Problem Solving Exercise for mbbs and bds

Problem Solving Exercise for mbbs and bds

1. Problem solving exercise

2. Q 1 . A 60-year-old woman complained of weakness, lethargy and easy fatigability. Investigation showed that she had iron deficiency anaemia ( Hb . 8 g/dl). She was prescribed cap. Ferrous fumarate 300 mg twice daily. She returned after one month with no improvement in symptoms. Her Hb . level was unchanged. On enquiry she revealed that she felt epigastric distress after taking the iron capsules, and had started taking antacid tablets along with the capsules.

3. 1. What could be the possible reason for her failure to respond to the oral iron medication? 2. What is the daily requirement for Iron in adult male ? 3. Name some oral Iron Preparations. 4. What are the adverse effects of Oral Iron ? 5. Name some Iron chelating agents.

4. Answer : 1. Antacids interfere with iron absorption.Absorption is much better when iron preparation is taken in empty stomach. 2. Daily requirement in adult male – 0.5-1 mg (13 microgram/kg) 3. Ferrous sulphate 15 mg Ferrous gluconate 300 mg Ferrous fumarate 300 mg 4. Epigastric pain, heart burn, nausea and vomiting. 5. 1) Desferrioxamine 2) Deferiprone

5. Q2.A woman aged 25 years came to OPD with history of seizures. She was diagnosed as generalised tonic- clonic seizures. 1 . Name the first line drugs to treat this condition 2. Mention the adverse effects of phenytoin . 3. What are the other uses of Carbamazepine ? 4. Name the newer anti-epileptic drugs 5. Mention the drugs used in febrile fits .

6. Answer: 1. First line- Valproate, Lamotrigine , Carbamazepine. 2. Dose related toxicity : At therapeutic plasma concentration : 1.Gum hypertrophy 2. Megaloblastic anemia 3. Cerebellar and vestibular manifestation- ataxia, vertigo, diplopia , Drowsiness, mental confusion, epigastric pain. Hypotension and cardiac arrhythmias. Foetal Hydantoin Syndrome. 3. Trigeminal neuralgia, maniac depressive illness. 4. Levetiracetam , Pregabalin , Topiramate, Gabapentin , Zonisamide. 5. Diazepam – 0.5mg/kg (Rectal route)

7. Q 3.A 45 year old female presented with complaints of loss of weight, anxiety, palpitation, tremors, excessive sweating and heat intolerance. She was diagnosed as hyperthyroidism and prescribed Tab. Carbimazole 200 mg TDS along with propranolol 40 mg per day.

8. 1. Why was propranolol added to the treatment ? 2. What are the other drugs available to control the hyperthyroidism in this patient ? 3. What are the advantages and disadvantages of using radioactive iodine ? 4. Outline the management of thyroid storm ( Thyrotoxic crisis) 5. Which antithyroid drugs can be given to pregnant women ?

9. Answer: 1. Propranolol is added to alleviate the symptoms like palpitation, tremors and anxiety. 2. Carbimazole, Propylthiouracil , Iodine. ( I 131 ) 3. Advantages : 1. Treatment with I 131 is simple, conveniently given on outpatient basis and inexpensive. 2. No surgical risk, scar or injury to parathyroid glands/recurrent laryngeal nerves. 3. Once hyperthyroidism is controlled, cure is permanent.

10. Disadvantages : 1. About 5-10% patients of Grave’s disease treated with I 131 become hypothyroid every year. 2. Long latent period of response. 3.Contraindicated during pregnancy – foetal thyroids will also be destroyed resulting in cretinism. 4.Not suitable for young patients.

11.  4.  Hydrocortisone 100 mg iv slowly followed by oral prednisolone . Other - Rehydration, Anxiolytics, Antibiotics Diltiazem 60-120 mg BD if tachycardia not controlled by Propranolol. 5. Antithyroid given during pregnancy. Low dose Propylthiouracil - especially in early pregnancy. Methimazole - now found to be safe but not given in India.

12. Q 4 . A 40 year old farmer is brought to the hospital by his relatives with the history of consumption of unknown substance. There is history of vomiting. The patient is unconscious and on examination his pupil is pin-point, pulse rate is 30/ min. There is a characteristic odour from the patient mouth. 1. What is the probable diagnosis ? 2. Name the drugs to treat this condition 3. When are the oximes contraindicated ? 4. Name other drugs used in this poisoning. 5. What is the universal antidote?

13. Answers 1 . Organophosphorus poisoning ( Anticholinesterase poisoning ) 2.Atropine 2 mg i.v repeated every 10 min until dryness of mouth and other signs of atropinization are observed. Pralidoxime i.v slow 1-2 g in adult Pralidoxime 20-40 mg/kg in Children. Another regime : 30 mg/kg iv 10th hourly dose followed by 8-10 mg/kg till recovery . 3. In Carbamate poisoning  - not effective because Anionic site not free for its attachment. It has weak AntiCHE activity on its own . 4. Obidoxime , Diacetylmonoxime 5. It consists of 2 parts of Powdered charcoal + 1 part of tannic acid and one part of magnesium oxide.

