CCR-I

Criticize, correct and rewrite the following prescription for an adult suffering from
acute attack of malaria.

For Mr.X 24years Date:

Rx
1. Tab. Chloroquine phosphate 0.5g (9)
One tablet to be taken 3 times a day for 3 days.
2. Tab. Pyrimethamine 50mg
One tablet daily for 10days.
3. Tab. Proguanil 100mg
One tablet daily for 10days.
4. Tab. Paracetamol 30mg
One tablet 3 times daily.
5. Tab. Primaquine 60mg
One tablet daily for 14 days.

Criticism :
In acute attack of malaria, chloroquine phosphate tablet 250mg (150mg
of base) is used in doses of 1gm followed by 0.5gm after 6hrs and 0.5gm daily
thereafter for 2 days.
Pyrimethamine and proguanil are given for causal prophylaxis not
for acute attacks. Pyrimethamine given as 25mg tab. When given alone it is not the
drug of choice for acute attacks.
Paracetamol dose is too low. It should be 500mg tab 3 times daily for
an adult. It is an antipyretic agent and has no antimalarial action.
Primaquine is given for radical cure for vivax malaria and the dose is
15mg daily for 14 days.

Correct prescription:

For Mr.X 25years Date:

Rx
Tab chloroquine phosphate 250 mg : 1gm (4 tabs) initially followed by 0.5gm
after 6 hrs and 0.5gm daily for the next 2 days given orally.
OR
Tab Amodiaquine (base) 600mg followed by 200mg (base) on day one ; 400mg
once a day on days two and three given orally.
 CCR-II

Criticize, correct and rewrite the following prescription for an adult female aged
about 50years suffering from moderate rheumatoid arthritis.

For Mr.X age : 50years Date:

Rx
1. Tab. Diclofenac sodium 50mg OD for 1 month.
2. Tab. Methotrexate 10mg OD daily for 1 month.

Criticism :
Rheumatoid arthritis is a chronic systemic inflammatory disease
predominantly affecting joints and synovial tissues. It is characterized by joint pain,
swelling, stiffness and deformity. So, the primary objectives are relieving the pain,
preserving the joint function and prevention of joint deformities.

Diclofenac sodium which is an NSAID given at bed time relieves the pain and
morning stiffness. It does not affect the disease process.

To reduce the disease progression and achieve remission, DMARDS are drug
of choice. Commonly used DMARD is methotrexate 7.5mg orally, once a week.

The toxicity of Methotrexate can be prevented by giving tab folic acid 1mg
OD for 1 month.

Correct prescription :

For Mr.X age : 50years Date:

Rx
1. Tab. Diclofenac sodium 50mg BD for 1 month.
2. Tab. Methotrexate 7.5mg once a week for 4-8 weeks.
3. Tab Folate 5mg OD for 4-8 weeks.
Review after 2 months.
 CCR-III

Criticize, correct and rewrite the following prescription for an adult suffering from
acute bacterial meningitis resistant to penicillin.

Name of patient: Mr.X age : 45yrs/M Date:

Rx
1. Inj. Benzyl penicillin G 4 million units IV every 4th hourly for 5-6 days.
2. Inj. Benzathine penicillin 1.2 million units IM once a day for a week.
3. Inj. Ampicillin 500mg IM 8th hourly for a week.
4. Inj. Chloramphenicol 4-6mg IV 6th hourly for a week.

Criticize :

The most common organisms for acute bacterial meningitis is streptococcal

pneumonia (50%) most common in age group >20yrs followed by Neisseria
meningitides (25%) most common 11-18 years, Group B streptococcus (15%) and
listeria monocytogenes (10%) most common in neonates.

When bacterial meningitis is suspected empirical therapy with 3 rd generation

cephalosporins and vancomycin should be started in immunocompetent persons
between the age group >3 months and adults <55 years. Depending upon culture
and sensitivity report specific antibacterial drugs may be started.

Inj. Benzathine penicillin is given prophylactically in rheumatic fever and

valvular heart disease in a dose of 0.6-1.2 million units IM once every 4 weeks.

Ampicillin is given as an empirical therapy in neonatal meningitis caused by

listeria meningitis as 3rd generation cephalosporins is ineffective in treatment of it.

Chloramphenicol was used as alternative in patients resistant to beta lactams,

but since many of the streptococcal strains are resistant to it, 3 rd generation
cephalosporins are used in treatment of it.

