PROBLEM SOLVING CHARTS (10 Marks)

1. A 45 year old male patient was posted for surgery under general anaesthesia. During surgery after the
injection of Succinylcholine to provide muscle relaxation during an operation, the patient developed prolonged
apnoea.
Question:
1) What do you think the probable reason is?
2) Would you like to give Neostigmine as antidote?
3) What is the line of treatment?
4) Name 4 drugs which potentiate neuromuscular blockers.
5) Name the drug given for d-tubocurarine overdose.
Answer no: 1

1. Succinylcholine is rapidly hydrolysed by plasma pseudocholinesterase. In patients with abnormal or deficient

pseudocholinesterase, succinylcholine causes muscle paralysis and prolonged apnea.

2. Neostigmine is not effective against succinylcholine as it produces neuromuscular blockade by depolarization

and depolarization will be enhanced by neostigmine.

3. Infusion of fresh frozen plasma is the treatment as it contains pseudo cholinesterase. Mechanical ventilatory
support is the mainstay of treatment until muscle paralysis resolves.

4. Ketamine, streptomycin, verapamil and diuretics potentiate neuromuscular blockers.

5. Neostigmine is given for d-tubocurarine overdose.

 PROBLEM SOLVING CHARTS (10 Marks)

2. Mr. X suffering from schizophrenia was given T. Chlorpromazine 100mg. 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?

2) Mention the drugs which can induce Parkinsonism.

3) Is Levodopa indicated to this patient?

4) Outline the management & the rationale for the drug chosen?

5) Mention anti-histamines that can be used in this condition.

Answer no.2

1. Symptoms are suggestive of drug induced parkinsonism as Mr. X has developed extrapyramidal motor side
effects due to D2 receptor blocking property of chlorpromazine.

2. Metoclopramide, fluphenazine, prochlorperazine, haloperidol, chlorpromazine can induce parkinsonism.

3. Levodopa is not indicated to this patient (schizophrenia) as it is not effective since D2 receptors are blocked.

4. An atypical antipsychotic should be used in this case as parkinsonian symptoms are less. Centrally acting
anticholinergics are the only drugs effective in drug induced parkinsonism. They act by reducing the unbalanced
cholinergic activity in the striatum of parkinsonian patients.

5. Orphenadrine and promethazine are the antihistamines used in this condition.

 PROBLEM SOLVING CHARTS (10 Marks)

3. 23 year old woman suffering from bronchial asthma was using Tab. Salbutamol ( 2 mg) tds for 30 days. She
came for review and complains of tremor and palpitation.

1. What is the mechanism of action of salbutamol.

2. What are all the various routes of administration for salbutamol ?

3. Name the longest acting ß2 agonist.

4. Mention the Adverse effects of salbutamol .

5. What are the drugs used as prophylaxis in seasonal bronchial asthma.

6. Name the other uses of Mast cell stabilizers.

Answer no.3

1. Stimulation of ß2 receptors activates Gs adenylyl cyclase-cyclic AMP pathway with a consequent reduction in
smooth muscle tone of the airway and also increases the opening of potassium channels causing relaxation of
the airway

2. Inhalational, intravenous and oral.

3. Salmeterol and formoterol.

4. Muscle tremors, palpitation, nervousness, restlessness, throat irritation and ankle edema.

5. Low dose inhaled steroid or cromoglycate, 3 to 4 weeks before seasonal attacks. Beclomethasone,
budesonide and fluticasone are inhalational steroids.

6. Other uses are for allergic rhinitis and allergic conjunctivitis.

 PROBLEM SOLVING CHARTS (10 Marks)

4. A 72 year old male with history of Parkinsons disease and benign prostatic hyperplasia (BPH) has recently
been prescribed Trihexyphenidyl 2 mg twice daily for parkinson’s tremors , he presents to the emergency
department with sudden onset confusion , blurring of vision, dry mouth and difficulty urinating.

1) What could be the cause for these symptoms?

2) How could you have avoided this problem?

3) Mention 4 other drugs used in BPH?