14. Q 5 . An osteoarthritis patient on treatment with NSAIDS came to OPD complaints of severe epigastric pain and vomiting of blood. 1. What is the reason for the complaints? 2. Name some drugs that aggravate Peptic ulcer. 3. Enumerate some antacids and anti-ulcer drugs useful in this condition. 4. Which type of NSAIDS can be given for osteoarthritis ? 5. Name some drugs used to control hematemesis ?

15. Answers: 1.NSAID'S induced peptic ulcer. 2. Corticosteroids, Metformin,Aspirin,SSRI . 3.PPI,Sucralfate and systemic antacids. 4.Paracetamol,Selective COX-2. 5. Octreotide , Terlipressin,Tranexamic acid.

16. Q 6 . During a surgical procedure a patient was given IV Succinylcholine as muscle relaxant and inhaled halothane as general anaesthetic agent. During surgery the patient developed muscle rigidity and tachycardia and the temperature started rising rapidly. 1. What is the name of this condition? 2. How is Succinylcholine action terminated ? 3. What is the treatment of the above condition? 4. What is the reason to cause muscle rigidity ? 5. Does paracetamol help in reducing temperature in this condition?

17. Answers: 1.Malignant Hyperthermia. 2.It is rapidly hydrolysed by plasma pseudocholinesterase . 3.Dantrolene Sodium. 4.Release of Ca+ from Sarcoplasmic reticulum. 5.No

18. Q7. Mr . X suffering from schizophrenia was given Tab. Chlorpromazine 100mg. After 10 days he developed muscle rigidity & tremor. The patient was assured & advised to take Tab. Levodopa 250 mg twice daily. What are his recent symptoms suggestive of? Mention the drugs which can induce this condition Is Levodopa indicated to this patient? Outline the management & the rationale for the drug chosen? Mention anti-histamines that can be used in this condition

19. Answers: 1. Drug Induced parkinsonism 2. Phenothiazine's such as chlorpromazine Butyrophenones such as haloperidol Thioxanthines such as flupenthixol Antiemetics such as prochlorperazine & metoclopramide Methyldopa 3. No, it is contra indicated in drug induced parkinsonism 4. Cessation of the offending drug(s ) Anticholinergics such as trihexyphenidyl or benztropine 5. Orphenadrine Promethazine

20. Q 8. After the injection of Succinylcholine to provide muscle relaxation during an operation the patient developed prolonged apnoea What do you think the probable reason is ? Would you like to give Neostigmine as antidote? What is the line of treatment? Name 4 drugs which potentiate neuromuscular blockers Name the drug given for d- tubocurarine overdose

21. Answers: 1. The probable reason is succinyl choline apnoea 2. Administration of cholinesterase inhibitors such as neostigmine is controversial for reversing succinylcholine -related apnoea in patients who are pseudocholinesterase deficient 3. Fresh frozen plasma transfusion Controlled ventilation till recovery Recombinant pseudocholinesterase administration 4. Amino glycosides such as streptomycin Quinidine Calcium channel blockers Thiazide Diuretics 5. Neostigmine

22. Q9 . A 56 year old hypertensive patient on Tab. Atenolol 50 mg OD complained of chest pain, following any sustained exercise. He was diagnosed as atherosclerotic angina and prescribed sublingual Nitroglycerine for treatment of acute chest pain. How does nitroglycerine relieve chest pain? Mention four adverse effects of nitrates Can you add Diltiazem or Verapamil to this patient? Justify. What are the other drugs prescribed for chronic angina? Mention two drugs used in patients with angina refractory to standard anti anginal therapy.

23. Answers: 1. Reduces pre and after load Increase blood supply to ischemic area Reversal of Coronary Vasospasm Decrease in Platelet Aggregation 2. Headache   Reflex Tachycardia  Orthostatic hypotension Tachyphylaxis and Tolerance 3. No .They might aggravate the haemodynamic conditions in this patient 4. Ranolazine , Nicorandil , Ivabradine,Molsidomine,Trimetazidine . 5. Ranolazine,Nicorandil .

24. Q10 . A 12-year-old girl presents to your clinic with a sore throat and fever. You diagnose her with pharyngitis caused by group A β- hemolytic Streptococcus. She was given an IM injection of penicillin. Approximately 5 minutes later, she was found to be in respiratory distress and audibly wheezing. Her skin is mottled and cool, she is tachycardic and her blood pressure had fallen to 70/20 mm Hg. What are her recent symptoms suggestive of? Which drug would like to administer to this patient and why? What is the rationale for using this drug in this condition? Define the type of drug action observed here. Give another example where this type of drug action is observed .

25. Answers: 1. Her recent symptoms are suggestive of anaphylactic reaction to the penicillin . 2. Epinephrine Anaphylaxis is an acute immune-mediated response to an allergen characterized by bronchospasm wheezing tachycardia & hypotension. Epinephrine is the drug of choice for this condition since it counteracts the pathophysiologic processes underlying anaphylaxis. It induces a rise in BP due to its vasoconstrictor effect mediated through α1 adrenergic receptors and causes relaxation of bronchial smooth muscles through stimulation of β2 adrenergic receptors .

26. 3. Physiological antagonism 4. The two drugs act on different receptors or by different mechanisms but have opposite overt effects on same physiological function. i.e. have physiological effects in opposite direction. 5. Glucagon and Insulin on Blood sugar level.