USE OF DRUGS IN HEPATIC AND RENAL FAILURE, PREGNANCY AND

LACTATION AND IN CHILDREN

Specific Learning Objectives: At the end of this learning activity, students should be able to:

1. List the physiological and pathological changes that warrant a modification of dose in
pregnancy & lactation, children and in hepatic & renal disease.
2. Choose drugs based on efficacy, suitability, tolerability and cost in these people.
3. Understand the modification in the pharmacokinetics of some common drugs in these category
of people.

Student Learning Outcomes

Lesson Plan
An introduction is given (5-10 minutes) on the importance of individualization of therapy.
The batch is divided into five small groups of 5-6 students in each group. Group tasks are
distributed. After 45 minutes a plenary is held (90 minutes).

TASKS

No. 1.
(a) List the physiological changes that take place during pregnancy which are likely to affect the
pharmacokinetics of drugs? Explain with examples.

Pregnancy induces physiological changes that notably affect how drugs behave in the body.
1. Gastrointestinal alterations - Elevated gastric pH and reduced gastric emptying duration can
influence drug absorption. For instance, drugs relying on an acidic environment for absorption,
like specific antibiotics like Amoxicillin, may be affected due to decreased acidity.
2. Cardiovascular shifts - Increased cardiac output and enhanced blood flow to organs might
modify drug distribution. Medications dependent on blood flow for distribution, such as
antihypertensives or anticoagulants, could display altered effects.
3. Renal modifications - Heightened renal blood flow and glomerular filtration rate can impact
drug elimination. Drugs eliminated through the kidneys, like certain antibiotics such as
Penicillins, might need dosage adjustments due to changes in excretion rates.
4. Hepatic transformations - Changes in liver metabolism due to increased hepatic blood flow
and altered enzyme activity can affect drug breakdown. Drugs metabolized by liver enzymes,
such as specific opioids, like Codeine, might require dosage modifications.
5. Expansion of plasma volume - Dilution effects may alter drug concentrations in the blood.
Medications with a narrow therapeutic range, such as some anti-epileptic drugs, might
necessitate dose adjustments to maintain therapeutic levels.
6. Changes in protein binding - Variations in plasma protein levels can affect the active fraction
of a drug. Drugs highly bound to proteins, like Warfarin might demonstrate changes in
effectiveness or toxicity due to fluctuations in protein levels.
7. Respiratory adjustments - Increased tidal volume and oxygen consumption might influence
the pharmacokinetics of certain inhaled medications or those influenced by respiratory
function.
8. Hormonal fluctuations - Fluctuations in hormone levels, like increased progesterone, might
impact drug metabolism and clearance rates. For instance, alterations in the metabolism of
certain psychiatric medications may occur due to hormonal changes.
(b) List the drugs of choice in pregnancy under the following groups and give reasons for selection. (I)
opioid analgesic (ii) grand mal epilepsy (iii)antihistaminic

(I) Opioid Analgesic:

● Morphine and Codeine - Selected due to their extensive historical use in pregnant individuals
without substantial evidence linking them to major birth defects or harmful effects on the fetus.

(ii) Grand Mal Epilepsy:

● Levetiracetam and Lamotrigine - Were chosen because they demonstrate a lower risk of
causing birth defects compared to other antiepileptic drugs (AEDs) and have a longer track
record of use in pregnant individuals without significant adverse outcomes.

(iii) Antihistaminic:
● Chlorpheniramine and Diphenhydramine - These are preferred for their well-established safety
profile during pregnancy, supported by their extensive historical usage and lack of substantial
evidence indicating harm to the fetus.

No. 2.

(a) List the physiological changes that take place during hepatic failure which are likely to affect the
pharmacokinetics of drugs? Explain with examples

● Reduced hepatic blood flow - During hepatic failure, the diminished blood flow through the
liver affects drug metabolism, potentially causing drugs dependent on hepatic clearance, such
as propranolol, to have extended half-lives due to reduced metabolic processing.
● Reduced synthesis of plasma proteins - like albumin, in the liver can impact drug binding,
increasing free drug concentrations for substances strongly binding to albumin such as
warfarin, leading to heightened pharmacological effects and a greater risk of toxicity.
● Impaired activity of various metabolic enzymes - In hepatic failure may decrease drug
clearance for medications metabolized by these enzymes, like diazepam metabolized by
CYP450, resulting in drug accumulation and possible adverse effects.
● Altered bile excretion - Liver dysfunction affecting bile production and excretion can disrupt
drug elimination, potentially causing drugs excreted via bile, such as erythromycin, to undergo
decreased elimination, leading to prolonged exposure and a risk of toxicity.

