1. Diagnosing shoulder injuries:
-People over 40 are more likely to have rotator cuff tears, under 40 are more likely to have nstability/dislocation
-Pain that travels past the elbow is more likely c-spine in origin
-People who are diabetic or have thyroid pathology are more likely to get frozen shoulder (adhesive capsulitis), which is a dramatic, dramatic loss of ROM.
-Pain with abduction past the shoulder may be rotator cuff, or bursitis, or tendinitis in rotator cuff
-Pain with weight lifting may be an AC joint pathology, as weight lifting loads the AC joint.
2. ROM test:
-Neers test: flex arm up, "near the ear", test impingement of rotator cuff
-Hawkins test, start with nears test, then bend elbow and advance towards opposite shoulder, also test of impingement.
-Speed's test: they hold hand palm up, elbow bent, you push down on their hand to test biceps & biceps tendon
-Yergesons' test: they try to supinate and flex, you try to prevent them. again tests biceps/biceps tendon.
-Obrien's test: hold arm straight out, across midline, thumb up and thumb down you press on it. More pain on thumb down = labrum injury
3. Ankle tests:
-If you squeeze their tib and fib together near the knee, it opens up the tib and fib by the ankle; if this is painful it may indicate syndesmotic/high ankle sprain
-Thomas test: have them lie prone, squeeze the calf muscle, pulls on achilles, if their foot fails to plantar flex, it indicates possible achilles injury.
4. Integrative medicine learning modules available online through the university of Arizona.
5. Diagnosis of hypertension:
-2 blood pressure measurements, >1 week apart. A good real world approach is if you find one elevated (not severe) have them attempt diet and exercise control, and to measure their BP at home (i.e. at walgreens) 3-4 times, and then follow up with you 1-2 months later. If it is still high, then you can start treatment.
-JNC 7:
<120/80 is target.
>140 sys or >90 diastolic was treated with starting 1 drug (thiazide)
>160 sys or >100 diastolic you start two drugs, thiazide + ACE/ARB or CCB or BB
-JNC 8:
definition of hypertension for everyone under 60 is >140/90 and for everyone over 60 is >150/100 should get treated.
6. DDx hypertension
-Smoking, caffeine, NSAIDs, cold medicines, cocaine. (To keep in mind when you are diagnosing essential hypertension)
-Vascular: renal artery stenosis, fibromuscular dysplasia, aortic coarctation (depending on location, may cause htn in brachial aa)
-Endocrine: hyper or hypothyroidism, hyperparathyroidism, cushing's disease, addison's disease
-Renal: ESRD, AKI, obstructive uropathy, nephritic or nephrotic syndrome, PCKD
-Other: sleep apnea, chronic alcoholism.
7. Initial workup of hypertension
-EKG for baseline
-Urine- microalbuminuria
-Lipids, A1C
8. Treatment & CI to drugs (JNC 8)
-You can start anything as first line- diuretic, ACE/ARB, or CCB.
-If the person is black, then prefer diuretic or CCB because of better response.
-ACEI: CI in pregnancy or in any woman of reproductive age who is not using reliable contraception and is sexually active, angioedema patients.
-B-blocker: severe heart failure, severe COPD
-Thiazide diuretic: gout, taking lithium
9. Treating hyperlipidemia: Old guidelines (ATP III)
-Old guidelines (ATP III): target LDL varies depending on cardiac equivalents, treat to target.
-Cardiac equivalents: DM, CVA, renal failure, symptomatic carotid disease, PAD, AAA
-Cardiac risk factors: smoking, hypertension (taking any antihypertensives or BP > 140/90), HDL<40, early CAD in first-degree family member (early =<55 males, <65 females), advanced age (women > 55, men >45)

Risk Factors	Target LDL	LDL to start statin:
1+ cardiac equivalents or 10 year risk >20%	100 (70 optimal)	130
2+ risk factors & 10 year risk 10-20%	130	130
2+ risk factors & 10 year risk <20%	130	160
0-1 risk factors	160	190

10-year risk factor calculator here
If someone higher than target LDL but not high enough to start a statin, then they should start diet and exercise.


(image from NHLBI ATP III guidelines)
10. Treating hyperlipidemia: New guidelines (ATP 4)
-Now there are 4 groups of people that should definitely be on statins, of varying intensity-
(1) Everyone with clinically significant cardiovascular disease (start high intensity statin)
(2) everyone with an LDL>190 (start high intensity statin)
(3) every diabetic with an LDL>70 (start medium intensity statin)
(4) everyone with an LDL > 70 and a 10-year cardiac risk > 7.5%. (start medium intensity statin)
-If someone comes in with terrible numbers on their lipid labs, generally you will start by treating LDLs first (i.e. starting a statin) and then if their triglycerides are still high after that, you can add a fibrate or niacin. Unless their triglycerides are >500, then you treat that first to avoid pancreatitis.
-If you start a statin, get baseline LFTs and follow them every year-- you need to see a 3x elevation to be adequately sure that the statin is causing a meaningful change to the liver.
-Don't start a statin in someone with either acute or chronic liver disease.