CLINICAL CASES IN PHARMACOLOGY

CASE 1 : CHRONIC HEART FAILURE

A 69-YEAR-OLD WOMAN SUFFERING FROM CHRON IC HEART FAILURE IS TREATED WITH 0.25 MG
DIGOXIN DAILY FOR 3 MONTHS. HEART FAILURE IS NOT CONTROLLED ADEQUATELY. WHAT WILL BE THE
TREATMENT TO CONTROL HEART FAILURE ADEQUATELY?

Presenting features:
Inadequate treatment of congestive heart failure.
Relevant information:
a 69-year-old woman suffering from chronic heart failure is treated with 0.25 mg digoxin daily for 3 months.
Inference:
As CHF is not controlled adequately by digoxin 0.25 mg daily alone, she needs additional treatment.
Treatment:
Rest: physical rest is absolutely essential.
Moderate salt restriction: 2-3 g/day
Digoxin 0.25 mg /day to be continued
[Digitalised muscle→ Digoxin withdrawn→ precipitates atrial fibrillation]
To start FRUSEMIDE @ 20-80 mg/day
To start ENALAPRIL low dose @ 2.5 mg/day for 1-2 days after stopping diuretic
If there is no hypotension, dose of ENALAPRIL is increased gradually over 3-4 days depending on the response.
Cause of heart failure is to be investigated and treated if possible.
Serum Potassium level to be monitored and treated accordingly.
[Hypokalaemia→ Arrhythmia, Constipation; Hyperkalaemia→ Arrhythmia]

CASE 2 : ACUTE GLAUCOMA

A MIDDLE-AGED PERSON WHILE WA TCHING TV IN DARK SU DDENLY DEVELOPS SEVERE PAIN IN RIGHT
EYE, VOMITING AND BL URRING OF VISION. ON EXAMINATION, RIGHT PU PIL IS DILATED, SLUG GISHLY
REACTIVE TO LIGHT, R AISED INTRA-OCULAR PRESSURE.THE CASE WAS DIAGNOSED AS ACUTE
CONGESTIVE GLAUCOMA. DESCRIBE THE MEDIC AL MANAGEMENT OF THI S PATIENT.

Presenting features:
Dilated Right pupil, sluggishly reactive to light, raised intra-ocular pressure.
Relevant information:
Middle-aged person watching TV in dark suddenly develops severe pain in right eye, vomiting and blurring of vision.
Inference:
Patient has developed acute congestive glaucoma and needs immediate treatment.
Treatment:
Treatment of choice: LASER iridectomy/ trabeculectomy
Before surgical procedure IOP has to be reduced by drug therapy.
Acetazolamide injection 500 mg IV followed by Acetazolamide tablet 250 mg each QID.
If not managed,
1. 20% Mannitol (1.5-2 mg/kg) to be given by rapid IV infusion over a period of 30-60 min.
2. Pilocarpine Nitrate (2%) 2 drops to be instilled in right eye every 10 min for 1 st hour and thereafter at 30 min
interval till desired IOP is achieved.
[if IOP is high, a miotic is ineffective due to pressure induced ischemic paralysis of sphincter pupillae muscle]
3. Timolol maleate (0.25-0.5%) 2 drops to be instilled in right eye every 6 hours.
CASE 3 : SNAKE BITE

6 YR OLD BOY WHILE PLAYING IN VILLAGE GROUND WAS BITTEN BY A SNAKE. THE SNAKE WAS
IDENTIFIED TO BE POI SONOUS. WRITE DOWN THE MANAGEMENT OF THI S PATIENT.

Presenting features:
Two round bite marks few millimetres apart at the site of bite seen after washing the area.
Relevant information:
H/O snake bite. Snake was identified to be poisonous.
Inference:
Patient has been bitten by a poisonous snake and needs immediate treatment.
Treatment:
1. Do not move/rub/shake the affected area and keep the bitten part below the level of heart and raise other part
of the body.
2. Patient is hospitalised and general measures of maintaining airway, breathing & circulation are done.
3. Other measures like tourniquet, washing with KMnO4/H2O2, slashing incision & drainage are obsolete now.
[Tourniquet only blocks superficial veins not deep veins and can be applied only over a single bone like humerus
or femur. KMnO4/H2O2 is effective only in dog bite]
4. Polyvalent snake anti-venom is given to the subject.
Every 20 ml contains- I. 0.6 mg std. Cobra anti-venom
II. 0.6 mg std. Viper anti-venom
III. 0.45 mg std. Saw scale anti-venom
IV. 0.45 mg Malaysian cobra anti-venom
Upto 300-900 ml can be given till symptoms subsides.
[Symptoms:
Cobra-Neurotoxic venom (Blocks Nm receptors on nerves and muscles)
Pain in bitten area
Tremendous Pain
Anaesthesia
Flaccid Paralysis
Viper-Hemotoxic venom (Causes haemolysis)
Oozing blood
Haematuria
Renal failure
Renal dialysis may be done as a part of treatment or Jet IV fluid along with Furosemide may be given]
5. If anaphylaxis is present give Adrenaline along with anti-venom.

