• Systolic murmur that increases in intensity when the patient is standing and also with the Valsalva maneuver (decreased ventricular filling, increased obstruction).
• This contrasts with most fxnal outflow murmurs that decrease in intensity when standing up or doing Valsalva.

1. any murmur of III/VI or greater
2. diastolic murmurs
3. holosystolic
4. continous
5. murmur that increases in intensity with valsalva or standing
6. signs of Marfan's syndrome (arachnodactyly, tall-thin, arm span greater than height, pectus excavatum, high-arched palate).

• Tdap (adult series, q10 yrs starting @ age 11)
• meningitis: MCV4. 11/12 with booster at 16.
• HPV
• "catch-up" immunizations, VZV if never had chickenpox.

• Echocardiography is the study of choice for the dx of HCM
• Note: electrocardiogram is abnormal in >90% of patients with HCM, and is thus a good screening test. Electrocardiogram should be done in anyone that has syncope (r/o arrhythmic d/os like prolonged QT).

• HEEADSSS
• Home
• Education/employment
• Eating 
• Activity
• Drugs
• Sex
• Suicide/depression
• Safety/violence

1. Superficial thrombophlebitis - very common (VC)
2. Trauma - fx, muscle tear, hematoma (VC)
3. Cellulitis - Group A Strep or Staph. (VC)
4. Dermatitis (VC)
5. DVT - uncommon

1. Chronic venous insufficiency (VC)
2. CHF - uncommon  (UC)
3. Pretibial myxedema - hypothyroidism, nonpitting (UC)
4. Hypoabluminemia (rare) - pitting edema
5. Postphlebitic syndrome (UC)

Note - chronic causes are usually bilateral vs. unilateral

• Apply Wells Clinical Decision Rule to evaluate the probability of DVT (low, moderate, or high risk - 3,17, 75%) using signs and sx from the H&P.

• Useful for ruling out DVT in low-risk patients. (If positive, then do US).
• Useful in patients with moderate or high risk and a normal duplex ultrasound result. 

A patient with moderate risk has a normal ultrasound and positive D-dimer. What is the next step?

What if the patient had a positive US?

• Follow up studies: 2nd ultrasound in 7 days or venography.
• If US is positive in a patient with moderate or high risk, treat for DVT.

• anticoagulation with LMW heparin followed by at least 3 months of warfarin

1. antihistamines - good for pts with mild & intermittent sx
2. decongestants
3. intranasal corticosteroids
4. systemic corticosteroids

• ex: pseudoephedrine
• can give orally or intranasally
• agonist of alpha receptor - constricts blood vessels in nasal mucosa and reduces overall volume of nasal mucosa
• oral decongestants can cause tachycardia, tremor, insomnia
• nasal decongestants - can have rebound hyperemia or worsening of sx with chronic use or upon discontinuation

• first line tx for longterm management of mild to moderate persistent sx
• reduce production of inflammatory mediators and recruitment of inflammatory cells
• Systemic absorption is low. 
• Side effects; nosebleeds, pharyngitis, URT infxns.
• Max effectiveness after 2-4 wks of use

• zafirlukast, montelukast, zileuton (all oral, Rx)
• used for both allergic rhinitis and maintenance therapy for persistent asthma
• Esp useful in pts with both asthma and allergies or in those whose asthma may be triggered by allergens
• NOT proven to be superior to nasal corticosteroids alone.

• used only for severe cases, in lowest effective dose, for shortest period possible
• Adverse effects: suppression of HPA axis, hyperglycemia. With long-term use: peptic ulcers, immunosuppression, reduced bone density

• attempted in pts who remain symptomatic despite maximal medical tx
• specific antigens to which pt is allergic are identified and highly diluted concentrations are injected, gradually increasing the concentration over time.
• May have severe (even anaphylactic) reactions

• hypotension/shock d/t widespread vasodilation
• respiratory distress from bronchospasm or laryngeal edema
• GI and uterine muscle contraction
• urticaria (pruritic wheals)
• angioedema (painless sub-q swelling, often in face).

• Subcutaneous or intramuscular injection of aqueous epinephrine 1:1000. 
• Dose: 0.2-0.5 mL.
• Repeat injections can be given evey 15-30 min if needed.
• Ensure ABCs (IV fluids, intubation, etc when necessary)
• Monitor patient for a period of time

1. patient education
2. allergen avoidance
3. pharmacologic management
4. immunotherapy

1. oxygen
2. bronchodilators (fast acting)
3. steriods (effect takes hours to occur)

1. cigarette smoking (MC) - associated with 90% of COPD cases
2. genetic alpha-1-anti-trypsin deficiency - more common in Caucasians; consider when COPD develops before 45 yo, esp in nonsmokers.

