CLINICAL PROBLEMS

 

1. A 50 yr old smoker with COPD takes Salbutamol, Ipratropium & theophylline. He presents to his doctor with an infective exacerbation of his bronchitis. As he is allergic to penicillin, the doctor starts him on erythromycin. What is the potential risk?

            Erythromycin is a CYT P450 enzyme inhibitor. So the levels of theophylline is likely to increase since it is metabolized by this enzyme. Theophylline has a narrow therapeutic index, so adverse effects like: dyspepsia, headache, nervousness, insomnia may occur. Therefore if erythromycin has to be started, theophylline should be stopped.

 

2. A 19 yr old man has gastroenteritis and is given metaclopramide. He develops acute involuntary spasm of neck muscles 2 days later, which is very painful.

1. What is the most likely diagnosis?

Torticollis: Extra pyramidal symptom.

2. What is the DOC in the management?

Stop metaclopramide & start pt. on benzhexol (Trihexyphenidyl) 2mg 4^th hourly. Continue for next 2-3 days. Inj Promethazine i.m; benztropin tab or inj.

 

3. A lady aged 25 yrs who was having periodic attacks of wheezing which were controlled by salbutamol inhalation. After her marriage, when she was full term pregnant labour pain failed to appear one weak after EDD. Her obstetrician induced labor with PGF_2a infusion. The pt developed severe bronchospasm with abdominal colic.

1. What is the cause of bronchospasm and abdominal colic?

Smooth muscle contraction due to PGF_2a.

2. Which alternative drug would have been used to induce labor?

Ø      Oxytocin: 10 IU/10ml dextrose 10 drop/ min i.v. infusion.

Ø      PGE₂ is a bronchodilator. It can be used.

3. What is the other use for PGF_2a?

DOC for postpartum hemorrhage when methyl ergometrin has failed. Also used in MTP.

 

4. In epiletic pt, who was on phenytoin therapy went to doctor complaining of dyspepsia. The physician who had kept him abreast with recent trends prescribed him cimetidine 200mg TID with meals, 400mg at night for 7 days. Renal and liver functions were normal. The pt. continued cimetidine with usual dose of phenytoin. Sometime later he developed nystagmusm, ataxia. The physican adviced him to stop cimetidine, following which these symptoms disappeared.

1. Which type of epilepsy did the pt. suffer from?

Grand mal epilepsy.

2. Why did phenytoin therapy produce toxic symptoms after introduction of cimetidine?

Cimetidine is a CYT P450 inhibitor Þ phenytoin levels increased since it is metabolized by this enzyme.

3. Which is a better alternative drug for acid peptic disease in these conditions?

Ranitidine or Famotidine; 150mg BD or 250 mg at night.

4. Mention 2 A/E produced in chronic administration of phenytoin.

Gingival hyperplasia, megaloblastic anemia, osteomalacia.

 

5. A woman takes cotrimoxazole for UTI. On the third day she feels unwell and shivers and complains of joint pain. In the hospital she is found to have a temparature of 38°C and lymph node enlargement. A diagnosis of bacteremia is made and cotrimoxazole is continued. On 4^th day she is very ill and developes generalized rashes plus ulceration of buccal mucosa.

1. What alternative diagnosis should have been considered?

An alternative diagnosis of A/E of cotrimoxazole; Steven- Johnson syndrome should have been considered.

2. What is the line of treatment?

Stop cotrimoxazole, give anti-histaminic: Diphenhydramine. Systemic corticosteroid: Prednisolone moderate to high dose, with or without immunosuppressants.

For oral lesions: Chlorexidine mouth wash, irrigation with hydrogen peroxide & water (1:1) TDS; for pain relief: lignocaine gel.

Adequate soft diet. Specimen should be sent for culture and sensitivity report and pt should be managed accordingly.

 

6. A male pt. aged 58 yr is admitted to hospital due to acute MI. On admission of streptokinase i.v. he shows evidence of bleeding.

1. How do you control this bleeding?

e-amino caproic acid: 5gm loading dose followed by 1gm/Hr. Max 30 gm/day; i.v. or orally.

2. Mention 2 drugs that act as streptokinase?

Urokinase, alteplase, Reteplase

 

7. A 45 yr old man who had a MI is found to have a moderately elevated serum cholesterol (6.5 mmol or 250 mg%)

1. Is this a cause of concern?

Yes. [The normal serum cholesterol level are: Total cholesterol: <200 mg%; LDL: <130 mg%. Abnormal level: Total: >240 mg%; LDL: >160 mg%]. IHD increases with risk factors like smoking, alcohol, HTN and DM.

2. His TG levels are normal & LDL is high. He is given low cholesterol diet. But the serum cholesterol does not improve over 3 months. What treatment should be considered now?

Drug therapy is given for:

1. People in whom dietary measures are not successful
2. People who find dietary restriction troublesome
3. People who have risk of pancreatitis.

The pt. has to agree to take the drug therapy lifelong. Drugs give only symptomatic relief but do not cure the disorder. However drugs can retard the atheroscerotic process and prolong life. Dietary therapy is better than drugs.

3. Should HMG COA reductase inhibitor be first choice of treatment of hypercholesterolemia?

Since TG are normal, statins are the DOC. [ if TG level was 200-400 mg% nicotinic acid would have been the first choice; If TG level > 400 mg% fibrates would be DOC].

4. Will lowering the serum cholesterol reduce the risk of further ischemic heart disease?

Yes.

5. Should all pt with cholesterol level 6.5 nmol/l receive drug therapy?

If cholesterol the risk further increases with factors like: smoking, HTN, DM & fatty diet. Therefore the pt should be investigated for uncontrolled DM, hypothyroidism, alcoholism, CRF. Weight reduction, appropriate diet modification, abstinence from alcohol & specific therapy of causative disease. These are much more important than lipid lowering drugs.

 

8. A 60 yr old man who smokes & has a h/o COPD is diagnosed of having angina on exertion.

1. What drug therapy might he be given?

For prophylaxis: Nitroglycerine skin ointment (½ - 2 inch) should be applied. Nitroglycerine aerosol (0.4 mg metered dose). Sublingual Nitroglycerine (0.3- 0.6 ng). Onset of action is within 1-3 min & duration of action is for 15-40 min.

2. What is nitrate tolerance and how can it be avoided?

Tolerance to anti-anginal action of nitrates develops when the pt. is exposed to nitrates throughout 24 hrs. It is common with long acting nitrate preparations. This can be avoided by omitting the night dose of long acting preparations. However during such nitrate free intervals the pt needs to be covered by other anti anginal drugs.

3. He uses nebulised high dose salbutamol for his COPD but notices that this tends to bring an attack of angina. What is it due to?

Inappropriate administration of repeated doses od potent sympathomemetics can induce lethal cardiac arrhythmias.

 

9. A 65 yr old man presents a history of severe central chest pain for 2 hrs & typical ECG changes of an acute inferior MI.

1. What drugs should be given?
2. The pt subsequently has an uncomplicating course, what drug therapy would be appropriate for him to continue taking at home after discharge?
3.