THE LAST PBL Bonus Doc: OMSII Block 3 2015

THE LAST PBL Bonus doc: OMSII Block 3 2015

A moment of your time, for we have given you a few moments of ours…

These were never done alone...the people who helped along the way have our eternal gratitude. It is our sincerest hope that these documents (labors of love!) helped you get at least a point or two along the way.

Best of luck on this PBL exam, boards and beyond.

We will leave you with a saying of two of the greatest warrior-poets of their generation. They are words to live by every day:

Be excellent to each other...and party on dudes.

IT BEGINS….

Case 1-Asthma AKA Evil Puppies Did It

12 y/o M uncontrolled asthmatic in respiratory distress, wheezing unresponsive to home meds ● Sitting in the tripod position (indicative of respiratory distress, esp in a kid) and unable to verbally answer questions ● *PEFR (Peak Expiratory Flow Rate) 50% of normal values PEFR is closely related to FEV1 values in spirometer pulmonary function tests.

Meds ● Fluticasone (inhaled steroid) ● Salmeterol (B2 agonist, long acting) ● Albuterol (B2 agonist, short acting) ● Ipratropium MDI (Metered Dose Inhaler, Muscarinic Antagonist)

Vitals P 104, R 32 BP 85/40 w/ inspiration, 100/50 w/ expiration ● Pulsus Paradoxus is a drop in systolic BP of >10mmHg w/ inspiration. Causes include asthma, tamponade, sleep apnea, pericarditis, and croup.

ENT: Nasal flaring present; oral mucosa dry (hyperventilation?)

Neck: Trachea midline (very important to check in a pt in respiratory distress to help evaluate for a pneumothorax)

Chest: ● Intercostal, suprasternal, substernal retractions. ● Expiratory phase longer than inspiratory phase. ● Wheezing in all lung fields.

Special Lung Tests ● Tactile fremitus-place the dorsum of your hand on the pts back, in the same areas you'd auscultate posteriorly, and have them say "99" or "Giant Hands". Increased vibration=consolidation ● Whispered pectoriloquy- Use your stethoscope in the areas of auscultation; have the pt whisper "99" or "Seriously, they're huge". Increased volume=consolidation ● Bronchophany- same as above, but they don't need to whisper ● Egophany- Listen w/ stethoscope in areas of auscultation; have the pt say "ee". If it sounds like "aa" in any given place=consolidation

OMM: Inhalation dysfx b/l

ABG showed severe respiratory acidosis w/ partial renal compensation ● More than one facilitator has spent an extended amount of time, in multiple sessions, discussing resp/met alk/acidosis. [Know it, love it, be it]. ● Before you do an ABG, gotta do that Allen's test Despite supportive meds in ER (B agonists, Ipratropium, steroids) pt's respiratory status declined (the wheezing went away, but that's because his respiratory effort did too!). Intubation w/ atropine, succinylcholine and etomidate was performed.

Had we looked at the histology behind asthma, we would have seen Curschmann Spirals "whorls" of shed mucous plugs Charcot-Leyden Crystals: from accumulation of eosinophils

CXR showed: ● Hyperinflated lungs ● Flattened diaphragm ● Peribronchial cuffing- also known as the donut sign, not specific for asthma but indicative of fluid or mucous buildup in the small airways ● NO infiltrates or atelectasis (we'll save the thoracic lymphatic pump for the next lucky pt! Also note that thoracic pump w/ assist is contraindicated.) ● NO pneumothorax/pneumomediastinum

Pt was transferred to ICU and placed on mechanical ventilation-prolonged expiratory phase (controlled hypoventilation) and Na Bicarb was given to correct his acid-base status. Rib raising was also performed, which cured the pt from asthma forever.