CASE 4 : ORGANOPHOSPHORUS POISONING

A 25-YEAR-OLD LADY BROUGHT TO EMERGENCY WITH UNCONSCIOUSNESS , PINPOINT PUPIL & FROTH
COMING FROM MOUTH. H/O OP INGESTION. WRITE THE MANAGEMENT OF THE P ATIENT.

Presenting features:
Unconsciousness, pinpoint pupil & froth coming from mouth.
Relevant information:
25-YEAR-OLD lady brought to emergency. H/O Organophosphorus ingestion.
Inference:
Patient has developed acute organophosphorus poisoning and needs immediate treatment.
Treatment:
1. Prevent further exposure of organophosphorus by removing contaminated articles/clothes from her body.
[Because OP is absorbed from any surface of the body]
 2. Maintain Respiratory passage and breathing. [Because there is frothing from mouth]
3. Gastric lavage may be given if it is within few hours.
4. Atropine 2mg doses to be administered IV at 10-20 min intervals till symptoms of atropinisation appears or till
symptoms of OP poisoning disappears permanently.
[Atropine comes in 0.5 mg ampules. 4 ampules to be given at once.]
5. Pralidoxime 10mg doses may be given upto 200 mg if poisoning is less than 24 hours.
[Chronic OP poisoning presents with peripheral neuropathy and jaundice]

CASE 5 : STABLE ANGINA PECTORIS

A 45-YEAR-OLD MALE PATIENT WITH A HISTORY OF SMOKING PRESENTED WITH EXERTIONAL

Presenting features:
Exertional retrosternal compressing pain radiating to the left arm and lasts for 2-5 min. The pain is relieved after taking
rest.
Relevant information:
45-YEAR-OLD man.
Aggravating factor: H/O smoking.
Inference:
Patient is suffering from stable Angina Pectoris and needs treatment.
Treatment:
General advice:
1. To stop smoking, alcohol intake etc.
2. Restrict fat & calorie intake
3. Weight reduction
Treatment proper:
1. In emergency, Glyceryl Tri-nitrate tablet 0.5 mg sublingually when there is an attack of angina.
2. Prophylaxis:
a. Isosorbide mononitrate 20 mg BD
b. Atenolol 50-100 mg OD
c. Nifedipine 5-10 mg TDS
d. Aspirin 75-150 mg OD (after heaviest meal of day)

CASE 6 : MODERATE HYPERTENSION

AN OVERWEIGHT MIDDLE AGED MAN IS FOUND T O BE HYPERTENSIVE WHILE ATTENDING A CLIN IC FOR
MEDICAL CHECKUP.HIS BP IS 170/105 M M OF H G ON TWO SUCCESSIVE O BSERVATIONS. WHAT WILL BE
THE TREATMEWNT FOR T HIAS PATIENT?

Presenting features:
BP 170/105 mm of Hg on two successive observations
Relevant information:
Overweight. Middle aged.
Inference:
Patient is suffering from moderate hypertension and needs treatment.
General measures:
1. Stop smoking, alcohol intake etc
2. Restrict fat & calorie intake
3. Reduce weight.
Treatment:
1. Hydrochlorothiazide 25 mg OD
2. Atenolol 50-100 mg OD
3. Amlodipine 5-10 mg OD
4. Enalapril 2.5-100 mg OD
[Start with any two of these drugs and adjust the dose according to the need]

CASE 7 : HYPERTENSIVE EMERGENCY

A 58-YEAR-OLD MAN WITH H/O SEVERE HYPERTENSION FOR 20 YEARS WHICH WAS WELL CONTR OLLED
WITH MEDICATION. HE STOPPED TAKING DRUGS FOR A LONG TIME. HIS BP IS FOUND TO BE 240/135 M M
OF H G WITH PAPILLEDEMA. WHAT WILL BE MANAGEMENT OF THIS C ASE?