Correct prescription:

Rx
1. Inj. Ceftriaxone 2g IV BD for 7-10 days.
2. Inj. Vancomycin 1g IV BD for 10-14 days.
3. Inj. Paracetamol 300mg 6th hourly until fever subsides.
 CCR - IV
Criticize, correct and rewrite the following prescription for an adult suffering from
UTI due to E.coli.
For Mrs.X 35 yrs/F Date:

Rx
1. Tab. Cotrimoxazole: (80-400) 2 tabs at bedtime - 3 days
2. Inj .Gentamycin : one vial IM every 4hr (10mg vial)
3. Tab. Norfloxacin : 100mg
4. Na Bicarbonate : 1g orally 6th hourly in water

Criticism:
 UTI is more common in females than in males. E.coli is the predominant
organism causing UTI.

 Tab Co-trimoxazole is used as double strength tablet given twice daily for 3 days
and Tablet nitrofurantoin 100mg twice daily are used as a first line drugs in UTI.

 Gentamicin is available as 40mg/ vial in 2 ml and is not used as a first line

therapy in treatment of UTI. It is used as twice daily regimen.

 Tab .Norfloxacin is available as 400 mg tablet and is given twice daily. The main
reason for not using fluroquinolones in uncomplicated UTI is the propagation of
fluroquinolones resistance, not only among urinary pathogens but also among
other organisms causing more serious and difficult to treat infections at different
sites. Quinolones use in elderly is associated with increased Achilles tendon
rupture.

 Na Bicarbonate is not used in treatment of UTI.

Correct Prescription:

Rx
1. Tab.Co-trimaxazole, (sulphamethoxazole 800mg + trimethoprim 160mg)
tablet BD for 5 days
2. Sodium Bicarbonate 1gm 6th hourly in water
3. Plenty of fluid intake orally
 CCR V

CCR the prescription for a 10 year old child suffering from petitmal epilepsy (avg
wt-30kg)
Rx
1. Cap .Diphenyl hydantoin 0.1 gm (30 caps) 1 caps daily for 1 month orally
2. Tab. Sodium Valproate 0.2 gm (30 caps) 1 tab daily for 1 month orally
3. Cap .Ethosuximide 250 mg1 cap/day

Criticism:
Diphenyl hydantoin is drug of choice in grandmal epilepsy. Petitmal epilepsy is
unaffected by this drug.
Sodium valproate and Ethosuximide both are equally effective in petitmal epilepsy.
The dosage of both drugs is low in above prescription. In petitmal epilepsy either of
the two drugs is used, not both drugs.

Correct:
1. Tab. Sodium Valproate 300 mg OD starting dose
Review after 3 months
 CCR VI a
CCR the prescription for an adult of 60kg weight suffering from serious sputum
positive pulmonary tuberculosis.
Rx
1. Tab. INH 100mg 1tab Orally daily
2. Cap. Rifampicin 100mg 1cap Orally daily
3. Tab. Clofazimine 50mg 1tab Orally daily
4. Tab. Ethionamide 100mg 1tab Orally daily
5. Tab. Ethambutol 200mg 1tab Orally daily

Criticism:
This patient belongs to category I of DOTS regiment (Directly Observed Treatment
Short course). The total duration of the course is 6 months. Two months intensive
phase four months continuation phase.
In intensive phase 4 drugs are used i.e, INH, Rifampicin, Pyrazinamide, Ethambutol.
In continuation phase 2 drugs are used i.e, INH, Rifampicin. With these drugs
pyridoxine 10mg is used to prevent peripheral neuritis caused by INH. These drugs
are given thrice daily under supervision.
In above prescription INH dose is low it should be given 300mg. To prevent
peripheral neuritis caused by INH pyridoxine 10mg should by given.
Rifampicin dose is also low it should be 600mg and it is given before breakfast.
Clofazimine is a anti leprosy drug not given in Pulmonary TB.
Ethionamide causes severe Gastritis and Neurological symptoms. Not included in
DOTS regimen.
Ethambutol dose is low should be given 1200mg.
Tab. Pyrazinamide 1500mg should be given along with these drugs in category I
DOTS regimen.

