Real patients, real problems!!

Student osteopathic manipulative treatment clinic this week was absolutely awesome! My partner and I have been treating two patients for over a month now, and this week they had a break, being asked to return in two weeks instead of one.
So we got a new patient. All the patients are referred to the clinic from physicians in the area with a complaint of low back pain, shoulder pain, neck pain, or something of the sort.
Our new patient was a really nice fellow whose doctor sent him in with low back pain. He had fallen several months ago, and the pain began about a month after the fall. He saw his doctor two weeks ago, and the doctor sent him to the student clinic for manipulation.
No problem. I absolutely love treating low back pain. The only problem was when he got there and I was doing the physical, I found a positive straight leg raising test, positive also in the seated position, decreased reflexes in one leg, decreased motor strength,no sensory or vibratory perception on the plantar, dorsal, or medial aspects of the hallux(big toe), and the total inability to dorsiflex the hallux. He also had an acute tenderpoint at the piriformis and at the PSIS (posterior superior iliac spine), which normally could be easily treated with OMT.
BUT, there were just too many red flags! All the physical findings, combined with numbness, tingling and pain down his leg, as well as extreme difficulty in changing positions, screamed to myself and my partner that this gentleman was not a candidate for OMT, but rather a candidate for an MRI to rule out acute lumbar radiculopathy.
So we took it to our supervising physician to discuss, he rechecked and absolutely agreed. Then it was the call to the referring physician to fill him in because we are not allowed to order tests yet. So the fellow is now scheduled for an MRI.
Back to our attending and lots of questions. What first tipped us off? Why shouldn’t we try to relieve the tenderpoints? By thinking about the dermatome, could we determine what spinal level the lesion might be at? It felt really good to be able to sit there and answer his questions and say, yes it is most probably at L4-L5 with the L5 spinal nerve being compressed.
So, as we are graded on our clinic performance, both my partner and I were ecstatic to see all 10s! Perfect score for the second time. But better than the grades is the fact that we used good judgment in determining the problem and discerning the fact that we should not try any manipulative treatments while the situation was acute.
This is what medicine is all about!!

this sounds so great - I wish I was learning those OMT skills…