Clinical Assessment and Diagnosis
Core concepts
The osteopathic examination layers structural assessment onto standard history and physical examination. Know the components of somatic dysfunction - asymmetry, range of motion alteration, tissue texture change, tenderness (often remembered as TART) - and how to document them by region and segment. Understand screening for red flags, neurologic examination, and the role of imaging as an adjunct rather than a substitute for examination.
Assessment sequence
History first, including onset, mechanism, modifying factors, and systems review. Then observation, active and passive motion, regional palpation, and segmental testing. Provocative maneuvers and neuro tests confirm or exclude. Always reassess after treatment to document change, because the recorded change supports medical necessity.
Traps
- Documenting only "restricted motion" without texture, tenderness, or asymmetry.
- Missing red flags: night pain, unexplained weight loss, fever, bowel or bladder change, progressive weakness, saddle anesthesia.
- Ordering imaging before a competent examination in uncomplicated presentations.
- Confusing muscle spasm with somatic dysfunction; spasm is one possible component.
Rule of thumb
If a finding would not change your management, it does not belong in the assessment paragraph - but if it is a red flag, it always does.
Worked example
A patient reports mid-back pain after a fall. Examination shows a single thoracic segment with tissue texture change, tenderness, and asymmetric motion. Document each element, treat, reassess, and record the improved findings - that sequence demonstrates both diagnosis and response.