Correct:
Intensive phase treatment (2 months)
Rx
1. Tab. INH 300mg Daily
2. Cap. Rifampicin 600mg Daily half an hour before breakfast
3. Tab. Ethambutol 25mg/kg Daily
4. Tab. Pyrazinamide 1500mg Daily
5. Tab. Pyridoxine 10mg Daily

Continuation phase treatment (4 months)

Rx
1. Tab. INH 300mg Daily
2. Cap. Rifampicin 600mg Daily half an hour before breakfast
3. Tab. Pyridoxine 10mg daily
 CCR VI b
CCR the prescription for an adult of 60kg wt suffering from sputum positive relapse
case of pulmonary tuberculosis
Rx
Tab. INH 100 mg 1tab orally daily
Cap. Rifampicin 100 mg 1caps orally daily
Tab. Clofazimine 50 mg 1tab orally daily
Tab. Ethionamide 100 mg 1tab orally daily
Tab. Ethambutol 200 mg 1tab orally daily
Criticism:
This patient belongs to category 2 of DOTS regimen (Directly Observed Treatment
Short course). The total duration of course is 8 months. Three months intensive
phase, five months continuation phase.
In intensive phase, 5 drugs i.e. INH, Rifampicin, Pyrazinamide, Ethambutol,
Streptomycin for 2 months and one more month only 4 drugs excluding
Streptomycin are used. In continuation phase, 3 drugs are used i.e. INH, Rifampicin,
Ethambutol. Along with these drugs, Pyridoxine 10mg is used to prevent peripheral
neuritis caused by INH. These drugs are given daily under supervision.
In above prescription, INH dose is low it should be given 300mg. to prevent
peripheral neuritis caused by INH, Pyridoxine 10mg should be given. Rifampicin
dose is also low it should be given 600mg and it is given before breakfast.
Clofazimine is an antileprotic drug not given in pulmonary TB.
Ethionamide causes severe GIT & neurological symptoms. Not included in DOTS
regimen. Ethambutol dose is low it should be given 1200mg. Tab. Pyrazinamide
1500mg & Inj. Streptomycin 750mg should be given in category 2 DOTS regimen.
Correct:
Intensive phase treatment (first 2 months):
Rx
Tab. INH 300mg daily
Cap. Rifampicin 600mg daily before breakfast
Tab. Ethambutol 25mg/kg daily
Tab. Pyrazinamide 1500mg daily
Inj. Streptomycin 750mg IM thrice weekly
Tab. Pyridoxine 10mg daily
Intensive phase treatment (3rd month):
Rx
Tab. INH 300mg daily
Cap. Rifampicin 600mg daily before breakfast
Tab. Ethambutol 25mg/kg daily
Tab. Pyrazinamide 1500mg daily
Inj. Streptomycin 750mg IM thrice weekly
Tab. Pyridoxine 10mg daily
Continuation phase treatment (6 months):
Rx
Tab. INH 300mg daily
Cap. Rifampicin 600mg daily before breakfast
Tab. Ethambutol 25mg/kg daily
Tab. Pyridoxine 10mg daily
C.C.R :7
Criticize correct and rewrite the following prescription for an adult suffering from
Typhoid fever.
For –Mr. X Age-30yrs Date:
Rx
1. Cap. Chloramphenicol - 500mg 1 O.D orally for 1 week.
2. Tab. Metronidazole - 100mg 1 O.D orally for 1 week.
3. Cap. Ampicillin - 100mg 1 O.D orally for 1 week.
4. Inj. Ceftriaxone 4g I.V daily for 2 days followed by 2g till 2 days after
fever subsides.
5. Tab. Ciprofloxacin -500mg 1 B.D orally for 14 days.

CRITICISM

1. Chloramphenicol was drug of choice , but now many salmonella

strains are resistant to it so we are not using it as 1st choice in
typhoid fever.

2. Metronidazole is effective mainly against anaerobic protozoa and

anaerobic gram +ve & gram – ve bacilli, used mainly in the
treatment of Amoebiasis, but not for typhoid fever, which is caused
by salmonella typhi, an aerobic gram -ve bacilli.

3. Ampicillin commonly used to treat typhoid carriers and typhoid

fever during pregnancy, it is not used commonly to treat typhoid
because many salmonella are resistant and high recurrence
rate(10%). The dose of ampicillin to treat typhoid is 500mg q.i.d for
10-14 days.

4. Ceftriaxone (3rd generation cephalosporin) dose is 1 to 2g IM/IV

for 10 days to treat MDR Typhoid fever. The dose of Ceftriaxone
given in the above prescription is used to treat severe typhoid
fever.