Pt was discharged with strict instructions to avoid puppies, especially the cute ones. :(

Because we had multiple pts w/ obstructive or restrictive patterns, gonna plop this here: Case 2-Rheumatoid Arthritis

CC of Dyspnea and Pain/Swelling in arms/legs *3 weeks ● Acetaminophen/Ibuprofen did jack all, pt did not fill rx for propoxyphene (opioid) ● Pain is 3/10, dull, relieved by rest & ice ● Coughing up "slimy white gunk", denies blood ● SOB w/ activity, relieved when lying flat (called “platypnea”, the opposite of “orthopnea”)

Denies ● Denies trauma ● past med hx ● systemic symptoms (fever, chills,N/V etc) ● Hx STIs

Meds-All the Abx, which did nada

Vitals BP: 137/89 P: 124 R: 30 Pulse Ox: 91% HEENT: Erythematous pharynx

Lungs: Scattered B/L expiratory wheezes. Decreased breath sounds over left lower lobe, w/ dullness to percussion over same field

Since it came up in multiple cases, here are some lung sound definitions from our H&P book (more info on p. 306-307)

Crackles-short, nonmusical, high pitched discontinuous breath sounds that are "explosive/popping"; caused by sudden opening of airways that were collapsed due to fluid/exudate and heard during inspiration (some sources don't distinguish between this and rales)

Rhonchi- low pitched "snoring" sound, produced on exhalation. Due to secretions, usually cleared w/ coughing

Wheezes-high-pitched, musical. Heard during inspiration or exhalation.

Pleural friction rub-scratching/crinkling sound

Stridor-high pitched sound, audible w/o a stethoscope, heard during inspiration. Caused by an obstructed airway and is a medical emergency.

Extremities: ● B/L swelling of the wrists, MCP, PIP w/ pain on palpation ○ RA can be associated w/ ulnar deviation of the fingers and radial deviation of the wrists ○ Swan-Neck=DIP hyperflexion w/ PIP hyperextension ○ Boutonniere deformities= PIP flexed, DIP hyperextended ○ DIP usually spared from nodules/inflammation (unlike in osteoarthritis) ● Decreased ROM ● Knees and ankles swollen b/l, tenderness to palpation/motion ● Warmth in knees only Pertinent negatives in the extremities: No pre-tibial edema or rashes (makes kidney, infection or SLE less likely)

When you palpated with your mad osteopath skills, you found TART: ● OA, AA ● T1-6 (lungs!) ● T2-8 (hands!) ● T11-12 (legs!) ● Chapman's point at the L 4th interspace and to the left of the T4 spinous process (lower lung lobe)

But because that wasn't quite enough to clinch the diagnosis, we ran some tests

CBC ● Normochromic, normocytic anemia ● Lymphocytosis ● Thrombocytosis ● Mild hypochloremia-exchange for HCO3 in RBCs

ABGs showed a fully compensated respiratory acidosis (kidneys have had time to compensate by reabsorbing bicarb)

ESR (erythrocyte sedimentation rate)= nonspecific, but a decent marker of acute inflammation, was elevated CRP (C-reactive protein)=an acute phase protein produced by the liver, a marker of inflammation

CXR showed a l sided pleural effusion; to prove it was fluid and not a mass we took a film in the l lateral decubitus film to demonstrate fluid level layering

Getting rid of the fluid involved a thoracentesis (which is typically done in the 7th-9th rib spaces, depending on which source you read, but always at the superior margin of the rib to avoid the neurovascular VAN (superior->inferior). Should be performed a space below the level of effusion) ● 500 CC of cloudy, non-bloody fluid was aspirated from the L lower lung field

Pleural fluid showed ● Cloudy ● Purulent ● Hella Mononuclear cells w/o organisms ● increased specific gravity (evidence for exudate, see below) ● +RBC ● +WBC ● increased protein ● decreased amylase ● decreased glucose ● increased LDH ● Rheumatoid Factor Positive (not run, but the most specific test for RA is actually for Anti-CCP antibodies)(Pimp Question: “What are two markers for RA?” Rheumatoid factor (RF) and anti- cyclic citrullinated peptide antibody (anti-CCP)) ○ RF is an IgM1 antibody against the Fc portion of IgG

