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The term ‘pseudo’ means ‘false’, ‘pretended’, ‘unreal’, or ‘sham’. Likely to be of Greek origin, pseudes means false. There are a number of ‘pseudo’ terms and syndromes that we see in the common practice. Even though the meaning of pseudo is unreal or sham, however several medical conditions/ syndromes are true entities as described above.


"D" sign:
In a physiologically normal heart, LV pressure > RV pressure. When viewing heart in a parasternal short axis during systole the LV maintains a circular appearance, bowing the intraventricular septum into the right ventricle. A D-shaped left ventricle or flattening of the interventricular septum with a D-shaped configuration is a feature described with significant RV overload / right heart strain such as that occurring with complications of a sizable pulmonary embolic event.

McConnell's sign:
An echocardiographic finding of segmental right ventricular wall‐motion abnormality with apical sparing, is highly specific in acute pulmonary embolism and may guide rapid intervention when other testing is not feasible.

 

Thyroid Storm

Thyroid storm is a rare and life-threatening condition characterized by an acute exacerbation of thyrotoxicosis, marked by elevated levels of free triiodothyronine (T3) or free thyroxine (T4) and suppressed thyrotropin (TSH). It presents with severe clinical symptoms and can lead to multiorgan failure, affecting various organ systems, including the central nervous system, cardiovascular system, hepatic system, pulmonary system, respiratory system, digestive system, and gastrointestinal excretory system.
Specific Strategic Steps for Treatment
  • Therapy to control increased adrenergic tone: Beta-blocker
  • Therapy to reduce thyroid hormone synthesis: Thionamide
  • Therapy to reduce the release of thyroid hormone: Iodine solution
  • Therapy to block peripheral conversion of T4 to T3: Iodinated radiocontrast agent, glucocorticoid, PTU, propranolol
  • Therapy to reduce enterohepatic recycling of thyroid hormone: Bile acid sequestrant

     

Theophilus Protospatharius, a seventh-century physician, authored the first manuscript focused exclusively on urine, titled "De Urinis." In this work, he demonstrated that heating urine precipitated proteins, thereby documenting proteinuria as a disease state. Later, in the 12th century, the French scholar Gilles de Corbeil classified 20 different types of urine based on variations in urine sediment and color. He also introduced the "matula," a glass vessel that allowed physicians to assess the color, consistency, and clarity of urine.

Following includes the complete analysis of urine:

Visual exam
• Color. 
• Clarity
Dipstick test
• Acidity (urine pH). 
• Bilirubin. 
• Blood (hemoglobin). 
• Glucose. 
• Ketones
• Leukocyte esterase.
• Nitrites. 
• Protein
• Urine specific gravity test. 
Microscopic exam
• Crystals. 
• Epithelial cells. 
• Bacteria, yeast and parasites (infections). 
• Red blood cells (RBC). 
• Urinary casts: 
• White blood cells 


Fractional excretion of Sodium (FE Na).
  • [(U Na x P Cr) / (P Na x U Cr)] x 100
  • U = Urine, P = Plasma, Cr = Creatinine, Na = Sodium.
  • Re-absorption and filtration accounted (Both).
  • Should not be used with normal renal function.

Acute Kidney Injury (AKI)
  • FE Na < 1%
  • Urine sodium < 20 mEq/L.

Acute Tubular Necrosis (ATN)
  • FE Na > 2%
  • Urine sodium > 40 mEq/L.


Hypoglycemia In Diabetics

Type 1 DM/Type 2 DM,
Kidney disease: insulin not cleared out of circulation well.
Medications for Diabetic.

More frequently:
Meglitinides, 
Sulfonylureas,
Insulin 
Very infrequently:
Metformin,
GLP-receptor agonists,
SGLT-2, and 
DPP-4 inhibitor

Hypoglycemia In Non-Diabetics:
Hormonal dysfunction             
Addison's disease
Hypopituitarism
Non-B cell tumors.
Post-gastric bypass
Insulinomas.
Drugs: 
NSAID’s, phenylbutazone, propoxyphene,  
Quinine 
Lithium, TCA, chlorpromazine,   
Fluoxetine, sertraline,
ACE-inhibitors, arbs, beta-blockers.
Levofloxacin, trimethoprim-sulfamethoxazole, 
Mifepristone, 
Heparin
Mercaptopurine.
Haloperidol, pentamidine, 
Disopyramide, 
isoniazid, methotrexate, 
fenfluramine, thiazide diuretics,        
Opioid analgesic tramadol.