5. Tab. Ciprofloxacin (fluroquinolones) is the first line drug to treat

typhoid fever, compared to Ceftriaxone, typhoid fever recurrence
rate with Ciprofloxacin is less (1.5%) and its merits being its oral
dosage form, convenient dosage schedule and a reasonable safety
profile. So Ciprofloxacin is preferable than Ceftriaxone in the
treatment of typhoid fever.
 CORRECT PRESCRIPTION

For –Mr X Age: 30 Yrs Date:

RX
1. Tab. Ciprofloxacin 500mg bd orally for 10-14 days.
2. TAB. PARACETOMOL 500mg qid for 5 days or till fever subsides.

Review after 1 week.

 CCR: 8
Criticize, correct and rewrite the following prescription for an adult suffering from
peptic ulcer.
Name- Mr. X Age-30yrs Sex-
Rx
1. Tab. Sodium bicarbonate - 500mg QID orally.
2. Tab. Aluminium hydroxide - 500mg orally every 3rd hourly.
3. Tab. Propanthalene -100 mg O.D orally .
4. Tab. Ranitidine - 150mg B.D orally.
5. Tab. Omeprazole -20mg OD orally half an hour before food.

CRITICISM

 Peptic ulcer is treated by locally acting antacid and the drugs which
reduce the gastric acid secretion. Sodium bicarbonate is a systemic
antacid & produce metabolic alkalosis, so not used in peptic ulcer.
 Antacids tablets are less efficacious than the liquid formulations, so
Aluminium hydroxide gel is preferable.
 Until the advent of H2 blockers and PPI’s, antimuscarinic drugs (
Propanthalene) were mainly used to treat peptic ulcer. These drugs
block basal acid secretion. Besides this, by increasing the gastric
emptying time they rather prolong the exposure of ulcer to gastric
acid making them unsuitable for treatment of peptic ulcer. Nowadays
Pirenzepine & Telenzepine are used.
 H2 blockers and PPI’s both act by decreasing the gastric acid
secretion, but PPI’s like omeprazole, Pantoprazole are more effective
than H2 blockers like Ranitidine, Cimetidine etc. PPI’s inhibit 90% of
24hr acid secretion when compared to H2 blockers which inhibit 65%
of 24hr acid secretion. So PPI’s are preferable.

CORRECT PRESCIPTION

Name- Age-30yrs Sex-

1. Aluminium hydroxide gel - 600mg/10ml, 4ml orally after each meal and at bed
time.
2. Tab. Omeprazole -20mg BD orally half an hour before food for 2 weeks.
3. Tab. Ranitidine - 150mg B.D orally.
 CCR IX
Criticize, correct and rewrite the following prescription for an adult suffering from
congestive heart failure with angina.
Name – Mr. X Age – 45 years Sex –
Rx
1. Tab. Digoxin - 2mg OD orally
2. Tab. Furosemide - 200mg OD orally
3. Tab. Nifedipine - 100mg OD orally
4. Tab. Quinidine - 200mg OD orally

CRITICISM:
 In the treatment of Congestive Heart Failure (CHF) with angina Digoxin and a
nitrate is given for better pharmacological activity.
 Digoxin is given initially in a dose of 0.75mg orally as a loading dose followed
by a dose of 0.25mg OD orally, 5 days in a week as maintenance dose.
 Isosorbide dinitrate is given in a dose of 10mg orally 6 th hourly to treat
angina.
 Furosemide is a potent diuretic and is to be given carefully as it is likely to
produce hypokalemia. It is indicated in acute heart failure and chronic heart
failure with edema.
 As potassium loss caused by Furosemide sensitizes the action of Digoxin,
Potassium sparing diuretic like Spironolactone is given in a dose of 25mg per
day.
 Nifedipine is a Calcium channel blocker and likely to produce edema on long
term use and hence not used in CHF.