4) Mention 4 other centrally acing anticholinergics?

Answer No: 4

1) Trihexyphenidyl is a centrally acting anticholinergic drug and hence causes dry mouth, blurring of
vision, constipation and urinary hesitancy.

2) We can use dopaminergic drugs instead of centrally acting anticholinergics.

3) Alpha 1 adrenergic blockers – Tamsulosin

5 alpha reductase inhibitors – Finasteride

Phosphodiesterase 5 inhibitors (PDE5) – Tadalafil

Beta 3 agonists – Mirabegron

4) Procyclidine, Biperidine, Benztropine,Orphenadrine.

 PROBLEM SOLVING CHARTS (10 Marks)

5. Mr. Suresh, 44 yr old male was on tablet warfarin 5 mg for DVT Prophylaxis. One day he developed severe
chest pain. He was diagnosed with acute MI, underwent appropriate treatment and was discharged. He was
advised to take following medicines as combination therapy.

[Link] 75mg OD( after food)

[Link] 25mg OD( after food)

[Link] 150mg BD

[Link] mononitrate 5mg OD

[Link] E 400mg OD

In addition to these drugs, he had to continue warfarin. After few days he developed haematuria.

1) What is the reason for haematuria?

2) Name 2 drugs which produce similar effects.
3) What is the mechanism of action of warfarin?
4) What are the uses of anti coagulants.?

Answer No: 5

1) Aspirin produces hypoprothrombinemia & displaces warfarin from plasma protein binding. Excess
warfarin leads to extension of pharmacological actions which leads to bleeding hematuria.
2) Cefaperazone, cefomandole, erythromycin, celecoxib, cimetidine, metronidazole

3) Warfarin inhibits synthesis of vitamin K dependent clotting factors. ( II, VII, IX, X)
4) DVT, pulmonary embolism, MI, unstable angina, rheumatic heart disease, prosthetic heart valves, atrial
fibrillation.
 PROBLEM SOLVING CHARTS (10 Marks)

6. A 30 yr old sales manager was on treatment for intestinal amoebiasis. On treatment he attended a party and
consumed wine. Suddenly he developed nausea, vomiting, giddiness, sweating, chest pain, head ache and
flushing. ECG was normal; BP- 100/70mm Hg.

1) What is the reaction called?

2) What could have been the cause?
3) Name other drugs producing similar effects.
4) Name drugs used in aversion technique of chronic alcoholism.

Answer No:6

1) Disulfiram reaction/ aldehyde syndrome.

Disulfiram inhibits aldehyde dehydrogenase.
When alcohol is ingested concurrently, concentration of acetaldehyde increases in tissue & blood which
causes the symptoms of nausea, vomiting, giddiness, visual disturbance, mental confusion &circulatory
collapse.

2) Metronidazole interacts with alcohol & produces disulfiram like reaction

3) Cefoperazone, Procarbazine, Cefomandole, Cefotetan, Moxalactam, Chlorpropamide.
4) Diazepam, Naltrexone, Acamprostate, Ondansetron, Topiramate.
 PROBLEM SOLVING CHARTS (10 Marks)

7. A 56 year old hypertensive patient on [Link] 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.

1. How does nitroglycerine relieve chest pain?

2. Mention four adverse effects of nitrates.
3. Can you add Diltiazem or Verapamil to this patient? Justify.
4. What are the other drugs prescribed for chronic angina?
5. Mention two drugs used in patients with refractory angina to standard anti anginal therapy.

Answer:
1. It counteracts coronary spasm by its relaxant effect on larger coronary vessels, reduces cardiac work by its
action on peripheral vasculature.
[Link] headache, flushing and sweating, lightheadedness.

3. Diltiazem or verapamil should not be given with Tab. Atenolol (ß- blocker) as it causes additive sinus
depression, conduction defects or asystole may occur.