Light's Criteria- Fluid is exudate if one of the following Light’s criteria is present

● Fusion protein/serum protein ratio greater than 0.5 ● Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6 ● Effusion LDH level greater than two-thirds the upper limit of the laboratory's reference range of serum LDH

1 Mostly, can be IgA, IgG etc; but if you are asked to pick go w/ IgM Rx ● Initially, steroids and NSAIDs ○ Pt continued to feel dyspnea and was worried she might have lung cancer (not worried enough to quit smoking, though.) ○ Dosing consideration w/ prolonged usage of steroids (among other things) ■ Iatrogenic Cushing's ■ PUD ■ Osteoporosis (prevent w/ Vit D, bisphosphonates, CA) ■ Impaired wound healing ■ Infections ● Pleural effusion was drained w/ a chest tube, showing a "central necrotic fibrous core, surrounded by palisading layers of mononuclear and polymorphonuclear cells"-> rheumatoid nodule ● Methotrexate (MTX, a dihydrofolate reductase inhibitor) ● Infliximab (anti-TNF antibody) and Etanercept (Decoy TNF receptor, a fusion protein of TNA-a and Fc of IgG1) ○ Because these mess your immune system up somethin' fierce, always have your get a PPD before going on these drugs-pts are subject to reactivation TB

OMT'd (if that wasn't a word before, it is now) w/ HVLA+ other treatments you won't bother reading about in the supplements at the bottom. ● Please, please, please for the love of William Garner Sutherland don't do cervical (esp OA) HVLA on someone w/ Rheumatoid Arthritis. They are at high risk for subluxation due to ligamentous laxity. Same goes for a pt w/ Down Syndrome)

Case 3-Scleroderma

53 y/o F w/ a CC of a painful nonhealing fingertip ulcer ● Hx recurrent similar ulcers ● Swollen fingers ● Raynaud Phenomenon ○ The most patriotic vascular dz ever-decreased blood flow to the skin due to vasospasm in response to cold or stress: color change from white (ischemia)->blue (hypoxia)->red (reperfusion)[Past Bonus Question]. ○ Can be idiopathic or part of a systemic issue like SLE, CREST etc. ○ Rx w/ Ca channel blockers. ○ Seen in people who live in cold climates mostly- if idiopathic ● Dysphagia (leading to a 5 lb wt loss) ● Heartburn ● SOB w/ exertion (but denies chest pain, diaphoresis, syncope, palpitations...and everything else that could be indicative of a primary cardiac issue) ● Twin sister has recently started manifesting similar sx

CREST =  Calcinosis  Raynaud’s phenomenon  Esophageal dysmotility  Sclerodactyly  Telangiectasia

Skin exam: As discussed in HPI

Chest: Coarse breath sounds b/l. No rhonchi, wheezes or rubs.2

Extremities: Hands swollen w/o pitting edema (makes +capillary pressure or hypoproteinemia less likely). Nailfold capillaries were abnormal via ophthalmoscope.

Blood vessels can be directly visualized in the EYES and NAIL BEDS

OMT: TART at the OA, AA, C2-7, T1-6 and aisle 3 next to the cookies.

CMP showed low creatinine, likely due to her poor diet. Your guess for the high cholesterol is as good as mine.

CXR: Bibasilar interstitial infiltrates. No mass/pneumothorax Barium Swallow showed distal stricture w/ proximal dilation of the esophagus

Pulmonary Function Tests Reduction in ● FEV1/FVC (scleroderma typically has a restrictive pattern, so not so sure why this should be...) ● TLC ● FVC

2 Pleural rub: low-pitched, grating, or creaking sounds that occur when inflamed pleural surfaces rub together during respiration. More often heard on inspiration than expiration, the pleural friction rub is easy to confuse with a pericardial friction rub. ● Diffusing capacity

Bronchiolar lavage revealed elevated neutrophils (indicative of acute inflammatory response) and eosinophils