CORRECT PRESCRIPTION:
Name – Mr. X Age – 45 years Sex –
Rx
1. Tab. Digoxin - 0.75mg orally in 24 hours as a loading dose
followed by a dose of
2. Tab. Digoxin - 0.25mg OD orally, 5 days in a week as
maintenance dose
3. Tab. Furosemide - 40mg OD orally
4. Tab. Isosorbide dinitrate - 10mg orally 6th hourly

-For acute attacks 2.5mg Sublingually 3–4

hourly.
 CCR X
Criticize, correct and rewrite the following prescription for an adult suffering from
grand mal epilepsy for 30 years male.
Name – Age – Sex –
Rx
1. Tab. Diphenyl hydantoin sodium 100mg, 1 tablet per day orally
2. Tab. Trimethadione 50mg, 1 tablet per day orally
3. Tab. Ethosuximide 100mg, 1 tablet per day orally
4. Cap. Chloramphenicol 250mg, 1 capsule per day orally

CRITICISM:
 In grand mal epilepsy, Diphenyl hydantoin sodium is drug of choice and
given 300 – 600mg per day dosage in 2 – 3 divided doses.
 Trimethadione is given in petit mal epilepsy in doses of 900 – 1200mg per
day.
 Ethosuximide is useful only in petit mal epilepsy in doses of 250mg per day.
 Chloramphenicol a broadspectrum antibiotic not used in any type of
epilepsy.

CORRECT PRESCRIPTION:
Name – Age – Sex –
Rx
1. Tab. Carbamazepine 200mg thrice daily upto 1200mg per day.
2. If the seizures are not controlled switch on to Tab. Phenytoin sodium 100mg
thrice daily.
 CCR – XI
CCR the following prescription for an adult suffering from maturity onset diabetes
and chronic bronchial asthma.
Name: Age:
Sex:
Rx
1. Tab. Glibenclamide 5mg once daily orally
2. Tab. Salbutamol 4mg one tablet thrice daily
3. Tab. Dexamethasone 2mg twice daily orally

CRITICISM
 Glibenclamide should be given 15 min before food.
 Salbutamol is a short acting beta2 agonist used to manage acute bronchial
asthma. To manage chronic bronchial asthma long acting beta2 agonist is
used. Patient’s compliance is good with pressurized metered dose inhaler.
 Oral steroids Dexamethasone on long term on long term administration is
known to aggravate diabetes by inhibiting the peripheral utilization of
glucose in skeletal muscle, adipose tissue and induces gluconeogenesis in
liver.
 Inhalational steroids act locally and are devoid of systemic adverse effects,
so they are preferred to oral steroids.

CORRECT PRESCRIPTION
1. Tab. Glibenclamide 5mg one tablet orally 15 min before food.
2. Fluticasone phosphate pressurized metered dose inhaler 100micrograms /
puff twice daily.
3. Salmeterol pressurized metered dose inhaler 100microgram / puff twice
daily
 CCR – XII
CCR the following for an adult suffering from acute exacerbation of chronic
bronchial asthma.
Name: Age: Sex:
Rx
1. Inj. Adrenaline 5mg ampoule, one ampoule intravenously.
2. Inj. Disodium cromoglycate 200mg vial, one vial IV daily
3. Tab. Pheniramine maleate 100mg one tablet once daily orally
4. Tab. Prednisolone 5mg one tablet twice daily orally

CRITICISM
 In the above prescription, dose and route of administration of Adrenaline are
wrong. Dose should be 0.2mg to 0.5mg 1 in 1000 dilution and route is
subcutaneous.
 Rapid relief occurs with Adrenaline but because of adverse effects like
palpitations, sudden death in patients with cardiac damage and hypoxia and
adverse effects on patients on TCA, so Adrenaline is not used routinely as
bronchodilator.
 Short acting beta2 agonist such as Salbutamol is first drug of choice in the
treatment of bronchial asthma.
 Disodium cromoglycate is mast cell stabilizer. It is a prophylactic agent.
 Pheniramine maleate is indicated in various allergies but not in asthma.
 Tab. Prednisolone is an oral steroid indicated in treatment of chronic severe
persistent asthma in doses of 30mg per day in divided doses for 5 to 9 days.
Tapering of the dose is done after that.

CORRECT PRESCRIPTION
1. Oxygen therapy
2. Nebulization of Levo salbutamol 2.5mg every 20 min until patient is stable
3. Inj. Hydrocortisone 200mg IV stat followed by 100mg thrice daily.
 CILINICAL PROBLEMS

1) A 50year old women suffering from acute rheumatoid arthritis was advised
prednisolone for a brief period. However, patient disregarded the advice and
continued medication for more than one year. Now she came with complaints
of headache, dizziness, edema of feet, excessive thirst, frequent micturition,
weight gain and nonhealing ulcer of foot.

Write :

a) What is the cause of ailments?

b) How can you manage the case now?
c) What precautions could have prevented the complications?
d) What new therapies are available?

