Today’s OMM question involves a 43-year-old man with a severe, throbbing holocranial headache. He has blurry vision, but no neck pain or stiffness, palpitations, chest pain, shortness of breath. Can you figure out where you would most likely palpate a Chapman point in this patient?
A 43-year-old man presents to the emergency department with two weeks of a severe, throbbing holocranial headache. He took 800 mg of ibuprofen today with no relief. He has blurry vision, but no neck pain or stiffness, palpitations, chest pain, shortness of breath. He also mentions early satiety for the past few months. His past medical history includes hypothyroidism from a total thyroidectomy in his 20’s for thyroid cancer. He takes levothyroxine 100 mcg daily. His temperature is 37.1 ºC (98.8 ºF), pulse is 114/min, respirations are 12/min, blood pressure is 197/121 mmHg. On physical examination he has no papilledema by fundoscopy. His neck is supple with full range of motion. His cardiopulmonary exam is normal other than tachycardia. His abdomen is distended with mild epigastric tenderness to palpation. Computed tomography of the abdomen with contrast is performed and shown below.
Source: https://doi.org/10.1016/j.radcr.2017.09.006
Where would you most likely palpate a Chapman point in this patient?
A. Between the spinous process of T2 and transverse process of T3
B. One inch lateral from the umbilicus
C. One inch lateral and two inches superior from the umbilicus
D. Between the spinous process of T10 and the transverse process of T11
E. In the 4th intercostal space on the left, near the sternum
Scroll down for the correct answer!
The correct answer to today’s OMM Question is…
C. One inch lateral and two inches superior from the umbilicus
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
The incorrect answers to today’s OMM Question are…
A. Between the spinous process of T2 and transverse process of T3
This corresponds to Chapman points for the esophagus, mainstem bronchi and thyroid. The patient’s thyroid cancer was in the distant past and he is unlikely to have a Chapman point there.
B. One inch lateral from the umbilicus
This does not correspond to any specific Chapman point. The anterior Chapman point for the kidneys is one inch lateral and one inch superior from the umbilicus.
D. Between the spinous process of T10 and the transverse process of T11
This corresponds to Chapman points for the small intestines and ovaries (in females). The posterior adrenal point is between the spinous process of T11 and transverse process of T12.
E. In the 4th intercostal space on the left, near the sternum
This corresponds to the anterior Chapman point for the lower lung. He is not having any pulmonary symptoms at this time and is unlikely to have a Chapman point there.
Main Explanation
The above patient most likely has a pheochromocytoma. This rare neoplasm most often presents in the 4th and 5th decade of life and affects men and women equally. The classic triad involves paroxysms of headaches, sweating and tachycardia. Most pheochromocytomas are located within the adrenal gland. They can occur on their own, or be associated with multiple endocrine neoplasia type 2, which this patient may have if his thyroid cancer was the medullary type.
Chapman points are palpable rubbery nodules in the skin which represent lymphatic stasis within the fascia due to increased sympathetic tone from viscera. They represent a viscerosomatic response. Treatment involves applying a gentle, rotary motion over the point for 15-30 seconds until the tissue tension releases. The anterior adrenal Chapman point is located one inch lateral and two inches superior from the umbilicus.
Major Takeaway
Pheochromocytomas most frequently present in the 4th and 5th decades of life with paroxysms of headaches, sweating and tachycardia. Approximately 90% are found in the adrenal gland. The anterior adrenal Chapman point is located one inch lateral and two inches superior from the umbilicus.
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