• Cough - often productive of thick, white mucus 
• may have intermittent exacerbations due to infxns (cough worsens, green/yellow mucus)

By the time sx develop, the patients FEV1 will be reduced by ~ 50%. 

• COPD pts have a decreased FVC, FEV1, and FEV1:FVC ratio.
• FEV1:FVC < 0.7 in patients with COPD, indicating airway obstruction.
• Reversibility is defined as an increase in FEV1 of >12% or 200 mL. 

• Smoking cessation - smoking cessation does not result in significant imporvement in pulm fxn, but it reduces the rate of further deterioration.
• Vaccinations: pneumococcus, influenza
• Exercise & maintain normal body weight

• person is at risk (smokes, chemical exposure)
• cough, sputum production
• spirometry normal

• mild
• FEV1/FVC < 0.7
• FEV1 ≥ 80% predicted
• with or without sx
• tx: shortacting bronchodilators: mainly beta agonists (albuterol), also anticholinergics (ipratropium). Inhaled is preferred over oral d/t fewer SE. 

• moderate COPD
• FEV1/FVC <0.7
• FEV1 is 50-80% of predicted
• with or without sx

• add long-acting bronchodilators; short-acting agents still used as rescue-therapy in exacerbations
• long acting include: salmeterol (inhaled beta agonist) and tiotropium (inhaled anticholinergic)
• Oral methylxanthines (theophylline) may be used but have narrow therapeutic windows and more drug-drug interactions. 

• severe COPD
• FEV1/FVC<0.7
• FEV1 is 30-50% of predicted
• with or without sx
• tx: inhaled steroids

• very severe COPD
• FEV1/FVC<0.7
• FEV1<30% predicted
• FEV1 >30% predicted, but with chronic hypoxemia
• tx: inhaled steroids, O2 therapy if there is hypoxemia, consider surgical interventions

• Inhaled steroids (fluticasone, triamcinolone, mometasone, etc) do not affect rate of decline of lung fxn in COPD, but they reduce frequency of exacerbations.
• Long-term tx with oral steroids is NOT recommended.

• Oxygen therapy is the only intervention that has been shown to decrease mortality
• Must be worn for at least 15 hours/day.
• [O2 saturation should be >90% or PaO2 >60)

• presence of 3 or more RBCs/high power field on 2 or more properly* collected urinalyses.

*Properly collected: important to instruct pts on proper technique for "clean catch" urine sample to reduce the # of FP findings.

1. Check for risk factors (H&P)
2. Repeat urinanalysis. If still shows RBCs, then:
3. Imaging of urinary tract to evaluate for malignancy AND
4. Perform urine culture to check of infxn.

• Upper (kidneys & ureters) - IVP or CT scan
• Lower (bladder and urethra)  - cystoscopy

How to differentiate hematuria with glomerular vs.

renal (nonglomerular) vs. urologic origin

• Glomerular: proteinura, dysmorphic RBCs, RBC casts.
• Renal (nonglomerular): proteinuria, no dysmorphic RBCs or RBC casts
• Urologic: hematuria with out proteinuria, dysmorphic RBCs, or RBC casts. 

• Follow up bp measurements, UA, and voided urine cytologic studies at 6, 12, 24, and 36 months in case there is an underlying lesion.
• If work up remains negative for 36 mo, no further f/u is necessary. 

Dyspepsia - what "alarm symptoms" should prompt the clinician to do an early endoscopy as part of the workup?