Presenting features:
BP 240/135 mm of Hg with papilledema
Relevant information:
Known hypertensive for 20 years. Topped intake of medicines for long time.
Inference:
Patient is suffering from hypertensive emergency and needs immediate treatment.
General measures:
1. Stop smoking, alcohol intake etc
2. Restrict fat & calorie intake
3. Reduce weight.
Treatment:
1. Sodium Nitroprusside
a. IV infusion with 5 % dextrose
b. Infused at rate of 5 µg/min but can be increased upto 20 µg/min depending on response
c. BP should not be decreased more than 20-30% of pre-treatment value & DBP should not go below 95 mm
of Hg within 48 hrs of crisis
2. IV Furosemide 20-40 mg may be given along with nitroprusside
[Target SBP <150-160 mm Hg; Target DBP <90 mm Hg after complete treatment]

CASE 8 : ACUTE MYOCARDIAL INFARCTION

A 45-YEAR-OLD MAN SUFFERING FROM ANGINA PECTORIS WAS ON TREATMENT WITH ISO SORBIDE
DINITRATE. HE IS ADMITTED TO HOSPITAL WITH SEVERE CHEST PAIN AND SWEATING AND DIAGNOSED
TO BE A CASE OF ACUTE MYOCARDIAL INFARCT ION. WHAT WILL BE MANAGEMENT OF THIS CASE?

Presenting features:
Chest pain and sweating
Relevant information:
45-year-old. Known patient of angina pectoris.
Inference:
Patient is suffering from Acute Myocardial Infarction and needs immediate treatment.
General measures:
1. Admitted to ICCU (Intensive Critical Care Unit)
2. Patient is put on ventilation
Treatment:
1. Moist o2 inhalation at 2-4 litres/min for upto 12 hours
2. Aspirin 150-325 mg 1 tab chewed
3. Morphine sulphate 2-4 mg IV repeated every 5-10 min till pain subsides. Maximum 20 mg/day
4. Metoprolol IV 5 mg every 15 min. Maximum 3 doses.
 5. Metoclopramide 10 mg IV if vomiting is present.
6. GTN IV infusion at 0.5-1.5 mg/kg/min
7. Streptokinase IV 1.5 million units in 100 ml normal saline over 1 hour.
8. Deltheparin 5000 units SC every 12 hours. If patient becomes stable switch to warfarin.
9. If patient enters cardiogenic shock, Dopamine IV infusion at 2.5 µg/kg/min until patient is normotensive.

CASE 9 DRUG INDUCED PARKINSONISM

A PATIENT OF CHRONIC PSYCHIATRIC DISORDER WAS BEING TREATED W ITH CHLORPROMAZINE. HE

Presenting features:
Tremor, rigidity & bradykinesia
Relevant information:
Chronic psychiatric patient on Chlorpromazine therapy
Inference:
Patient is suffering from Drug induced Parkinsonism and needs treatment.
Treatment:
Tab. Trihexiphenidyl hydrochloride/ Benzhexol
Each tablet containing 1 mg.
1 tab. Twice daily. Dose to be increased gradually upto 15 mg per day as per the response in 2-3 divided doses.

CASE 10 : STATUS ASTHMATICUS

A 16-YEAR-OLD GIRL SUFFERING FROM SEVERE SHORTNESS OF BREATH IS ADMITTED TO HOSPITAL. SHE
HAS BEEN USING METRE DOSE INHALATIONAL S ALBUTAMOL, IPRATROPI UM AND BECLOMETHASONE.
INSPITE OF TREATMENT HER SITUATION IS NOT CONTROLLED. WHAT WILL BE MANAGEMENT OF THIS
CASE?

