PROBLEM SOLVING EXERCISES
1. A 25 year old male diagnosed as a case of schizophrenia was treated with tablet
Haloperidol 5mg once daily at bed time. His dose was gradually increased and was
maintained with 10mg daily. After 3 months his family members reported that his
restlessness has reappeared, he keeps pacing around in the room but is not
aggressive or combative? On questioning the patient admitted that he has an
uncontrollable urge to move around and he feels uncomfortable in remaining still.
He has difficulty in falling asleep.
a) What could be the reason for the motor restlessness?
b) Should any other drug be given to treat the condition?
c) What is the mechanism of action of typical Neuroleptics?
d) Name some non- psychiatric therapeutic uses of typical antipsychotics?
ANSWERS:
a. The most likely cause is appearance of a common extra pyramidal side effect of
the antipsychotic drug – Akathisia.
b. One of the atypical antipsychotic drugs can be given for this patient instead of
Haloperidol. (Atypical antipsychotics have a low propensity to cause extra
pyramidal adverse effects) Quetiapine with its sleep promoting effect will be more
suitable for this patient.
c. Potent dopamine D2 receptor blocking action. Blockade of dopaminergic
projections to the temporal and prefrontal areas constituting the ‘limbic system’
and in mesocortical areas is probably responsible for the antipsychotic action.
d. Treatment of Anxiety
As antiemetic
To potentiate hypnotics, analgesics and anaesthetics
Intractable hiccough
Tetanus
Alcoholic hallucinosis and Huntington’s disease
2. A 60 year old, known ischemic heart disease patient on a drug combination of
Aspirin and Clopidogrel underwent tooth extraction .The patient did not reveal to
the Dentist that he is on drug therapy for I.H.D. After extraction the patient
developed profuse bleeding from the socket.
a) What is the reason? How could it be avoided?
b) What is low dose Aspirin?
c) What are the contraindications for aspirin use?
d) What is Reye’s syndrome?
ANSWERS:
a. Drug induced prolongation of bleeding time. Aspirin and Clopidogrel should be
withheld at least 5 to 7 days before any surgical procedure (Aspirin acetylates and
inhibits the enzymes COX1 and TXA synthase irreversibly. Since platelets have no
nuclei they cannot synthesize these enzymes. So TXA2 formation is suppressed till
fresh platelets are formed)
b. Low dose Aspirin – 75 to 150 mg/ day or 300 mg twice weekly.
c. Hypersensitivity individual, peptic ulcer, bleeding tendencies, chronic liver
disease, children suffering from chicken pox or influenza
d. A rare form of hepatic encephalopathy seen in children having viral (varicella,
influenza) infection treated with aspirin
3. A 40 year old man has been on primary therapy for active pulmonary
tuberculosis for the past two months. At his regular clinical visit, he c/o ‘pins and
needles’ sensation in his feet.
a) What could be the probable reason?
b) How will you manage this patient?
c) What are indications for chemoprophylaxis of TB?
d) Which ATT drug is used for chemoprophylaxis? What is the dose?
ANSWERS:
a. INH induced peripheral neuropathy.
b. Treatment for INH induced neurotoxicity -Pyridoxine 100 mg/day.
c. (i) Contacts of open TB case who show recent Mantoux conversion
(ii) Children with a sputum positive TB patient in the family
(iii) Neonate of tubercular mother
(iv) Patients of leukaemia, diabetes, silicosis or those receiving
immunosuppressant medication or those on long term corticosteroid therapy
d. Isoniazid 300 mg (10 mg/kg in children) daily for 6 months
4. A 10 year old boy was brought to the OPD with c/o itching between fingers and
all over his body, which was more during the nights. His family members also
have the same problem.
a) What is the diagnosis?
b) Select an appropriate drug.
c) Give instructions on how it should be used?
d) Which is the only drug effective orally for this condition?
ANSWERS:
a. Scabies
b. Permethrin 5% cream or Gamma benzene hexachloride 1% lotion
c. The cream or lotion should be applied all over the body except head and face
and should be washed after 8 to 12 hours. All the family members should be
treated concurrently. Garments and bed linen should be washed in hot water and
put in sunlight to prevent cross infection and reinfection
d. Ivermectin
5. A 25 year old female comes to the OPD with severe pallor. Her hemoglobin
level is 7gm/dl. Peripheral smear show microcytic hypochromic blood picture. She
is intolerant to oral drug therapy.
a) What is the diagnosis?
b) What are the parenteral preparations available for the treatment of the above
patient?
c) What is ‘Z’ technique?
d) What are the other indications for parenteral therapy?
ANSWERS:
a. Iron deficiency anaemia
b. For I.M route of administration – Iron dextran and Iron citric acid sorbitol
For I.V route- Iron dextran, Ferrous - sucrose, Ferric carboxymaltose
c. Intramuscular injection of Iron causes discoloration of the injection site. To
prevent this skin is pulled to one side and then needle is inserted deep
intramuscularly. The stretched skin is released after withdrawal of the needle.
d. (i) Oral iron is not tolerated: bowel upset is too much
(ii) Failure to absorb oral iron: malabsorption, inflammatory bowel disease
(iii) Non-compliance to oral iron
(iv) Along with erythropoietin in chronic kidney disease patients
6. Mrs. Kala a 65 years old female a known case of atherosclerotic angina came
with complaint of severe muscle pain. One month before she was prescribed statin
along with other antianginal drugs. On examination she had muscle tenderness &
her CPK levels were raised.
a) What is the diagnosis?
b) What is the reason?
c) Comment on statin + gemfibrzil combination.
d) What are the indications for statin therapy?
ANSWERS:
a. Statin induced myopathy
b. By inhibiting cholesterol synthesis, statins probably alter muscle composition
and their electrical properties. Genetic variation in an anion transporter
(OATP1B1) is associated with severe myopathy.
c. Gemfibrozil inhibits the hepatic uptake of statins by the organic anion
transporter OATP2 and should not be given with them. Myopathy and liver injury
is more common with this combination.
d. (i) Clinical atherosclerotic cardiovascular disease
(ii) Primary hypercholesterolemia
(iii) Diabetes aged 40 -75 yr with LDL-CH 70 – 189 mg/dL and no Clinical
atherosclerotic cardiovascular disease