Acute Pulmonary Embolism

"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.

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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

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Urinalysis & Urine Sodium

     

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.

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Capnography

Capnography V/S Pulse Oximetry Capnography 

·         Provides a measure of ventilation – or concentration of CO2 exhaled air

(aka end tidal CO2 or etCO2).

·         Not effected by supplemental oxygen.

·         Reflects breath-to-breath ventilation.

·         Appear not normal if the patient has stopped breathing.

·         Apnea or hypoventilation is detected immediately by capnography

Pulse Oximetry 

·         Measures oxygenation or arterial blood oxygen saturation & pulse rate.

·         Detects oxygen deficiency (hypoxia).

·         May appear normal even if the patient has stopped breathing.

·         Takes time to detect Apnea or hypoventilation.

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Hypoglycemia

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.

                                                          

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Liver Abscess

 

• 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.

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