Answer:

a) Cause of ailments is prolonged steroid therapy.

b) We can manage by gradual withdrawal of steroid i.e., tapering from
20mg/day then10mg/day then 5mg/day over a period of one to two months.
Check the patient for hypertension, if present treat with antihypertensives
along with salt and water restriction.
c) For acute rheumatoid arthritis start with NSAIDS especially COX-2 inhibitors
like Celecoxib 100mg BD orally.
d) Methotrexate (DMARD) can be added.

2) A diabetic patient on chlorpropamide therapy had a sprained ankle and was

prescribed ibuprofen. Later he came with giddiness, palpitation, sweating.

Write:

a) What is the cause of the symptoms?

b) How could you manage the case?
c) What could have avoided the problem?

Answer :

a) The symptoms are due to hypoglycemia which is a consequence of increased

plasma concentration of chlorpropamide due to its displacement by
ibuprofen from protein binding sites.
 b) Give oral glucose or fruit juice, if patient is conscious (OR) Glucose IV with
saline if unconscious (OR) Inj. Glucagon.
c) By prescribing NSAIDS which donot interact with oral hypoglycemic. Eg:
Diclofenac sodium, selective COX-2 inhibitors like Celecoxib and Rofecoxib.

CLINICAL PROBLEM

3. A 28 year old lady on oral contraceptives for past 8 months was prescribed INH,
Rifampicin, Ethambutol to treat Cervical lymphadenitis. After 3 months she came
back with pregnancy.

Write:
a. Explain the reason for failure of OCP's?

b. Could the pregnancy have been avoided?

Answer:
a. Rifampicin is a microsomal enzyme inducer, thus rapid metabolism and
degradation of estrogen of OCP's causing contraceptive failure.

b. Yes the pregnancy could be avoided by prescribing women with barrier

contraceptive method like condom (male partner) or IUCD (Cu-T), without
stopping her antitubercular treatment. OR she can be provided with higher
Estrogen doses.
4. An obese adult diabetic male has been on Glibenclamide 5 mg once a day for past
10 years. He had recently developed a non-healing ulcer on his feet and has
increased the dose to 10 mg twice a day on his own. This has not given any relief
and come to see the physician.
Write:
a. Reason for non healing ulcer?

b. Reason for its not responding to increasing dosage?

c. How to manage the case now?

Answer:
a. A known diabetic case on oral sulfonylurea is dependent on stimulation of B-
Cell function and consequent insulin release. Obviously the pancreatic B-Cells
are not functioning properly.

b. Probably the patient has developed resistance to oral anti diabetic drugs.

c. Intermediate category of insulin like NPH/Isophan after dose adjustment.

 Clinical problem – 5
A patient with valvular heart disease underwent tooth extraction. Two days
later, developed continuous fever, malaise, clubbing, sub ungul hemorrhage,
microscopic hematuria, spleenmegaly and changing murmers.
Write:
a. What is the cause?
b. How would you manage?
c. How it could have been prevented?
Answer:
a. The tooth extraction has pre disposed to bacteremia: sub-acute bacterial
endocarditis is most commonly caused by streptococcus viridans.
b. Management – Penicillin G 20lakhs units I.V 6th hourly
Plus
Gentamycin 1mg/kg I.V/I.M 8th hourly for four weeks. In patients allergic to
pencillin, ceftriaxone 2g I.V/I.M once daily for 4 weeks.
c. Prophylactic treatment – This could have been prevented by Amoxycillin 2g
I.V/I.M dose given half an hour before the procedure.

Clinical problem – 6
A leprosy patient who is on chemo therapy has suddenly developed exacerbation of
lesions with erythema, swelling.
Write:
a. What is the cause?
b. How would you manage?
c. Does it affect your treatment course?
Answer:
a. The clinical manifestations are due to type II lepra reaction.
b. Management – Clofazamine is given in the dose of 100mg 3 times a day.
Plus
Prednisolone in the dose of 40mg per day, gradually tapered and continue till the
lesions subside. In the resistant cases thalidomide 400mg per day orally.
c. Treatment is not stopped.
Dapsone 100mg daily + clofazamine 50mg daily and clofazamine 300mg once a
month, rifampicin 600mg once a month.
 Clinical problem – 7
An adult male patient with amoebiasis is advised a course of treatment with
Metronidazole. During therapy he attended a party where he took a small amount of
alcohol. He developed sudden throbbing headache, confusion, blurring of vision and
fainting.
Write:
a) What is the cause?
b) Could it have been prevented?

