Tularemia (Choice D) typically presents with fevers, chills, myalgias, and
lymphadenopathy associated with an ulcerative cutaneous lesion. The causative agent of tularemia is Francisella tularensis, an aerobic gram- negative bacillus. Tularemia is typically transmitted by tick bite or direct cutaneous inoculation by an infected animal, most commonly the cottontail rabbit.
The excess corticosteroids have some mineralocorticoid effects, thus causing renal overproduction of bicarbonate The metabolic alkalosis is most severe with the syndrome of ectopic ACTH production from adrenal adenomas.
o Low pH, Low HCO3, High Base Deficit, Low pCO2 (choice A) is consistent with metabolic acidosis such as diarrhea (non gap acidosis) or the MUDPILES high anion gap acidosis (methanol intoxication, uremia, diabetic ketoacidosis, para- aldehyde, isoniazid/iron, lactic acid, ethyleneglycol, salicylates).
Low pH, High HCO3, High Base Excess, High pCO2 (Choice B) is consistent with respiratory acidosis such as inadeqaute aveolar ventilaltion (ARDS or Myasthenia gravis) o Neutal pH, Low HCO3, High Base Deficit, Low pCO2 (choice C) is consistent with a mixed metabolic/respiratory problem such as salicylate poisoning.
o High pH, Low HCO3, High Base Excess, Low pCO2 (Choice E) is consistent with respiratory alkalosis as in hyperventilated states (e.g. pulmonary embolism)
he two common ketones produced in humans are acetoacetic acid and -hydroxybutyrate.
Macrolides and Clindamycin ----> blocking the trans-location step of translation (50S subunit); streptogramins may also work on the extrusion of the completed peptide.
Aminoglycosides ----> Prevent initiation complex by causing misreading of the mRNA code (30S subunit)
Chloremphenicol and cycloheximides ----> inhibit peptidyl transferase (50S subunit)
Tetracyclines, Streptogramins, and Linezolid ----> inhibit initiation complex formation by inhibiting the attachment of tRNA to the A site (30S subunit for tetracylin: 50S subunit for streptogramins and linezolid)
Pencillins and cephalosporins ----> bind to PBP and inhibit transpeptidation of the cell wall
Flouroquinolones ----> inhibit topoisomeras II (DNA gyrase) and topoisomerase IV
Trimethoprim and pyrimethamine ----> blocks dihydrofolate reductase
Vancomycin ----> binds to D-Ala-D-Ala muramyl pentapeptide and halt transglycosylation of the peptidoglycan elongation in bacterial cell wall
Metronidazole ----> free radicals formation (needs oxygen to work)
Polymyxins ----> damages the membrane osmotic properties
INH ----> inhibit synthesis of mycolic acid
Rifampin ----> works on sigma factor needed for initiation of transcription
Ethambutol ----> inhibit synthesis of arabinogalactan a cell wall component of mycobacterium
Puromycin ----> attaches to the A site leading to premature termination of translation encephalopathy can impair our primary defense against hypernatremia, which is thirst and water ingestion. Elderly, debilitated, or encephalopathic patients are at particular risk secondary hyperaldosteronism in severe cirrhosis creates a tendency to sodium retention and potassium loss
significant hypokalemia such as this man has may impair renal concentrating mechanisms preventing proper defense against hypovolemia
The Ottawa ankle rules help clinicians decide if an X-ray study is worth doing. X-rays are required only if there is any pain in the malleolar zone and either bone tenderness along the distal 6 cm of the posterior edge of either malleolus (medial or lateral), or inability to bear weight both immediately and ion clinical evaluation for four steps. Remember that malleolar pain may be anywhere but the tenderness must be in the posterior malleolus region, medial or lateral.
o There is no tenderness at the posterior aspect of either malleolus. Also, the patient obviously can weight-bear because he was able to play tennis after the injury. No X-ray is required.
o There is evidence of a partial tear of the anterior talofibular ligament (note the location of tenderness and swelling), but no ankle instability. Surgery is not necessary. A non-weight- bearing status for four weeks will permit deconditioning. To avoid the formation of adhesions, passive range of motion needs to be preserved beginning as soon as possible. (This principle is more important for the shoulder than for the ankle, but is worthwhile nevertheless.)
o Other considerations regarding the Ottawa ankle rules include litigation issues (liability for a slip-and-fall injury), impaired sensation so that pain and tenderness may be falsely negative, a previously injured ankle or foot that may have internal fixation that can work loose or break, and mental-health issues that interfere with disclosing pain or its absence as you examine the ankle. Do not follow the Ottawa ankle rules blindly. o In general, prescribe large doses of vitamin C after any ligament or tendon injury to make sure that collagen repair proceeds quickly and with a strong result. o