(b) List the drugs of choice in hepatic failure under the following groups and give reasons for
selection. (I) opioid analgesic/ non opioid analgesic (ii) hypertension (iii) antibiotcs

(I) Opioid Analgesic/Non-opioid Analgesic:

● Opioid Analgesic: Morphine or Fentanyl are preferable due to their reduced hepatic
metabolism and reliance on renal excretion, minimizing the risk of accumulation in hepatic
failure.
● Non-opioid Analgesic: Acetaminophen is favored as it undergoes primarily glucuronidation and
sulfation, with minimal metabolism by the liver, reducing the risk of hepatotoxicity in hepatic
failure.

(II) Hypertension:
● Angiotensin-converting enzyme (ACE) inhibitors or Calcium Channel Blockers (Amlodipine,
Felodipine) are often used since they have minimal hepatic metabolism and can be safely
used in hepatic failure without significant dosage adjustments.
(III) Antibiotics:
● Antibiotics like Ceftriaxone, Azithromycin, or Vancomycin are preferred due to their limited
hepatic metabolism and elimination primarily through non-hepatic pathways.

(a) Which tests will you order to guide dosage?

● Drug Interaction Screening: Utilize databases or seek guidance from a pharmacist to assess
potential interactions, particularly concerning medications metabolized by the liver.
● Liver Function Tests: Regularly monitor liver health by examining serum bilirubin, alanine
transaminase (ALT), aspartate transaminase (AST), and international normalized ratio (INR) to
evaluate the extent of hepatic impairment
● Renal Function Tests: Evaluate kidney function through tests like serum creatinine and blood
urea nitrogen (BUN) as hepatic failure can affect renal function, especially important when
considering drugs eliminated through the kidneys.
● Serum Drug Levels: Monitor concentrations of medications with narrow therapeutic ranges or
known liver-related risks by assessing serum drug levels, aiding in dosage adjustments as
necessary.

No. 3.
(a) List the physiological changes that take place during renal failure which are likely to affect the
pharmacokinetics of drugs? Explain with examples.

● Altered Drug Filtration - Reduced glomerular filtration rate (GFR) in renal failure affects drug
excretion, leading to prolonged half-lives and potential drug accumulation. Example: Digoxin
requires dose adjustment due to reduced renal clearance in renal failure.
● Changes in Tubular Secretion -Diminished active tubular secretion affects drugs cleared by
this pathway, potentially leading to increased drug levels. Example: Penicillin and cimetidine
levels may rise due to impaired renal secretion in renal failure.
● Fluid and Electrolyte Imbalance - Renal failure disrupts fluid balance, altering drug
distribution within the body's compartments. Example: Drugs like lithium, with a narrow
therapeutic index affected by changes in sodium and fluid balance, may require dosage
adjustment.
● Altered Protein Binding - Changes in plasma protein levels or composition in renal failure
can impact drug-protein binding, influencing the concentration of free, active drug. Example:
The increased free fraction of phenytoin due to reduced albumin binding in renal failure can
lead to enhanced drug effects.
● Impaired Metabolism - Renal failure may affect drug metabolism, primarily when drugs are
metabolized in the kidney. Example: Accumulation of morphine-6-glucuronide, a metabolite of
morphine, occurs in renal failure, potentially causing adverse effects.

(b) List the drugs of choice in renal failure under the following groups and give reasons for
selection (i) analgesic (ii)antibiotic for gram negative infection (iii) cardiac glycoside

● Analgesic: Acetaminophen is the preferred option due to its minimal elimination through the
kidneys and reduced risk of causing harm or worsening kidney function in individuals with renal
failure.

● Antibiotic for gram-negative infection: Ceftriaxone is commonly selected due to its predominant
elimination via the liver, decreased dependence on renal clearance, and its effectiveness
against various gram-negative bacteria without notable kidney-related toxicity.
 ● Cardiac glycoside: Digoxin is favored for use in renal failure because it is mainly metabolized
by the liver, has a narrow range of effective doses, allowing for easier dose adjustments
despite impaired kidney function.