4. Nicorandil, ivabradine, ranolazine and trimetazidine are prescribed for chronic angina.

5. Nicorandil and trimetazidine are given for refractory angina. Aspirin, clopidogrel and statins are given to
prevent future attacks.
 PROBLEM SOLVING CHARTS (10 Marks)

8. Miss Priya , 20 yr old female complained of cough with expectoration and breathlessness. She was prescribed
a cough mixture which contains cough suppressant. After taking the syrup she developed severe breathlessness.

1) What is the cause for worsening of this condition?

2) How will you treat this patient?

3) What is the role of bronchodilators in cough?

4) Name two ß 2 agonists & two anti cholinergics used in asthma.

Answer 8

1) Codeine & chlorpheneramine both are anti tussives ( cough suppressants)

Cough suppressant codeine should not be given for cough with expectoration & in patients with
breathlessness.
Chlorpheniramine- dried up the secretions
Effect of both drugs has worsened the condition
2) Administration of mucolytics like bromhexiene along with a bronchodilator

3) Bronchospasm can induce or aggravate cough. Bronchodilators will clear the secretions by increasing
surface velocity of wind flow during cough & thus relieve cough.

4) ß 2 agonists- salbutamol, terbutaline,

Anti cholinergics – Ipratropium bromide,

Tiotropiumbromide.
 PROBLEM SOLVING CHARTS (10 Marks)

9. A hypertensive patient with congestive cardiac failure was given a diuretic Hydrochlorothiazide (HCTZ).
After few weeks he developed pain and swelling of the great toes. On investigation it was found that his serum
uric acid was 8.0 mg/dl.

1) What is the reason for this symptom?

2) Name 3 other drugs which may cause this condition?
3) What is the rationale of prescribing Allopurinol on this condition?
4) Name the newer non purine xanthine oxidase inhibitor used in this condition?

Answer No: 9

1) Hydrochlorothiazide induced hyper uricemia , Drug induced Gout

2) Furosemide, Pyrazinamide, Ethambutol
3) Allopurinol inhibits Xanthine oxidase enzyme which is responsible for uric acid synthesis , thereby
reduces the symptoms
4) Febuxostat
 PROBLEM SOLVING CHARTS (10 Marks)

10. Mr. Rajesh , 45 yr old male , a known peptic ulcer patient one day developed severe headache. He went to a
medical shop and asked for medicine to relieve his headache. The pharmacist gave him a tablet and his
headache resolved, but he developed severe epigastric pain & vomiting which was blood stained.

1) What could be the reason for haematemesis?

2) What is the role of Prostaglandins in peptic ulcer?
3) Name the PG analogue used in peptic ulcer.
4) Write 2 other uses of prostaglandins.

Answer No: 10

1) The prescribed tablet should have been an NSAID. This induces bleeding of ulcer due to inhibition of
COX -1 mediated synthesis of gastro protective prostaglandins.
2) PGs are gastroprotective because they
Increase bicarbonate secretion
Increase mucous production
Increase mucosal blood flow
3) Misoprostol, Enprostil
4) To maintain patency of ductus arteriosus

Induction, augmentation of labour, cervical priming

Post partum haemorrhage – 15 methyl PGF2α

Glaucoma- PGF2α analog- Latanoprost.

 PROBLEM SOLVING CHARTS (10 Marks)

11. A 58 year old woman was being treated for chronic suppression of ventricular arrythmias. After 2 months of
therapy she complains of feeling tired all the time. Examination reveals resting heart rate 10 beats per minute
lower than the previous rate. Her skin is cold and clammy. Lab test showed low thyroxine and elevated TSH

1. Which anti arrythmic drug is the cause of the symptoms and how?

2. What are the other drugs used in ventricular arrythmias?

3. What is torsades de pointes?

4. Mention the drugs which precipitate Torsades De Pointes.

5. Mention the drugs used in paroxysmal supraventricular tachycardia.

Answer 11:

1. Which anti arrythmic drug is the cause of the symptoms and how?
Amiodarone is the cause of above symptoms. It blocks peripheral conversion of T4 to T3 and so this leads to
hypothyroidism and its related symptoms.