(9) 

• unintentional weight loss
• progressive dysphagia
• odynophagia
• recurrent vomiting
• unexplained anemia
• GI bleeding/hematemesis
• FHx of CA, esp upper GI CA
• H/o of gastric surgery 
• jaundice
• Esp. in pts >55 yo or >45-50 yo and of Asian, Hispanic, or Afro-Caribbean descent

• H. pylori infxn (present in 48% of cases)
• NSAID use
• Cigarette smoking
• Personal of family h/o PUD
• Race: more commin in Blacks and Hispanics

• epigastric pain that improveswith ingestion of food 
• pain develops a few after eating
• nocturnal pain
• OTC antacids provide some relief

• Preferred office test = stool antigen testing. For test to be accurate, pt must take no PPIs 2 weeks prior to testing.
• Alternative = serologic testing of H. pylori Abs (serum IgA ELISA). Does  not distinguish active infxn from treated infxn. Follow with urea breath test to determine presence of active infxn. 
• gold standard = endoscopy with biopsy testing for H. pylori

• Overall - give mutliple abx plus PPI
• ex. of triple therapy: omeprazole (PPI), clarithromycin, and either amoxicillin or metronidazole (if pt is allergic to PCN)
• ex. quadruple tx: omeprazole, bismuth subsalicylate, metronidazole, tetracycline.

• Fasting glucose > 126 is positive.
• A1c > 6.5 is positive.

• Best predictor of low BMD =low body weight (2nd = low ER)
• Best predictor of hip fx = DEXA sca of femoral neck

• Men begin at age 35
• Women begin at age 45
• If pt has risk factors (smoking, DM HTN, FHx) start earlier.
• Screen q5 years if results are normal.

• 25-44: 1)unintentional injuries, 2)CA, 3) heart dz
• 46-64: 1)CA, 2)heart dz, 3)injuries
• 65+: 1)heart dz, 2)CA, 3)cerebrovascular dz

• change in size and force of stream
• sensation of incomplete emptying
• enlarged prostate on DRE
• advancing age

• Start with UA
• If UA shows RBCs: consider cystoscopy (CA)
• If UA shows WBCs: consider cystitis or prostatits infxn.
• Optional tests: urine cytology (bladder CA), PVR volume (>350), max urinary flow rate

• Usually d/t ascending UTI
• Least common type of prostatits
• Sx: urinary sx and perineal/pelvic pain, fever
• PE: tender, boggy prostate on DRE
• labs: UA (WBCs) and urine culture
• Tx: abx (TMP-SMX or fluoroquinolone) for 4-6 wks and NSAIDs for pain
• Can become septic --> hospitalize.

• Sx: gradual onset of mild-modersate urinary sx with or without h/o acute prostatitis. Low back pain, perineal pain, painful ejaculation or hematospermia
• PE: minimally tender or normal DRE
• labs: UA is consistent with UTI. Do urine culture.
• Tx: TMP/SMX or fluoroquinolone for 6-12 wks.

• MC prostatitis syndrome
• Sx are similar to chronic bacterial prostatitis, but no known source of infxn.
• UA is not consistent with UTI.
• Tx - alpha blockers, NSAIDs for 6 mo.

• Age: rare before 45 yo. 
• Race: more common in AA
• Genetics: patients with 1st degree relatives have 2x risk; BRCA may increase risk
• Diet: high in animal fat or low in vegetables increases risk. 

• PVC13 - can give to kids < 2yo
• PPV - give to ages 2 and up.

• Have increased risk of:
• infxn
• anemia
• orthostatic hypotension
• decubitus ulcers

• presbyopia 
• ARMD - leading cause of severe vision loss in elderly
• glaucoma
• senile cataracts - MC cause of blindness worldwide
• Diabetic reitnopathy

• Age-related sensorineural hearing loss.
• MC form of hearing loss in the elderly
• Selective high frequency loss and difficults with speech discrimination 
• Dx of exclusion
• Hearing aids helpful

1. HTN
2. A fib

• Work-up should looking for renal parenchymal dz: UA, urine culture, renal ultrasound.

• Abdominal obesity - waist circumference>40" in men or 35" in women OR waist:hip ratio>0.9 in men or 0.85 in women.
• Dyslipidemia - defined as TG of 150 or more, HDL<40 in men or <50 in women
• bp above 130/85
• fasting glucose of 100 or more

• fasting blood sugar
• lipids
• TSH
• liver enzymes

• Pts with BMI>40 who failed diet/exercise (with or without meds) OR
• pts with BMI>35 with comorbidities.