(c) The creatinine clearance of a patient with renal failure is 35ml/min. How would you adjust the
normal dosage of gentamicin for this patient using the nomogram provided. (dose of gentamicin 80
mg three times a day. (see last reference given below)

No. 4.
(a)What are the physiological differences in a child which are likely to affect the pharmacokinetics of
drugs? Explain with examples

● Body Composition - Children possess distinct body compositions from adults. They typically
have higher body water percentages, impacting the distribution of water-soluble medications,
while lower fat content may influence the distribution of fat-soluble drugs. For instance,
diazepam, a lipophilic drug, might have an expanded distribution in children due to their
reduced fat content.
● Organ Function and Size - As children's organs, like the liver and kidneys, mature and grow,
drug metabolism and excretion are affected. Immature enzyme systems in young children can
influence drug clearance rates. For example, newborns and infants with lower hepatic enzyme
levels might experience altered metabolism of drugs such as acetaminophen.
● Gastrointestinal Function - Variances in gastric pH, gastrointestinal motility, and absorption
surface area between children and adults can affect drug absorption rates and bioavailability.
For instance, infants might experience slower absorption of acidic drugs like aspirin due to
higher gastric pH.
● Blood Flow and Cardiac Output - Children exhibit differing blood flow rates and cardiac outputs
compared to adults, impacting drug distribution and elimination. Drugs reliant on blood flow for
distribution, such as certain antibiotics, may demonstrate changed kinetics in children due to
differences in circulation.
● Body Surface Area - Pediatric dosing often adjusts for body size using body surface area
rather than weight. This approach is utilized, for example, with certain chemotherapy drugs to
minimize potential toxicity based on variations in body size.

(b)List the drugs of choice in children under the following groups (i) analgesic (ii)grand mal epilepsy
(iii) antibiotics

(i) Analgesic
● Acetaminophen (Paracetamol) is frequently used in children for pain relief and reducing fever
due to its safety profile when used at appropriate doses. Ibuprofen is another option for pain
and fever management in children above a certain age.

(ii) Grand Mal Epilepsy

● Antiepileptic drugs (AEDs) are often prescribed. Some commonly used AEDs in children with
grand mal seizures include:
○ Valproic acid (Sodium valproate)
○ Carbamazepine
 ○ Lamotrigine
○ Levetiracetam

(iii) Antibiotics
● Antibiotic selection in children varies based on the type of infection and the child's age.
Common antibiotics used in pediatric infections include:
○ Amoxicillin: Effective against a range of bacterial infections in children, such as ear
infections, strep throat, and urinary tract infections.
○ Ceftriaxone: Used for more severe infections or when intravenous administration is
necessary.
○ Azithromycin: Often prescribed for respiratory tract infections in children.

No. 5.
(a) What are the physiological differences in the elderly which are likely to affect the
pharmacokinetics of drugs? Explain with examples
Physiological changes in the elderly can significantly impact the pharmacokinetics of drugs due to
alterations in various bodily functions:

Physiological alterations in the elderly can profoundly affect how drugs are processed in the body due
to changes in various bodily functions:

● Absorption - Changes in the digestive system, such as reduced stomach acid production and
slower intestinal movement, can influence how drugs are absorbed. For instance, the
absorption of certain medications like antibiotics or iron supplements may be modified in older
individuals due to these shifts, potentially impacting their efficacy.
● Distribution - Age-related changes in body composition, such as increased body fat and
decreased muscle mass, can impact how drugs spread throughout the body. This can lead to
higher concentrations of fat-soluble medications in the bloodstream, resulting in prolonged
effects. For example, lipid-soluble drugs like benzodiazepines may last longer in the elderly
due to these distribution changes.
● Metabolism - Aging can lead to a decline in liver function due to changes in liver size and
reduced blood flow. This can affect how drugs are processed by the liver. For instance, certain
opioids like morphine might be cleared from the body at a slower rate in older individuals,
potentially causing stronger drug effects and longer durations of action.
● Renal Function - With age, renal function typically decreases, leading to a reduced ability to
filter blood and lower kidney blood flow. Drugs eliminated primarily through the kidneys may be
excreted at a different rate, potentially causing drug buildup and an increased risk of toxicity.
Medications like digoxin, eliminated mainly through the kidneys, may require dosage
adjustments in the elderly to prevent adverse effects.
● Drug-Drug Interactions - Elderly individuals often take multiple medications for chronic
conditions, increasing the chances of interactions. These interactions can be due to changes in
how drugs are processed, potentially resulting in adverse effects or reduced effectiveness.