Rx: ● Amlodipine-Raynaud ● Omeprazole-heartburn ● Prednisone-alveolitis ● OMT: T4 and 4th interspace b/l (lower lobe lung); T2 2nd interspace B/L (esophagus) ● Cyclophosphamide (alkylating agent) and Cyclosporine (inhibits T cell f(x) by binding cyclophilin)-reduction in pulmonary inflammation

Ultimately our pt succumbed to pneumonia/pulmonary insufficiency (most common cause of death in scleroderma)

Was not necessary to test for, but the antibody associated w/ Scleroderma is AntiScl-70 (also called DNA Topoisomerase I). >Without the pulmonary involvement, one of our top differentials was CREST syndrome: Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly (what's going on with her fingers), Telangiectasia. This dz, which has little to no systemic involvement and a much more benign clinical course, is associated w/ anti-centromere antibodies.

Case 4-Burn CC of extensive burns ● Denies SOB, wheezing, and voice is clear (along with singed nasal hairs, could be signs of smoke inhalation) ● Fishy story-suspect for abuse or self-inflicted wounds

Med Hx ● Emphysema/COPD ● PUD ● Seizure d/o ● Depression (if she didn't already have a clinical diagnosis, a Beck Depression Inventory might be a good idea in a non-acute setting) ● Alcoholism (unlikely bonus question twice, but don't forget the CAGE questions!) ● Possible hx abuse by ex-husband, son (“Do you feel safe at home?”)

Meds ● Ranitidine (H2 blocker) ● Phenytoin (sodium channel blocker, also acts as a class IB antiarrhythmic!)

Hospitalizations ● 1 year ago for malnutrition

Vitals-Pulse elevated at 116 (Likely stress/Pain), Everything else WNL including pulse ox.

HEENT: ● Right sclera hyperemic (red) ● Nasal hairs/eyelashes signed ● No carbonaceous staining sputum ● Right lower lip burned w/ blistering

Lungs: Bibasilar crackles w/o wheezing

Heart: Distant S1/S2

GU: Labia totally involved; skin tags on the anus and the anus exam burned. (We did not do a bimanual exam; if we had we'd probably have seen that her uterus was anteverted and anteflexed)

Skin: Approximately 42% of total body SA has 2nd-3rd degree burns (pt is at risk for hypovolemic shock, infections and a dangerous increase in metabolic rate)

• Superficial burns ( formerly known as first-degree burns) are confined to the epidermis • Partial thickness burns (formerly known as second-degree burns) involve injury to the dermis. • Full-thickness burns (formerly known as third-degree burns) extend to the subcutaneous tissue. Full-thickness burns may also involve damage to muscle tissue underneath the subcutaneous tissue (these were known formerly as fourth-degree burns).

Was explicitly told not to memorize the burn chart

Pt was admitted for fluids, prophylactic abx, and fluid resuscitation (calculated via the Parkland Fluid Resuscitation Formula) Know the formula and be able to use it if given hypothetical values.

cc’s of fluid = (4) x (patient’s weight in kg) x (% of body surface area burned) (first 1/2 is delivered within 8 hours, the rest delivered over the next 16) AP CXR ● Tortuosity of the aorta (can indicate an enlarged aorta, or a bendy aorta-which could be a nl finding in an older person) ● No evidence pleural fluid ● Interstitial edema in the lower lung fields with the presence of septal lines (could they be talking about Kerley B lines?!) in the costophrenic area ● Old rib fx

Kerley B lines have multiple causes (edema, infection, malignancy)

CBC showed elevated white count, or leukocytosis (in the absence of any other findings, this is likely due to stress)

ABGs showed low O2, low normal CO2 and low bicarb. Given the clinical picture, this is likely a fully compensated metabolic acidosis (given the pt isn't tachypneic, and her tissues are underperfused, we can deduce the primary disturbance in the Force here. With her emphysema her CO2 should be sky high.)