                                                          

 

  • Pyogenic abscess, accounts for 80% of abscess.
  • Amebic abscess due to Entamoeba histolytica, accounts for 10%.
  • Fungal abscess, accounts for < 10%.
  • 50% of solitary liver abscesses occur in the right Liver lobe.
  • Right hepatic lobe (~75%), less commonly left (20%) or caudate (5%) lobes.
  • Pyogenic abscesses are usually polymicrobial.
  • 50% of the bacterial cases develop by cholangitis. 
  • Pyogenic Abscess- initial manifestation of an occult intra‐abdominal malignancy (up to 15%).
  • Positive blood cultures in up to 50%.
  • Most common organisms: E. coli, Klebsiella, Streptococcus, Staphylococcus, & anaerobes.
  • K pneumoniae thought to be associated with colorectal cancer.
  • Fever in 90% & abdominal pain in about 50-75%.
  • In-hospital mortality estimated at 2.5% -19%

       Drainage of the abscess & antibiotic treatment are the cornerstones of treatment.

  • Antibiotic Therapy: 
        If the size of the abscess < 3-5 cm
        Oral antibiotics are given after intravenous antibiotics are first administered. 
  • Percutaneous Drainage: 
         Abscess > 5 cm
         Continuous fever despite 48-72 hours of ABX therapy
         Indications that the abscess may rupture
         U/S or CT-guided aspiration & drainage- first-line treatment. 
  • Surgery:
          Where percutaneous drainage is impractical.
          When there are complications like rupture or numerous abscesses. 
          Open surgery or laparoscopic surgery.



Significant electrolyte depletion can result in serious complications. These guidelines are meant to assist with empiric dosing of electrolytes for inpatients. Doses may need to be adjusted based on patient-specific factors, including creatine & cardiac status; & responses to initial doses.

  • Goal serum potassium concentration 4.0 – 5.0 mEq/L
  • Goal serum ionized calcium concentration 1.12 – 1.3 mmol/L
  • Goal serum magnesium concentration 2.0 – 2.4 mg/dL
  • Goal serum phosphorus concentration 2.7 – 4.6 mg/dL

IV electrolyte replacement can produce life-threatening complications, serious arrhythmias & phlebitis; therefore, supplementation must be carefully monitored.  There are multiple underlying factors for electrolyte disorders in adult inpatients, including alterations in absorption, distribution, hormonal, and/or homeostatic mechanisms that can all cause disturbances. Treating the underlying cause and prescribing adequate therapy is essential for repletion. In addition, the intracellular vs. extracellular electrolyte concentrations must be considered. Due to distribution variances, labs may not directly correlate with true electrolyte levels. Therefore, continuous monitoring is essential to properly replete patients.

 


A systematic approach to the analysis of the fluid in conjunction with the clinical presentation helps to understand the etiology, narrow the differential diagnoses, & design a management plan. Includes biochemistry, microscopic examinations & infectious disease tests.


 

 Chronic, constantly progressive disease. Initially, it affects the muscle tissues of the face, then spreads to the trunk. The following types of MG are distinguished:
  • Ocular – the nerve endings in the cranial region are affected, and the eyelids fall asymmetrically. The patient complains of double vision and deterioration in visual acuity. Gradually focusing on one subject becomes difficult.
  • Bulbar – the lesion extends to the masticatory muscles and tissues of the larynx. The patient’s voice changes, speech becomes quieter and nasal. Some consonants are very difficult to pronounce, and stuttering develops. Due to the penetration of fluid into the respiratory tract, the risk of pneumonia increases.
  • Lambert-Eaton – the muscles of the arms, legs, and neck do not receive nerve impulses. It is difficult for the patient to coordinate these areas of the body. This form is diagnosed in the elderly and is characterized by rapid progression.
  • Generalized – the muscles of the eyes are immediately affected, then the process spreads to the larynx, arms, legs, and hips. The main danger of this form is that the respiratory muscles are affected over time.
The disease is characterized by constant progression. 

Plasma exchange (PLEX) is first-line for severe exacerbation & usually causes improvement in a few days. It directly removes anti-acetylcholine receptor antibody from the body. May be more effective in MuSK+ patients.

IVIG may be useful for less severe exacerbations; takes longer to work (e.g., 2-3 weeks), but the efficacy may be more sustained. The dose of IVIG is 2 grams/kg, usually divided over 2 or 5 days.


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