Presenting features:
Severe shortness of breath
Relevant information:
Known patient of asthma taking metred dose inhaler.
Inference:
Patient is suffering from Status Asthmaticus and needs immediate treatment.
Treatment:
1. Moist O2 inhalation at rate of 2-3 litres/min before and after nebulisation.
2. Inhalation of Salbutamol 5 mg through nebuliser.
[If not controlled repeat. If still not controlled increase dose]
3. Injection Hydrocortisone 200 mg IV stat followed by 400 mg TDS
4. Normal saline infusion
5. If acidosis present give Inj. Sodium Bicarbonate
6. Injection Amoxicillin 500 mg TDS

CASE 11 : EXERCISE INDUCED ASTHMA

A 10-YEAR-OLD SCHOOL GIRL SUFFERING FROM MILD EXERCISE INDUCED ASTHMA TREATED WITH
METRE DOSE INHALER C ONTAINING 500 µG TER BUTALIN AS & WHEN RE QUIRED WHICH CONTROLS
INDIVIDUAL ATTACKS. SHE HAS ATTACKS OF WHEEZING EVERY 3-4 WEEKS OCCURING DURING EXERCISE
EVEN AFTER ABOVE TRE ATMENT SCHEDULE. WHAT WILL BE MANAGEMENT OF THIS CASE?

Presenting features:
Wheezing every 3-4 weeks during exercise
Relevant information:
Metred dose inhaler containing 500 µg Terbutaline as & when required
Inference:
Patient is suffering from Exercise induced asthma and needs treatment.
Treatment:
1. Continue terbutaline
2. Sodium Chromoglycate (100 µg/puff) thrice daily for 6-8 weeks

OR

3. Montelukast 10 mg once daily for 6-8 weeks

CASE 12 : IRON DEFICIENCY ANAEMIA

A LADY IN THE 2 N D TRIMESTER IS FOUND TO BE MODERATELY ANEMIC ON ROUTINE CHECK UP. WHAT
WILL BE MANAGEMENT OF THIS CASE?

Presenting features:
Moderate anaemia
Relevant information:
2nd trimester
Inference:
Patient is suffering from Iron deficiency Anaemia and needs treatment
Treatment:
1. Tab. Ferrous sulphate 200 mg elemental Iron 3 times a day after meal till Hb >10 g/dl. [Therapeutic dose]
After that 30 mg elemental Iron once daily after meal upto 3 months after delivery.
2. Tab. Folic acid 500 µg once daily after meal till 3 months after delivery.

CASE 13 : HYPOGLYCAEMIC COMA

A MIDDLE AGED DIABETIC PATIENT ON ORAL HYP OGLYCEMIC UNDERWENT HEAVY EXERCISE AND MISSED
BREAKFAST. HE DEVELOPED SWEATING, TACHYCARDIA, RESPIRATORY DISTRE SS AND
UNCONSCIUOSNESS. WHAT WILL BE MANAGEMENT OF THIS CASE?

Presenting features:
Sweating, tachycardia, respiratory distress and unconsciousness
Relevant information:
Diabetic patient on oral hypoglycaemic drug
Inference:
Patient is suffering from Hypoglycaemic coma and needs immediate treatment.
Treatment:
1. Measure blood glucose on glucometer
2. 50 ml of 50% Dextrose IV
3. Inj. Glucagon 0.5-1 mg IV if the above does not work
CASE 14 : DIABETIC KETOACIDOSIS

A 20-YR-OLD DIABETIC MAN ON INSULIN THERAPY MISSED HIS USUAL DOSE OF INSULIN. HE HAD FEVER
AND BECAME UNCONSCIOUS. WHAT WILL BE MANAGE MENT OF THIS CASE?

Presenting features:
Fever and unconsciousness
Relevant information:
20-yr-old diabetic man on insulin therapy missed his usual dose of insulin
Inference:
Patient is suffering from Diabetic Ketoacidosis and needs immediate treatment.
Investigation:
1. Blood glucose every hour
2. Electrolytes (K+, PO43-, pH)
3. Arterial blood gas analysis
Treatment:
1. IV Normal Saline ≥1 litre in 1st hour
Gradually decrease to 500 ml in 4 hrs and change to 0.5 NS
Fluid change is based on Heart rate BP & Urine output
When blood glucose reaches 300 mg/dl add 5% dextrose to 0.5 NS
2. Regular Insulin IV 0.1-0.2 U/kg bolus.
0.1U/kg/hr IV Infusion till blood glucose is 300 mg/dl.
After adding 5% Dextrose 0.05 U/kg/hr
[Target of therapy 150-250 mg/dl glucose → change over to SC Insulin Inj.]
3. KCl 10-20 meq/hr
Start after 1-2 hrs of Insulin therapy
4. Sodium Bicarbonate if pH < 7.1
5. Sodium phosphate 5-10 meq/hr if not corrected by insulin
6. Antibiotics