(b) List the drugs of choice in elderly under the following groups (i) opioid analgesic / non- opioid
analgesic (ii) hypnotic (iii) antibiotics

(i) Opioid Analgesic / Non-opioid Analgesic

● Opioid Analgesics: In elderly patients, opioids are cautiously prescribed due to potential side
effects and increased sensitivity. If necessary, opioids such as Tramadol or Oxycodone (with
careful titration and monitoring) might be considered for severe pain management.

● Non-opioid Analgesics - Nonsteroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen or

 Acetaminophen (Paracetamol) are often preferred for mild to moderate pain relief in the elderly
due to a lower risk of adverse effects compared to opioids.

(ii) Hypnotic
● Sedative-hypnotic medications should be used cautiously in the elderly due to increased
susceptibility to adverse effects. Short-acting benzodiazepines like Lorazepam or Temazepam
are occasionally prescribed for insomnia in the elderly due to their shorter half-lives and lower
accumulation in the body.

(iii) Antibiotics
● Antibiotic choice in the elderly depends on the type of infection and the patient's health
condition. Commonly prescribed antibiotics for various infections in the elderly include:
○ Amoxicillin: Used for treating respiratory or urinary tract infections.
○ Ciprofloxacin: An option for certain bacterial infections but requires cautious use due to
the risk of side effects like tendon rupture or confusion in the elderly.
○ Trimethoprim/Sulfamethoxazole (Bactrim): Effective against a range of infections
including urinary tract infections and respiratory infections.
 Learning Activity No. 18

GENERAL PRINCIPLES OF ANTIBIOTIC USE AND SURGICAL PROPHYLAXIS

Specific Learning Objectives: At the end of this learning activity, students

1. Select antibiotics appropriately for a given clinical situation.
2. Limit indiscriminate use of broad-spectrum newer agents.
3. Appreciate the common prescribing errors when using antibiotics

Student Learning Outcomes

Tasks: Comment and correct the prescriptions given below. Give reasons for alternate choice of drugs if
any.

1. (a) A 35 year old man came with history of yellowish purulent urethral discharge for two days.
Gram's stain of urethral exudate showed gram negative diplococci. Patient said that he was allergic
to penicillin. He was prescribed:

Clarithromycin 2 gm orally single dose

The prescription of Clarithromycin 2 grams orally as a single dose for a 35-year-old man with a
suspected Gram-negative diplococci infection and a reported penicillin allergy requires reevaluation.

● Clarithromycin, primarily used for respiratory and skin infections, might not be the ideal choice
for a Gram-negative diplococci infection, particularly presumed gonorrhea, which usually
demands antibiotics effective against Neisseria gonorrhoeae.

Considering the penicillin allergy, a better alternative could be:

● Ceftriaxone - Highly effective against Neisseria gonorrhoeae, commonly causing urethral
discharge. A single intramuscular dose (usually 250 mg to 500 mg) of Ceftriaxone is
recommended for gonorrhea treatment, especially when a penicillin allergy exists.
● Alternatively, Azithromycin by mouth could be considered if Ceftriaxone isn't suitable.

(b) A 18 year old girl came with fever, headache and abdominal pain for 3 days. The blood culture
was positive for Salmonella. She was advised: Complete bed rest for 3 weeks
SHe was prescribed

Chloramphenicol cap. 500 mg q.i.d. x 1 day followed by 250mg t.d.s x 6 days

B. Complex tab. 1 t.d.s x 7 days
Vit. C. tab. 500mg o.d. x 7 days.

Chloramphenicol, though effective against Salmonella, carries significant risks like bone marrow
suppression, making it less favorable. Safer options like Ciprofloxacin or Ceftriaxone are preferred
due to their lower risk profiles.

● The duration of chloramphenicol treatment for 7 days seems lengthy. Standard therapy
for uncomplicated Salmonella infections typically lasts 5-7 days, varying based on
infection severity.
● Vitamin C's effectiveness in treating Salmonella isn't well-established; focus should
primarily be on antibiotics and supportive care.
 ● Enforcing bed rest for 3 weeks might be excessive unless complications arise; gradual
return to normal activities as symptoms improve is generally recommended.
● Consider adjusting the antibiotic therapy to Ciprofloxacin or Ceftriaxone for 5-7 days,
while emphasizing hydration and a bland diet. Vitamin C might not be essential in
treating Salmonella.