Ans
a) The cause of symptoms like throbbing headache, confusion, blurring of vision
and fainting is an antabuse / Disulfiram like reaction which occurred due to
alcohol consumption during Metronidazole therapy. This antabuse reaction
is due to inhibition of alcohol dehydrogenase and blockade of metabolism of
acetaldehyde leading to accumulation of acetaldehyde.
b) This could have been prevented by asking the patient not to consume alcohol
during or within 3 days of Metronidazole therapy.

Clinical problem – 8
An elderly woman developed septicemia in postoperative period showing
sensitivity to carbenicillin and Gentamycin. For her Carbenicillin and Gentamycin
are prescribed and administered by combining together, but to the surgeon’s
surprise there was no improvement.
Write:
The reason
Ans
The treatment is correct but failure is due to incompatibility of drugs invitro. These
drugs should be administered by different syringes separately.
CLINICAL PROBLEM : 9
9. A patient taken for surgery has developed apnoea after the administration of
neuromuscular blockade.
Write:
a) What could be the drug, why apnoea has developed?
b) How could you treat the apnoea?
c) How will you assess and prevent such reaction in future?

Ans:
a) The drug is succinylcholine, which is a persisting depolarizing
neuromuscular blocking drug. Due to genetic abnormality the patient has
absence pseudo cholinesterase.
This leads to non- metabolism of succinylcholine and thus persistent
blockade leading to failure respiration (paralysis of intercostal muscles &
diaphragm, which are skeletal muscles).

b) Keep the patient on respiratory machine and supply fresh blood from
outside, which is not from a relative. This results in supply of pseudo
cholinesterase which removes the blockade.

c) Performing of “dibucaine number’’ test on the relatives of the patient can

predict chances of succinylcholine apnoea.

CLINICAL PROBLEM : 10
10. A patient suffering from chronic persistent severe bronchial asthma was advised
to take Beclomethasone inhalation. After few months, patient complains of sore
throat and hoarseness of voice.
WRITE:
A. What is the cause?
B. How to treat?
C. How to prevent it?

ANS:
A. Superinfection i.e., oropharyngeal candidiasis due to long term use of
Beclomethasone dipropionate.
B. Fluconazole oral suspension 2mg/ml. Rinse with 5 ml 3 times a day
C. Daily mouth and throat gargling after each inhalation can maintain oral
hygiene.
 Clinical Problem 11

11. A diabetic patient who was receiving insulin injection has suddenly developed
high blood pressure with tachycardia for which PROPRANOLOL was given.

Write

A. What is the drug interaction?

B. What is the alternate drug?

ANS:

A. Diabetic patient receiving insulin should not be given PROPRANOLOL for

anti-hypertensive effect for the fear of dangerous hypoglycemia.
B. The other drugs which can be tried are
a. Selective drugs like ATENOLOL.
b. Calcium channel blockers.

Clinical Problem 12

12. A tuberculosis patient who is on Streptomycin developed pedal edema and

puffiness of face for which he was given Furosemide.

Write
A. What is the expected toxicity?
B. What is the alternative?

ANS:

A. A Tuberculosis patient receiving an aminoglycoside antibiotic like

STREPTOMYCIN should not be given FUROSEMIDE for treating pedal edema
and puffiness of face for the fear of enhanced ototoxicity.
B. The alternative is TRIAMTERENE which is an inhibitor of epithelial sodium
channel and does not have ototoxicity.
 Clinical problem – 13
A patient of Bipolar maniac depressive illness was on Lithium therapy and he
developed acute lithium toxicity and was treated with a diuretics like Furosemide to
remove excess lithium.
Write:
a) What is the dangerous consequence involved in it?
b) What is the better alternative for renal excretion of lithium?

Ans
a) There is increased lithium reabsorption and hence more toxicity with Na+
depleting diuretics like Frusemide or thiazide diuretics because most of the
renal tubular reabsorption of lithium occurs PCT.
b) The alternative is diuretic like Mannitol, Triamterene, Acetazolamide.

Clinical problem – 14
A person suffering from Gouty Arthritis is being treated with Allopurinol and he
developed acute bronchitis for which he was prescribed Ampicillin.
Write:
a) Expected toxicity
b) How to overcome it?

Ans
a) Allopurinol and Ampicillin produce high incidence of skin rashes
b) Other group of antibiotics like Cephalosporins (or) Quinolones can be
prescribed