• Everyone >20
• q5 years (if no risk factors present)

1. cigarette smoking
2. HTN (140/90+) OR pt taking antihypertensive agent
3. low HDL (<40) [*HDL of 60 or more is negative RF]
4. FHx of premature CHD (male 1st-degree relatives 55 or younger, females 65 or younger).
5. Age - 45 and above for males, 55 and above for females

• A  CHD risk equivalent indicates the risk of CHD is 20% or greater within 10 years.
• Ex: atherosclerotic dz (AAA, peripheral artery dz, CVA); T2DM

• LDL<100 mg/dL
• Start meds at 130 (before meds do lifestyle changes, meds optional for 101-129)
• Optional LDL goal for pts at very high risk is < 70. 
• "very high risk" = pts with CHD AND either multiple risk factors (esp DM), poorly controlled risk factors (smoking), multiple traits of metabolic syndrome, or acute coronary syndrome.

• Must do invididual risk assessment (using individual risk assessment calculator). Then:
• if risk is 10-20% (intermediate) goal is 130 or less. Would start meds at 160.
• if risk is 20% or more: LDL goal<100 (start meds at 130)

• Goal is <160
• Start meds at 190

• Metformin CANNOT cause hypoglycemia! It decreases glucose synthesis via hepatic gluconeogensis. Has been shown to result in evidence-based decrease in M&M.

• Increase physical activity
• Stop smoking
• Diet: limit saturated fats to less than 7% total calories, limit cholesterol intake to less than 200 mg per day
• Addition of dietary soluble fiber (10-25mg) and plant stanols/sterols (2g)

• SE include myopathy, myaglia, and increased liver enzymes
• Pts that are taking statins must have LFTs monitored - initially q 6-12 weeks, later q 16-12 months).

What is the 1st line medication for lowering LDL?

Which medications (2) are most effect for lowering TG and raising HDL?

• 1st line med for lowering LDL: statin
• Best for lowering TGs and raising HDL: nicotinic acids (niacin), fibric acids (gemfibrozil, fenofibrate)
• (Niacin somewhat more effective than fibrates for HDL. )

• cardiac (ex. CHF)
• pulmonary
• hematologic (anemia)
• psychogenic (panic disorder)

• wheezes
• increased AP diameter
• decreased diaphragmatic excursion
• prolonged expiratory phase

• pulmonary edema evidenced by inspiratory crackles and/or dullness to percussion
• JVD
• S3
• PMI diffuse and laterally displaced
• peripheral edema
• hepatojugular reflex

• Peripheral etiologies often will have:
• unidirectional nystagmus that resolves with gaze fixation 
• the nystagmus does not change direction
• + head thrust test

• BPPV - vertigo occurs with changes in position and not constant
• vestibular neuritis - vertigo not position-dependent; may follow URI
• Meniere's dz - vertigo accompanied by hearing loss & tinnitus

• #1: BPPV (Dix-Hallpike)
• #2: vestibular neuritis (or acute labyrinthitis)

1. diuretics, low salt diet - Meniere's dz (inconclusive evidence)
2. Epley maneuvers (canalith repositioning) - main tx for BPPV
3. Vestibular rehabilitation (PT)
4. Vestibular suppressant medications: anticholinergics like meclizine and dimenhydrinate, anti-emetics: metoclopromaide, promethazine

• CBT = best tx, particularly sleep restriction/sleep compression therapy.
• Zolpidem

• cephalosporin for 7-10 d
• penicillin VK 250 mg PO QID for 10 d
• amoxicillin 1g PO BID for 6 d

• diarrhea
• Tx: erythromycin

• Staph aureus
• erythromycin

• MRSA - vancomycin
• H. influenza - cefuroxime
• Strep pneumo - PCN

1. immediate tx includes meds to decrease damage to myocardium and reduce bp: nitroglycerin, beta blockers. Also: aspirin, oxygen, morphine.
2. ECG and CXR, constant monitoring & continuous telemetry
3. stat labs

• ST elevation or depression
• T-wave inversion
• Pathologic Q wave suggests necrosis from a previous, completed infarction.
• NOT All MIs will have ECG changes!

• new onset
• at rest or with minimal exertion
•  pattern with episodes of increasing frequency, severity, or duration

• Echocardiogram: help identify cardiac wall abnormalities, cardiomyopathy, ventricular or septal hypertrophy, cardiac ejection fraction, tamponade, pericardial constriction, PE , valvular abnormalities

• Restrict sodium and fluid intake. Initial restriction of Na should be 2-4 g/d; may need further restriction in severe cases.
• Weight loss through diet and exercise if pt is overweight
• strict management of bp and modification of cardiac risk factors

• ACE-I - reduces preload, afterload, improves CO, resulting in improved sx and reduced mortality. Also delays development of sx in asymptomatic pts w/ reduced EF. 
• Alternative = ARB