Blood Chem ● Hyponatremia (borderline, likely dilutional since we're pumping her full o' fluid) ● Elevated BUN+Creatinine (despite the ratio being <20, this is likely a pre-renal azotemia, see below) ● Hypomagnesemia (in her case, could be dilutional, her burns, or caused by her alcoholism)3 ● Low Phenytoin levels

Rx: ● Promethazine (First generation H1 blocker, used as a sedative or adjunct to pain meds)

3 Causes of low Mg- "DADA has no Magnesium-> Diuretics, Alcohol, Diarrhea, Aminoglycosides) ● Sulfadiazine cream on the burn for infection prophylaxis (a facilitator called special attention to the name Silvadene (silver sulfadiazine)) ● TPN (total parenteral nutrition)

They showed us the fishbone diagram again and this...just for your reference. 3 bonuses seems a bit excessive.

After a decent take to her skin grafts, the pt decided to be an excellent boards vignette and picked up some Pseudomonas (rx'd w/ Piperacillin/Tazobactam).

We gave her a Dobhoff tube (ng tube to facilitate feeding) and PCA (patient-controlled analgesia) for the pain.

Case 5-Breast Cancer AKA Save a life, play with your boobs.

36 y/o F w/ hx of fibrocystic changes4 in her breasts and a CC of a new pea-sized "different lump".

Denies ● Discharge ● Skin Changes ● Pain ● Hx Trauma ● Personal Hx breast cancer ● Fam Hx Breast cancer (most cases aren't inherited anyway; conversely, most people with BRCA mutations will not go on to get breast cancer.) ● Changes w/ menses (the best time to do breast self exams and mammograms is after the end of the menstrual cycle. Fibroadenomas and fibrocystic changes will vary w/ the cycle.)

Breasts ● small5.

4 "Lumpy bumpies"-just the sort of buzzword COMLEX loves 5 They're not being mean; size and density play a role in detection and our ability to see things clearly on mammography ● Lumpy-bumpy-humpty-dumpty B/L ● Mass is rock hard, mobile, upper/outer quadrant <1cm

Lymph-no nodes in supraclavicular, axillary or cervical regions

Mammography: Calcifications in the upper/outer quadrant (most common location for malignancy; would metastasize first to the axillary nodes)

Biopsy showed changes consistent with infiltrating ductal carcinoma

CXR and Bone Scan, performed to check for mets, was neg

Tissue Assessment-hormone receptor expressivity will guide treatment6 Immunohistochemical staining (IHC) revealed the tumor was ER/PR+ IHC and FISH (fluorescent in situ hybridization) showed HER2 negativity

Rx: ● Lumpectomy ● sentinel lymph node sampling ● radiation ○ Because our patient asked, radiation kills cancer cells by direct damage of DNA and creating free radicals ○ She needed multiple treatments because the rx damages normal body cells too, and these need time to recover ● Tamoxifen (mixed estrogen agonist/antagonist w/ a +risk for endometrial CA if used long term)

Case 6-Prostate Cancer AKA: Save a life, put a finger up there

62 y/o male w/ a 1,047 year pack-hx, COPD, +in frequency/hesitancy of urination, nocturia.

Denies ● Dysuria ● Back pain (prostate cancer loves to metastasize to bone! creates osteoblastic lesions, which is unusual for a cancer) ● Constipation (prostate CA can metastasize by direct extension) ● Confusion/dizziness/neuro hx (one of the more common cancers to go to the brain, probably because it's so common) ● Drinking more coffee/H20/Jackie D's than usual

6 It was actually inappropriate to put her on tamoxifen before she did these studies; if she'd been Her2 positive we'd have given her Trastuzumab. Agonist in bone and endometrium; antagonist in boobies. ● Hematuria

Med Hx: MI, "smoker's cough", SOB w/ exertion (clouds the possibility of looking for signs of lung mets)

Chest ● Increased A-P diameter ● Prolonged expiratory phase of respiration ● B/L hyperresonance to percussion ● Vocal fremitus intact (that's a sign of consolidation!) ● No rales, crackles or rubs