2. What are the other drugs used in ventricular arrythmias?

Propranolol, Sotalol, Esmolol, Lidocaine, Procainamide and Disopyramide

3. What is Torsades de pointes?

It is a life threatening form of polymorphic ventricular tachycardia associated with long Q-T interval. Torsades
de pointes- twisting of points.

4. Mention the drugs which precipitate Torsades de pointes.

Quinidine, Quinine, Moxifloxacin, Terfenadine, Amitriptyline, Thioridazine and Cisapride.

5. Mention the drugs used in paroxysmal supraventricular tachycardia.

Adenosine, Verapamil, Diltiazem, Esmolol, Propranolol and Sotalol are the drugs given for PSVT.
 PROBLEM SOLVING CHARTS (10 Marks)

12. An intern was performing a suturing in casualty. While suturing the needle penetrates his glove and skin to a
depth of 3mm. He withdrew the needle immediately and washed with running water. On enquiry the patient was
found to be HIV +ve, but not taken any treatment.

1) Should the intern take post exposure prophylaxis?

2) How will you give perinatal HIV prophylaxis?
3) What is HAART?
4) What are the anti retroviral combinations to be avoided.?

Answer No:12

1) Yes the intern should be considered for post exposure prophylaxis.

2) HIV positive women who are not on ART should be started with standard 3 drug.
(Zidovudine+Lamivudine+Nevirapine).This should be continued during delivery and into postnatal
period.

3) HAART is ‘highly active anti retroviral therapy’ where combination of 3 or more drugs are used
whenever indicated.

4) Zidovudine + stavudine

Lamivudine + didanosine

Stavudine + didanosine.
 PROBLEM SOLVING CHARTS (10 Marks)

13. A 65 year old female was on treatment for post menopausal osteoporosis with [Link]. she
developed heart burn, abdominal pain, nausea & vomiting.

1) What were the symptoms due to?

2) How will you avoid the problem?
3) What is the role of Vit.D in osteoporosis?
4) What is Teriparatide? Where it is used?

Answer No:13

1) The symptoms were due to esophageal erosion caused by Alendronate.

2) Advise the patient to take the drug on empty stomach in the morning with full glass of water and instruct
her not to lie down or take food for at least 30 min.

3) Vitamin D + calcium have adjuvant role to BPNs/HRT/raloxifene both in prevention and treatment of
osteoporosis.

4) Teriparatide is recombinant human PTH introduced for treatment of osteoporosis.

In addition it is used to differentiate pseudo from true hypoparathyroidism.
 PROBLEM SOLVING CHARTS (10 Marks)

14. [Link], a 45 yr old female had history of 2 episodes of tonic clonic seizures. Patient is not a known
epileptic. MRI revealed cysticercosis.

1) Which anti helmintic is indicated?

2) What are the contra indications?
3) What other drugs should be combined?
4) Which anti helmintic is safe in pregnancy?

Answer No:14

1) Albendazole is the anti helmintic of choice for the treatment of neurocysticercosis.

2) Pregnant women, hepatic and renal disease.
3) Corticosteroids (Prednisolone or dexamethasone)
Must be started 2 days before & continued till 2 weeks after completing anti helmintic course.
Anticonvulsants ( phenytoin, carbamazepine)
4) Niclosamide.
 PROBLEM SOLVING CHARTS (10 Marks)

15. [Link] a known diabetic was on treatment for diabetes mellitus with [Link] 5mg od. He
developed UTI and a nearby physician prescribed [Link] took the drug and suddenly developed
giddiness, behavioural changes, confusion,fatigue, palpitation.

1) What were the symptoms due to?

2) What are the advantages of metformin?
3) Name 2 DPP4 inhibitor?
4) What is Acarbose? How it should be taken?

Answer No:15

1) The symptoms are probably due to hypoglycaemia.

Cotrimoxazole displaces SU from protein binding and further inhibits metabolism/excretion.

2) Non hypoglycaemic, promotes weight loss, prevent micro and macrovascular complications, no
acceleration of ß cell failure.

3) Sitagliptin , Vildagliptin

4) α glucosidase inhibitor should be taken at the beginning of each major meal.