• pregnancy
• hypotension
• hyperkalemia
• bilateral renal a. stenosis
• use cautiously in pts with renal insufficiency

• recent UTI
• DM
• recent incontinence
• new sexual partners
• use of spermicide
• mother with h/o UTI

• foreign object aspiration - never do blind finger sweep!
• Bronchiolitis: MC lower respiratory dz of infants and MC reason for hospitalization of infants < 1 yr
• Croup: MC cause of airway obstruction in 6 mo - 6 yo. MC reason for hospitalization in kids <4 yrs.
• Epiglottitis - usually affects kids < 5yo
• Deep neck abscess (retropharyngeal or peritonsillar)
• Note: sufficient airflow is required to produce wheezing sound. Disappearance of wheezing in pt who initially presents with wheezing suggests complete blockage of airway/imminent respiratory failure

• RSV accounts for 70% cases
• Tx: supplemental oxygen if SpO2 < 90% and supportive care (fluids and suction nasal and pharyngeal secretions).

• cause: viral infxn (often parainfluenza) that leads to inflammation of subglottic region
• frontal neck x-ray: steeple sign
• Tx - depends on severity (chest retractions, stridor at rest, cyanosis, LOC). Often includes glucocorticoids +/- nebulized epinephrine

• bacterial (commonly Hib) infxn of supraglottic tissue
• muffled "hot potato" voice, toxic appearance, drooling
• lateral neck x-ray: thumb sign
• medical emergency: visualization is preferably done in OR. Tx is airway management (may need intubation) and abx

• wounds > 18 hours old (>24 hrs on the face)
• animal and human bite wounds (exceptions: facial wounds and large wounds from dog bites)

• age < 2 years (peak age of onset: first 6 years of life)
• male
• genetic predisposition
• previous episodes of otitis media
• cigarette smoking in household
• attendance at daycare
• recent URI

• ear lobule erythema - erysipelas (begin antistreptococcal abx immediately to stop spreading)
• CN VII palsy - malignant otitis externa
• ulceration or non-healing lesion in ear canal - tumor
• tenderness over mastoid  - mastoiditis (often requires surgery)

• otitis externa with invasion of adjoining tissue
• usually caused by infection with P. aeruginosa
• can lead to widespread local invasion and bacteremia with sepsis and death
• associated with 7th nerve palsy on affected side
• Pts with DM are at increased risk
• Tx - surgical debridement of necrotic tissue and 4-6 wks of IV abx if cranial bones are involved.

• epiglottitis - stridor, drooling, toxic appearance, patient in "tripod" position
• peritonsillar abscess - peritonisillar swelling with tonsil pushed toward midline and contralateral uvula deviation, trismus (pain with chewing)
• GAS infection - abrupt onset of sore throat & fever, palatal petechiae, tender cervical adenopathy, absence of cough, +/- sandpaper rash.

• Sx are very similar to those seen with GAS infxn, including: sore throat, palatal petetchiae, tonsillo-pharyngeal exudate, etc.
• In addition, in mono: retrocervical or generalized adenopathy, hepatosplenomegaly, atypical lymphocytes of blood smear

• bronchodilators, ex. albuterol
• antitussives: dextromethorphan, codeine
• RTC in 2 - 3 wks.
• do not give abx b/c it's usually a viral etiology! (exception=pertussis)

• Prolonged fever
• Abnormal vital signs: HR>100, RR>24, Temp>100.5
• findings consistent with pulmonary consolidation (dullness to percussion in one area, vocal fremitus, etc).
• Next step: chest x-ray.

• purulent nasal discharge
• maxillary, tooth, or facial pain
• unilateral maxillary sinus tenderness
• worsening sx after initial improvement
• sx last longer than 7-10 days (vs viral - shorter)

• Adults: Strep pneumoiae, haemophilus influenzae
• Children: S. pneumoniae, H. influenza, Moraxella catarrhalis.
• [chronic sinusitis - anerobes: bacteroides, peptostrepto, fusobacterium]

• directly at likely causative pathogens
• First line: amoxicillin and TMP-SMX, 10-14 days. 
• decongestants & NSAIDs for sx relief as needed

• In adults, vast majority is viral.
• Peak incidence is btwn ages 4 and 7
• Causes in young adults: Mycoplasma pneumoniae, chlamydia pneumonia, and arcanobacterium haemolyticus
• Group A Strep causes 30% of pediatric cases and 15% of adult cases. 

