📚 Osteopathic Exam Revision

A 45-Year-Old Male with Rib Pain

Case 2 — Structured breakdown of assessment, diagnosis, and treatment

🦷 45-year-old male · Left-sided chest pain · Ribs 5–7
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Patient Presentation

A 45-year-old male presents with left-sided chest pain and difficulty breathing following a coughing episode. No trauma. Pain is sharp, worse on deep inspiration and palpation of ribs 5–7.

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Section 1

Case History & Communication

History of Presenting Complaint
  • 45-year-old male, sudden onset left-sided chest pain after a coughing fit
  • Pain is sharp and localised to ribs 5–7
  • Worsened by deep inspiration and palpation
  • No history of trauma
Communication Skills
  • Build rapport and trust with the patient
  • Use open-ended questions to gather a detailed history
  • Actively listen to the patient's concerns
  • Clearly explain the examination and treatment plan
Rapport Open Questions Active Listening
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Section 2

Differential Diagnosis & Justifications

Rule Out Pneumothorax No trauma; likely normal breath sounds on auscultation.
Unlikely Pulmonary Embolism Mechanism is coughing; no leg swelling or other signs.
Less Likely Cardiac Issues Pain is localised, sharp, and reproducible — not crushing or radiating.
Possible Rib Fracture Less likely without trauma; X-ray needed for definitive diagnosis.
Possible Pleuritis Localised palpation pain points more towards musculoskeletal.
Most Likely ✓ Rib Dysfunction / Intercostal Strain Consistent with history and clinical presentation.
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Section 3

Examinations & Medical Assessment

  • Observation: Note breathing rate and effort
  • Palpation: Gently palpate ribs and costovertebral joints to identify pain location
  • Rib Spring Test: Assess mobility of the ribs
  • Chest Expansion Measurement: Check for restrictions in breathing
  • Auscultation: Listen to breath sounds; rule out respiratory issues
  • Cardiac Screen: Rule out any cardiac involvement
Observation Palpation Rib Spring Auscultation Cardiac Screen
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Section 4

Diagnosis & Justifications

Working Diagnosis Somatic dysfunction of ribs 5–7 with associated intercostal muscle strain.
Justification
  • Pain is localised and reproducible on palpation
  • Directly related to a specific event (coughing fit)
  • Consistent with a musculoskeletal presentation
  • Viscerosomatic reflex at T5–T7 may also contribute to symptoms
Somatic Dysfunction T5–T7 Reflex Musculoskeletal
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Section 5

Treatment Application & Justification

  • Rib Raising: Improve lymphatic drainage and reduce sympathetic tone
  • Soft Tissue to Intercostals: Release tension in muscles between the ribs
  • Muscle Energy Technique (MET): Correct rib dysfunction (inhalation or exhalation)
  • Thoracic Spine Mobilisation: Improve thoracic mobility and its influence on the ribs
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Safety Note: No HVLA if a fracture is suspected. Use gentle pressure and continuously monitor the patient's breathing throughout treatment.
Rib Raising Soft Tissue MET Mobilisation
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Section 6

Planning (Short & Long Term)

⏱ Short Term · 1–2 Weeks

Goals

  • Reduce pain and inflammation
  • Restore normal rib mechanics
  • Improve breathing
How: Weekly osteopathic treatment, gentle breathing exercises, ice for pain management.
📆 Long Term · 2–6 Weeks

Goals

  • Address underlying postural issues
  • Strengthen respiratory & core muscles
  • Prevent recurrence
How: Bi-weekly or monthly treatment, tailored exercise programme.
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Section 7

Patient Management

🎓 Educate Explain the diagnosis, treatment plan, and expected recovery timeline clearly to the patient.
🏠 Home Advice Demonstrate breathing exercises and stretches the patient can perform at home.
📊 Monitor Progress Schedule follow-up appointments to assess progress and adjust the treatment plan as needed.
🔗 Refer if Necessary If symptoms worsen or do not improve, refer to a GP for further investigation.