Heart ● PMI 2 cm left of the MCL and 3 cm in size (should be about 1 cm) ● S4 gallop (dat atrial kick, tho)

Rectal ● Enlarged (grade 3), indurated L prostate lobe ● Guaiac negative7

OMM ● TART between T12-L2

PSA was markedly + at 16.2 ● In general, this is a crappy test. Elevated PSAs can overlap w/ BPH, and not all prostate cancer will have elevated PSA

Alk Phos was normal-alk phos is produced by liver, bone and (not in our pt) placenta-might be indicative of his prostate cancer metastasizing

CXR revealed hyperinflation of the lungs and a slightly enlarged heart

We referred the pt to urology, where a biopsy revealed a GLEASON SCORE of 6, and malignancy only in one lobe ● In prostate CA, lesions are graded from 1 (well-differentiated) to 5 (holy shit). You take 2 scores from the most prevalent patterns and add them together (aka this pt could have had a 3+3 or 2+4 and would have arrived at the same place) ● This is integrated into the TNM system as a crucial part of determining the prognosis of prostate cancer

7 A facilitator felt compelled to remind us that it was Guaiac, not guac and wouldn't go quite as well w/ tortilla chips. #Readerproblems ● Gleason 6 is a relatively low score (some physicians will not actively rx but 'watch and wait', depending on the pts age), and is the most common

Abdominal CT ● Enlarged seminal vesicles ● NO lymphadenopathy ● Simple renal cysts (incidental) ● AAA 4.7 cm (so much for that benign abdomen exam!) ○ >5 cm buys you a ticket to the OR

Treatment Options ● Radical prostatectomy/pelvic lymphadenectomy ● daVinci prostatectomy and pelvic lymphadenopathy-less invasive than above ● Radiation therapy/proton therapy ● Hormonal manipulation8 ● Brachytherapy-radiation source directly inserted to the prostate ● Cryotherapy-freeze the tumor cells ● Nothing Because it was strongly encouraged that we know the anatomy of the prostate:

8 Eg Finasteride (5-a-reductase inhibitor) and Flutamide (Androgen antagonist). Just a note: Urinary frequency doesn't usually present early on in prostate CA because of the typical anatomical location (peripheral zone). Advantage? Posterior lobe lesions are better felt on DRE.

By contrast, the reason BPH pts pee so much is these lesions tend to be in the central/median lobes (periurethral zone)

OMM Supplements

Asthma patient:

General treatments (also see printouts from The 5 Minute OMM Consult as emailed) * Normalize parasympathetics and sympathetics to the pharynx, larynx, trachea, lungs) * Treat rib dysfunctions, o Don’t forget 1st ribs o Don’t forget to treat the key rib (BITE) * Treat thoracic dysfunctions * Lymphatics o Thoracic inlet o Thoracic pump (CONTRAINDICATION with asthma (and other obstructive lung processes) THORACIC PUMP WITH ASSIST!) o Abdominal diaphragm

* Chapman’s points (3rd and 4th ICS) = Lungs Post endotracheal intubation * Treat OA, as well as remainder of cervical spine (I personally would use BLT, ME, or Still technique for this 12 y/o patient) * Hyoid and cricoid release (Nicholas Atlas, page 492) * Consider cervical chain drainage technique (Nicholas Atlas, page 493)

Other * Consider splenic pump (if no contraindications and if patient had an infectious process going on)