Tests for GAS pharyngitis (2)

• rapid Ag test = quick in-office test; highly specific, but lower sensitivity
• throat culture = gold standard

• rheumatic fever
• glomerulonephritis (may occur whether or not pt receives appropriate abx)
• TSS
• peritonsillar abscess
• meningitis
• bacteremia

• MC pathogens: S. pneumonia, H. influenza, M. catarrhalis.
• Tx: most cases resolve spontaneously. If sx are prolonged, recurrent, or severe tx, or child is < 2 yo,  with abx is indicated: amoxicillin (1st line) for 5-7 days. 

• Diagnosis or diagnostic work-up
• Treatment
• Pt education/prevention
• Follow up

"As a physician it's important for me to understand:"

1. How  do you view your health condition/illness?
2. What do you think is causing it?
3. What do you think are the main problems tht the sickness is causing?
4. What do you fear most or worry about regarding your illness?
5. What tx do think you should receive for it?
6. What are the most important results you hope to receive from the tx?

1. Superficial spreading melanoma - MC type 
2. Lentigo maligna - least common type
3. Acral lentiginous melanoma - MC type in AA and Asians
4. Nodular melanoma - Most aggressive and 2nd MC type. 

• radial/superficial growth phase is slower than the vertical (invasive) growth phase
• Men - upper torso
• Women - legs
• Appearance: raised borders and brown lesions with pink, white, gray, or blue

• MC type in AA and Asians
• Usually found under nails, on soles of feet, or on palms of hands
• Appearance: flat, irregular, dark brown to black.

• If there is a change in a pre-existing lesion or if any of the ABCDE signs are presents (D: > 6mm) - excise completely w/ 2-3 mm margin if possible
• If you want to avoid to excising completely, do biospy in several areas. 

• Tx - complete excision wth 5 mm margins
• Px - depends on thickness. Melanomas < 1 mm thick have a low rate of mets and high cure rate with excision.

• 20% of dog-bite wounds become infected, whereas cat and human bites have higher rates of infection.
• Amoxicillin-clavulanate given orally (7-14 days) is appropriate prophylaxis for most bite wounds. 
• Abx prophylaxis should be given in high-risk bites (those on hands, late presentation, cat bites).

• Scrape or brush off the stinger (vs. grasping it at the base which may result in increased venom release)
• Rapidly removing the stinger is preferable to taking the time to locate scraping implements if one is not readily available. 

• Local reaction: occurs immediately and lasts a few hours. Response to toxic properties of the venom.
• Delayed reaction, "large local allergic reaction": mediated by IgE reacting to hymenoptera venom. A large area of redness and warmth develops over 24-48 hrs. Best treated with steroid initiated early after sting.
• Anaphylaxis - treated with subQ or IM injection of 0.3-0.4 mL of 1:1000 epi. May also need to give antihistamines, steroids, and bronchodilators. 

• MI
• cholecystitis
• lung cancer
• ruptured ectopic pregnancy

• Joint disease: loss of active AND passive ROM
• Muscle/tendon pathology: only lose active ROM

• adhesive capsulitis: MC in diabetes and pts with decreased movement of shoulder (ex post injury or stroke)
• Glenohumeral joint arthritis: MC >60 yo; less common site for OA
• Acromioclavicular joint arthritis: all ages with h/o repetitive overhead lifting/heavy weight training. 

• Tests abduction and external rotation with flexed elbow; internal rotation
• Some pain/decreased ROM: rotator cuff tendonitis
• Unable raise arm above head: rotator cuff tear
• Significant pain/decreased ROM: impingement, bursitis, adhesive capsulitis (older pts, DM)

Which tests look for a labrum tear?

(labrum = fibrous structure that encircles th glenoid fossa)

• O'brien test - pt has arm at 90 degrees forward flexion, adducted 45 degrees across body. Pt resists downwards force applied by examiner with pt's arm first interally rotated (thumb down) and then with arm externally rotated.Pain or popping/clicking = + test. Can have a FP if there's AC or rotator cuff pathology.
• Crank (clunk) test - with pt's arm overhead, elbow flexed, press head of humerus into glenoid & labrum, then move joint (external and internal rotation).  Popping or clicking = + test.

