine Journal, 2008) and NICE Guideline NG133, Hypertension in Pregnancy: Diagnosis and Management (2019)