PROBLEM SOLVING EXERCISE

[Link].1

An adult male of age 60 years old suddenly developed drooping of eyelids

and weakness of muscles which was more pronounced in the evening. He
was diagnosed to be suffering from myasthenia gravis.

Enumerate the drugs used in this condition with rationale.

• Neostigmine, Pyridostigmine –increases Ach concentration in NM
junction
• Corticosteroids – decreases the production of NR antibodies,  synthesis
of NR
• Azathioprine, Cyclosporine - immunosuppressant action.

2. What are the other modalities of treatment?

• Plasmapheresis, Thymectomy.

3. What are the other uses of anticholinersterases?

• Cobra bite, Miotic, Alzheimer’s disease, Post operative decurarization,

Post operative paralytic ileus & Belladona poisoning.

4. How will you differentiate between cholinergic crisis and myasthenic

crisis?

• By Edrophonium test.

When 2mg of edrophonium is given iv,

❖ if muscle strength improves, it is myasthenic crisis

❖ if muscle strength worsens, it is cholinergic crisis.

 Ex No: 2

After injection of Succinylcholine to provide muscle relaxation during

operation, patient developed prolonged apnoea.

1. What do you think the probable reason is?

It is Succinylcholine apnoea. Succinylcholine is metabolized by

Pseudocholinesterase. The reason for this apnoea is presence of atypical
pseudocholinesterase which metabolise succinylcholine very slowly.

2. Will you give Neostigmine as antidote?

No. Neostigmine should not be given.

3. What is the line of treatment?

Provide Pseudocholinesterase enzyme by fresh blood transfusion.

4. What is dibucaine number?

The ability of Pseudocholinesterase enzyme to metabolise Sch can be
assessed by dibucaine number.
▪ Dibucaine (a local anaesthetic) inhibits the normal enzyme by
about 80% and atypical Pseudocholinesterase only by 20%.
▪ Dibucaine number less than 80 shows the proportionate
concentration of atypical enzyme.
 Ex No: 3

Mr. Rajesh suffering from schizophrenia was given [Link]

200mg. After 10 days he developed muscle rigidity & tremor. The
patient was assured & advised to take [Link] 250 mg twice
daily.

1. What are his recent symptoms suggestive of?

Drug induced Parkinsonism

2. Mention the drugs which can induce the above condition.

Phenothiazines, Butyrophenones and Metoclopramide.

3. Is Levodopa indicated in this patient?

No. Levodopa is not indicated as the D receptors are already blocked by

2
the drugs.

4. Outline the management & the rationale for the drug chosen?
It should be treated with centrally acting anticholinergics like
Trihexyphenidyl, Benztropine, Procyclidine and Biperidin. They act by
reducing the unbalanced cholinergic activity in the striatum .
Ex No:4

[Link] aged 45 years is a known manic depressive. She was on Lithium

250mg q.i.d. for 6 years.
Her serum lithium concentration was maintained between 0.8 and 1.1
meq/L. However on one occasion, the routine serum lithium, showed a
concentration of 1.6meq/L. On enquiry she revealed that she was given
hydrochlorthiazide 50mg/day by her family physician for mild
hypertension.

1. How does hydrochlorthiazide increase the lithium level?

Promotes proximal tubular absorption of Li by causing Na²+ loss, producing
a rise in plasma Li¹+.

2. What is the alternative drugs for this patient?

Na valproate, carbamazepine, olanzapine, Lamotrigine.

3. What is the alternative to hydrochlorthiazide in this patient?

Calcium channel blockers.

4. What is the therapeutic concentration of lithium?

0.8 – 1.1 mEq/L.
Ex No:5

[Link], an epileptic woman was being treated with phenytoin sodium

for the last 5 years. For the past 6 menstrual cycles she was taking oral
contraceptive pills. This time she did not start menses even 2 weeks after
stopping the pills. She consulted the gynaecologist and gave a H/o
spotting before the incidence.
Gynaecologist found softening of cervix, with breast changes indicative of
pregnancy.

1. How will you account for pregnancy in spite of oral

contraceptive?
Phenytoin - Enzyme inducer.

2. What are the other causes of oral contraceptive failure? what method
of contraception will you advice her in future?
Ritonavir, Primidone, Supression of intestinal microflora by antibiotics
like tetracycline, ampicillin, etc.,
Barrier method.

3. Name two more drugs interacting with oral contraceptives.

Rifampicin, Phenobarbitone.

4. Drug of choice for epilepsy during pregnancy.

Levetiracetam/ phenobarbitone.
 [Link].6
A 50 year old woman presented with intense pain, warmth and
redness in the first toe on her right foot. Examination of fluid
withdrawn from the inflamed joint revealed uric acid crystals .

1. What is the probable diagnosis?What are the drugs that can be

used for treating this patient and to prevent subsequent attacks?

It is an acute attack of gout

Acute gout:
1. NSAIDs 2. Colchicine 3. Corticosteriods

Chronic gout:
1. Uricosuric agent → Probenecid
2. Synthesis inhibitor → Allopurinol.

[Link] NSAIDS which drug is contraindicated for the treatment of gouty

arthritis? Why?
Aspirin slows down the renal secretion of uric acid and increases
the uric acid level in blood. So it should not be given.

[Link] are the drugs that precipitate Gouty arthritis?

Thiazides, Furosemide, Pyrazinamide, Ethambutol, Levodopa, Anticancer
drugs like Azothioprine & Mercaptopurine.

[Link] is the mechanism of action of probenecid?