1. Empty can - pt has shoulders abducted to 90 degrees and arms 30 degrees from horizontal. Pt attempts to resist downward overpressure applied by examiner.
2. Full can - strength test for supraspinatus
3. Drop arm - large supraspinatus tear

• Neer Test - passive forward flexion of shoulder
• Hawkins - baby-bird position - apply pressure of internal rotation
• Painful arc - 60-120 degrees
• Consistent with: rotator cuff tendonitis, inflammation of subacromial bursa

• 1st line tx for HTN
• most cost effective medication for HTN
• requires periodic monitoring of electrolyte serum levels (can cause hyponatremia)
• should be avoided in pts with gout
• can cause elderly pts to have urinary incontinence

• If thiazide diuretic by itself does not sufficiently lower bp, add another agent:
• ARB, ACE-I, CCB, BB

• Resistant HTN = failure to achieve goal bp (<140/90) on full doses of an appropriate 3 drug regimen that includes a diuretic.
• Contributors: improper bp measurement, excess sodium intake, inadequate dose of diuretic, medication problems (inadequate doses, drug interactions, etc), excess alcohol intake, underlying causes of HTN (secondary HTN). 

• Healthy weight: 5% to 85%
• Overweight: 85% to 95%
• Obese: equal to or greater than 95%

• random glucose of 200 or more with classic sx
• 2 hour glucose tolerance test of 200 or more after 75-g glucose load
• fasting glucose more than 125
• HbA1c of 6.5% or more

• Speed's test - pt has arm forward, elbow extended, palm facing up. Pt flexes arm (overhead) while examiner applies downward pressure. Pain in biceps groove = biceps tendonitis.
• Yergason test - Pt has elbow at side, flexed forward 90 degrees, hand protonated. While examiner palpates bicipital groove, ptt attempts to supinate arm and externally rotate against examiner's resistance. Pain or clicking = + test. 

• older woman with pain and stiffness in cervical spine, shoulder & hip girdles. 
• Pt often has malaise, weight loss, sweats, fever
• Elevated ESR, anemia, sometimes elevated ALP and LFTs.
• Tx - low dose steroids for weeks to months.
• 10-20% also have giant cell (temporal) arteritis. 

• follows GI (shigella, salmonella, campylobacter) or GU (C. trachomatis) infxn
• MC in young, HLA-B27+ males Increased incidenence in HIV +.
• Triad: non-gonococcal urethritis, oligo-articular arthritis, conjunctivitis. (+/- rash on plams/soles)

• Assess overall CV risks: DM, smoking, obesity, FHx, ROS.
• Look for 2ndary causes of HTN: renal, endocrine, obstructive sleep apnea
• Check end-organ damage: retinopathy, atherosclerosis, AAA
• Labs: serum K+, creatinine/GFR, Ca, glucose, Hct, UA (proteinuria, cells), ECG (LVH, CAD)

• If pt is 20/10 mmHg above goal bp (140/90 or 130/80 is pt has DM and renal dz)
• Pt has stage II HTN (160/100).

• The lateral ankle is injured much more commonly than the medial ankle.
• The anterior talofibular ligament (ATFL) is the most commonly injured ligament, followed by the calcaneofibular ligament (CFL).
• [the ligaments of the lateral ankle: ATFL, PTFL, CFL).

• bony tenderness over medial (navicular bone) or lateral  (fifth metatarsal bone) midfoot
• inability to bear weight

• PRICE
• Protection - split or cast to prevent further injury
• Rest
• Ice
• Compression
• Elevation
• also: NSAIDs or acetaminophen for pain. 

• Sprain: stretching or tearing injury of a ligament.
• Strain: stretching or tearing injury of a muscle or tendon. 

• age 55 or older
• isolated patella tenderness
• tenderness of the head of the fibula
• inability to flex knee to 90 degrees
• inability to bear weight for 4 steps (regardless of limping)

It is when there is rupture of the fibrocartilarge between the vertebrae, leading to leakage of the nucleus pulposus that may imping on the nerve roots and cause pain. 

[Sciatica is usually caused by a herniated disc in the lumbar spine.]

• Infectious sx: chronic corticosteroids, immunosuppression, fever.
• Things that suggest CA: h/o CA, worsening pain at night, weight loss. 
• Sx of cauda equina syndrome: neurologic deficits, leg weaknes, bow and urinary incontinence, "saddle" paresthesia/anesthesia
• others: trauma, suspcicion of AS, osteoporosis