(c ). A 7 year old boy had pain and weakness of left leg for 3 days. He was diagnosed by a private
practitioner as a case of poliomyelitis. He was prescribed:

Placentrix inj. 1 amp. x 20 days

Ampicillin syp. 1 tsp x q.i.d.X 3 days
Sioneurons tab. 1 o.d. x 30 days.

There are several issues with the prescriptions given for the 7-year-old boy diagnosed with suspected
poliomyelitis:

● Placentrix Injection: Placentrix (Placental Extract) lacks evidence for treating poliomyelitis,
making it an unconventional and unsupported therapy for this viral infection.
● Ampicillin Syrup: Ampicillin, an antibiotic, is ineffective against poliomyelitis, a viral condition.
Its use without a bacterial infection may lead to antibiotic resistance and is not recommended.
● Sioneurons Tablet: Sioneurons, a multivitamin-mineral combination, isn't specifically indicated
for treating poliomyelitis. While beneficial for overall health, it doesn't address this viral
disease.

Poliomyelitis treatment typically involves supportive care, symptom management, and physical
therapy. Specific antiviral medications, such as polio immunoglobulin or drugs such as Ribavirin (in
specific situations), might be considered in certain situations. However, there's no standard antiviral
treatment for poliovirus infection.

2. (a) A 45 year old executive reports with 15 years history of chronic amoebiasis. Stool examination
revealed E.H. cysts 14 years ago, but subsequently all tests including barium studies were normal.
He had diarrhoea of 3 days duration. Per abdomen - colon was palpable in left iliac fossa. He was
prescribed:

Dyrade-M tab. 2 t.d.s. x 5 days

Baralgan tab. 1 t.d.s. x 3 days
Ampicillin cap. 500mg q.i.d. x 5 days
Vitamin C tab. 500 mg o.d.
Pectokab 15 ml t.d.s. x 5 days.

The prescription provided for the 45-year-old executive with a history of chronic amoebiasis and
recent onset diarrhea includes several medications:

● Dyrade-M, primarily used for diarrhea and dehydration, may not target the specific cause of
chronic amoebiasis despite addressing symptoms.
● Baralgan an NSAID, may relieve abdominal discomfort but poses risks for individuals with
intestinal inflammation or chronic gastrointestinal issues.
● Ampicillin, an antibiotic prescribed, might not effectively treat chronic amoebiasis caused by
Entamoeba histolytica; alternatives like metronidazole or tinidazole are more suitable.
● Vitamin C lacks established efficacy in managing amoebiasis-related symptoms and may not
directly impact the infection.
● Pectokab, an antidiarrheal agent, may alleviate diarrhea symptoms but doesn't directly address
 the underlying cause of chronic amoebiasis.

Alternate Drug Suggestions:

● Metronidazole or Tinidazole: These are the recommended medications for treating chronic
amoebiasis caused by Entamoeba histolytica.
● Loperamide: It is an anti-diarrheal agent that could be considered to manage diarrhea
symptoms.
● Oral rehydration solution (ORS): Essential for rehydration in cases of diarrhea to prevent
dehydration.

(b) A 13 year old boy (30 Kg) with recurrent mild pain abdomen was found to be clinically normal.
The stool examination revealed ascaris and a few hook-worm ova. He was prescribed:

Piperazine citrate tab. 3gm at night

Pyrantel pamoate tab. 400 mg.

The prescribed medications, Piperazine citrate and Pyrantel pamoate, are commonly used
Anthelmintic drugs to treat intestinal worm infections, including ascariasis (caused by roundworms
like ascaris) and hookworm infections. However, there are some points to consider and alternative
choices that can be discussed:

● Piperazine Citrate (3g at night)

○ Effective against roundworms like ascaris; dosage prescribed falls within standard
range.
○ Multiple doses may be required for complete parasite elimination.
● Pyrantel Pamoate (400 mg)
○ Effective against roundworms and hookworms; appropriate dosage for common
intestinal worm infections.

Alternatives Considerations:
● Albendazole or Mebendazole are broad-spectrum anthelmintics and potential alternatives if
resistance or incomplete response to Piperazine or Pyrantel occurs.
○ Depending on infection severity, repeated doses may be needed. Follow-up stool
examinations are advised for full parasite clearance.
○ Considering potential adverse effects and drug interactions, healthcare providers must
review medical history and allergies before prescribing anthelmintics.