It inhibits tubular reabsorption of uric acid. It promotes the excretion of uric
acid and reduces its blood level.
[Link].7
A young adult female comes with a history of frequent episodes of severe
headache on the right side with vomiting, and increased sensitivity to light
and sound.

1. What is the probable diagnosis? What are the drugs used to treat this
condition?

The probable diagnosis is acute attack of [Link] drugs used are

NSAIDs, Antiemetics, Ergot Alkaloids, Sumatriptan.

2. Give two limitations of ergot alkaloids.

Erratic oral absorption, Nausea and Vomiting.

3. What is the mechanism of action of sumatriptan?

It is a selective 5HT1B /1D agonist.

4. What are the drugs used for prophylaxis of this condition?

β blockers, Tricyclic Antidepressants, Calcium Channel Blockers,
Sodium valproate, Gabapentin.
[Link].8.

A 33 yr old women presents with complaints of fatigue, sluggishness,

weight gain, cold intolerance, dry skin and muscle weakness for the past
2 months.
On physical examination, her BP is 130 / 89 mm of Hg with pulse rate
50 / min. Her weight is 61.5kg, an increase of 4.5 kg in the last year.
Reflexes are delayed; lab findings shows TSH 14.9 g / L. (Normal 0.5 to
5.5 g / dl).

1. What are the drugs that can be used in this patient?

• L–thyroxine sodium and tri-idothyronine can be used for replacement of
thyroid.

2. How will you manage a patient with Myxoedema coma?

• It is an Emergency. Drug of choice is thyroxine (T4) 200 – 500 g
i.v. followed by 100 g i.v od, till oral therapy can be instituted.
• Hydrocortisone to cover adrenal insufficiency
• Ventilatory and cardiovascular support
• Correction of hyponatremia, hypoglycemia etc. are the other
measures.

3. Name the drugs which cause hypothyroidism.

• Lithium, Amiodarone, Sulfonamides, Para Amino Salicylic Acid, Iodides.

4. What are the advantages and disadvantages of radioactive iodine?

• Adv: Simple, Inexpensive, and can be given as outpatient basis.
• Once hyperthyroidism is controlled, cure is permanent.
• No surgical risk, Scar or injury to parathyroid glands.
• Disadvantage: Hypothyroidism and long latent period of response.
 [Link].9.
A 40 year old lady diagnosed to be having ovarian tumor was treated
with Cisplatin, Paclitaxel & Doxorubicin. She develops severe nausea
and vomiting after administration of chemotherapy.

1. What is the drug of choice for chemotherapy and radiotherapy induced

vomiting?
• 5-HT3 antagonists: Ondensetron, Granisetron, Palonosetron
• Corticosteroids are given as an adjuvant drug.

2. What are the types of drugs used for motion sickness? Give one example.
• Anticholinergic drugs - Hyoscine
• Antihistaminics drugs - Cinnarazine.

3. What are the drugs that can be given for morning sickness?
• Doxylamine with Pyridoxine.
• Promethazine.

4. What is the mechanism of action of Domperidone?

• It blocks the D2 receptor at Chemoreceptor Trigger Zone and Nucleus
Tractus Solitarius.
Ex No:10.

A patient aged 70 yrs developed septicaemia in the post operative period.

Blood culture showed growth of Pseudomonas. The patient was given
gentamycin and crystalline Penicillin, intravenously in a single injection
once a day. The patient’s condition detoriated fast.

1. Explain why there is no improvement.

When Gentamicin & penicillin are mixed, penicillin will inactivate Gentamicin.
This a the case of pharmaceutical incompatibility. They should be given as
separate injection.

2. Suggest suitable regimen for this patient.

As penicillin is effective only against gram positive bacteria, it is not suitable
for pseudomonas infection, instead a broad spectrum penicillin like
Carbenicillin may be included in the regimen.

3. Name two other anti pseudomonal drugs?

nd rd
Monobactams, Carbapenams & 2 & 3 generation Cephalophorins,
Quinolones & Aminoglycosides, Penicillin: Carbenicillin, Ticarcillin,
Piperacillin.

4. What are the other two drugs not given in same syringe? Why?
Thiopentone Sodium with Succinylcholine/ Morphine
Heparin with Penicillin/ Gentamicin/Hydrocortisone
Noradrenaline with Sodium Bicarbonate.
Ex No:11
A 58 year old male Patient with lepromatous leprosy who was treated with
Multi Drug Therapy (Dapsone, Rifampicin & Clofazimine) presented
with erythematous subcutaneous nodules, fever, myalgia and arthralgia.

1. What is the diagnosis & management?

• Lepra reaction
• Thalidomide, Clofazimine.

2. Name the anti leprosy drug which causes reddish brown

discolouration of the skin ?
• Clofazimine.

3. What is the mechanism of action of the same drug?

• Interference with DNA,

4. Name the antibiotics which are active against Mycobacterium leprae.

• Ofloxacin, Minocycline.
 [Link].12.
A 40 year old lady presented with the complaints of maculopapular
rings of erythematous lesion with central clearing and
hyperpigmentation in the loin.

1. What is the probable diagnosis? Name the topical antifungal agents that
can be used in this case.
• Tinea corporis
• Miconazole, Terbinafine, Clotrimazole, Ketoconazole, Ciclopirox
Olamine, Tolnaftate, Butenafine.

2. What is the mechanism of action of triazoles?

• They inhibit fungal CYP 450 enzyme-lanosterol 14 des methylase and
thus impair ergosterol synthesis causing fungal death.

3. Mention some systemic antifungal agents.

• Ketoconazole, Fluconazole, Voriconazole and Itraconazole.

4. Mention some polyene antibiotics.

• Amphotericin B, Nystatin, Natamycin, Hamycin.