MCCE NOTES

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


Sulfonamides ----> blocking dihydropterate synthetase


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