Rheumatoid Arthritis o Treatment focused on areas of concern – b/l wrists/hands, knees, and ankles in this case § Parasympathetic: not applicable § Sympathetic – just treat T1-L2 · Arms T2-8, legs T11-L2 (help improve blood flow to area, increase oxygenation and improve pH at area) § Lymphatics · Thoracic inlet · Abdominal diaphragm · Pelvic diaphragm · Extremity effleurage (distal to proximal) · Pedal pump (if tolerated due to any areas of active arthritis) § Other · Counterstrain to joints and muscles as necessary o Rheumatoid nodule in left lower lung – overlap with above § Parasympathetic - vagus nerve (OA, AA, C2, consider occipitomastoid sutures) § Sympathetic T1-6 § Lymphatics – as above, also thoracic pump § Other · Thoracolumbar area – posterior diaphragm connections · Phrenic nerve – C3-5 · Rib dysfunctions · Sternum · Chapman’s points – anterior and posterior – specifically lower lung in this case · Accessory muscles as needed – scalenes, SCM, Pec minor, serratus anterior o *Overall be very careful when chest-tube or other medical apparatus in place at area being treated. o HVLA IS CONTRAINDICATED ESPECIALLY AT THE OA JOINT DUE TO INCREASE LAXITY AT AREA AND POTENTIAL FOR HARM o HVLA may also be relatively contraindicated in other joints depending on individual patient laxity o Overall, safer to choose another technique.

Systemic Scleroderma case – there is a lot of overlap with RA case (due to extremity and lung involvement) o Hands/digits – Raynaud’s phenomenon, scleroderma, ulcer(s) § Parasympathetic – none § Sympathetic – Arms T2-8, (may do lower extremities if needed – T11-L2) § Lymphatics · Thoracic inlet · Effleurage to upper extremities (distal to proximal) and may tx legs if needed. o Esophagus AND Lung involvement § Parasympathetic – Vagus (OA, AA, C2, consider occipitomastoid sutures) § Sympathetic T1-6 (T5-9 for stomach involvement/GERD) § Lymphatics – · Thoracic inlet · Thoracic pump · Abdominal diaphragm § Other options for lung area · Thoracolumbar area – posterior diaphragm connections · Phrenic nerve – C3-5 · Rib dysfunctions · Sternum · Chapman’s points – anterior and posterior · Accessory muscles as needed – scalenes, SCM, Pec minor, serratus anterior

***Contraindications – avoid HVLA with chronic steroid use (risk of osteoporosis and thin skin with increased risk of bruising/bleeding)

Burn case o Treat areas not burned as necessary and possible – DO NOT TREAT OVER AREAS OF BURN o Depression § Parasympathetic – Vagus (OA, AA, C2, consider occipitomastoid sutures) · Consider pelvic splanchnic nerves based on complaints § Sympathetic T1-4 (down to L2 depending on symptoms), cervical chain ganglia, and sympathetic collateral ganglia as necessary § Other – more likely to have “aches and pains” · As necessary o GER(D) – overlap with above § Parasympathetic – Vagus § Sympathetic T1-9 (esophagus T1-6, stomach T5-9) § Lymphatics – as usual o Other – consider splenic pump if area not involved in burn to stimulate immune system and help prevent secondary infections of burned area.

- Breast Cancer case o Avoid lymphatic techniques while patient receiving treatment for cancer and when any concern of cancer present. o Other techniques are case dependent, being sure of no other contraindications

- Prostatic Adenocarcinoma case o CONTRAINDICATIONS § Avoid lymphatic techniques while patient receiving treatment for cancer and when any concern of cancer present. § Avoid direct abdominal techniques with abdominal aortic aneurysm § Avoid thoracic pump WITH ASSIST in COPD o To decrease risk of urinary incontinence and erectile dysfunction § Parasympathetic – pelvic splanchnic nerves (S2-4) § Sympathetic T11 – L2 § Other · Innominates · Chapman’s points o COPD – § Parasympathetic - vagus nerve (OA, AA, C2, consider occipitomastoid sutures) § Sympathetic T1-6 § Other · Thoracolumbar area – posterior diaphragm connections · Phrenic nerve – C3-5 · Rib dysfunctions – likely all held in inhalation dysfunction · Sternum · Chapman’s points – anterior and posterior – specifically lower lung in this case · Accessory muscles as needed – scalenes, SCM, Pec minor, serratus anterior