(c). A 30 year old bus driver reported with complaints of severe headache, cold hoarse voice and
unproductive cough. He had no fever or lung signs. Investigations: TLC : 8,400/cc DLC : N68 L30
E2 He was prescribed:

Mox cap. 500 mg t.d.s. x 5 days

Otrivin nasal drops q.i.d.
Actifed tab. 1t.d.s.
Benadryl expectorant 10 ml t.d.s.
Vitamin C tab. 500 mg o.d.
Corbutyl tab. 1 t.d.s.
Dequadin lozenges 1 s.o.s.
Avoid cool drinks for 1 week.
The prescription provided to the 30-year-old bus driver appears to address symptoms of severe
headache, cold, hoarse voice, and unproductive cough. The prescribed medications aim to alleviate
symptoms and manage the suspected upper respiratory tract infection.
 ● Mox (Amoxicillin) 500 mg t.d.s. x 5 days - Antibiotic targeting potential bacterial infection due
to symptoms like cough and hoarse voice.
● Otrivin nasal drops q.i.d. - Nasal decongestant to alleviate stuffy or runny nose symptoms
associated with cold or allergies.
● Actifed tab. 1 t.d.s. - Contains antihistamine and decongestant to relieve common cold
symptoms like runny nose, sneezing, and congestion.
● Benadryl expectorant 10 ml t.d.s. - Contains guaifenesin to aid in loosening mucus, facilitating
easier coughing, and relieving chest congestion.
● Vitamin C tab. 500 mg o.d. - Supplementation to support the immune system and potentially
reduce severity or duration of cold symptoms.
● Corbutyl tab. 1 t.d.s - Relieves abdominal discomfort associated with gastrointestinal issues.
● Dequadin lozenges 1 s.o.s. - Contains an antiseptic for sore throat relief.

Considerations:
● Caution advised on antibiotic use to prevent antibiotic resistance; confirmation of bacterial
infection before administration.
● Monitoring for potential interactions or adverse effects, especially phenylephrine's impact on
blood pressure and Actifed's interaction with hypertension.
● Potential alternative therapies like Saline nasal spray or Steam inhalation to manage
congestion without rebound effects.
● A watchful waiting approach could have been considered due to the absence of lung signs and
fever before prescribing antibiotics.

3. (a) A 40 year old male teacher presented with a growing patch on his back with severe itching.
The margins were raised, spreading revealed scratch marks. He was prescribed:

Betnovate-N cream for external use.

The prescription of Betnovate-N cream for the described condition of a growing patch on the back
with severe itching, raised margins, and scratch marks raises concerns.

● Betnovate-N contains betamethasone (a potent corticosteroid) and neomycin (an antibiotic).

Prolonged use, especially when the cause is uncertain, can lead to adverse effects like skin
thinning and exacerbation if the condition is caused by an infection.
● The inclusion of Neomycin might be inappropriate if the cause isn't confirmed as bacterial, as
extended use of topical antibiotics can lead to resistance and skin sensitization.
● A more suitable initial approach could involve using a mild, non-steroidal, and non-antibiotic
cream, like a simple moisturizer or a lower-potency hydrocortisone cream, to alleviate itching.

(b) A 12 year old patient complained of passing watery stools for 4 days. On examination:

Pulse: 92/mt, low in volume

BP : 90/60 mm Hg
Mildly dehydrated
No abnormality detected in cardiovascular, respiratory or gastrointestinal system.

He was prescribed: Chloromycetin cap. 250 mg q.i.d. x 5 days

The prescription of Chloromycetin (chloramphenicol) capsule 250 mg four times a day for five days to
a 12-year-old patient with watery stools and signs of dehydration raises concerns due to several
reasons:
 ● Chloramphenicol, prescribed at a dosage of 250 mg four times a day for five days to a 12-year-
old experiencing watery stools and signs of dehydration, raises concerns for various reasons:
● Chloramphenicol, though effective against certain bacterial infections, is not the first-line
treatment for diarrhea, especially if viral or parasitic causes are suspected. It can pose serious
risks, such as bone marrow suppression, particularly in younger patients.
● Addressing dehydration adequately is crucial, and the prescription lacks emphasis on
rehydration therapy, like oral rehydration solution (ORS), vital for managing diarrhea-related
dehydration.
● Administering antibiotics without conducting stool tests to identify the specific pathogen might
not be suitable. Empirical treatment without a clear diagnosis can contribute to unnecessary
antibiotic use and antibiotic resistance.
● Given the patient's low blood pressure (90/60 mm Hg), concerns arise regarding potential
complications linked to chloramphenicol, known for adverse effects on blood cell production
that could further impact blood pressure and overall health.

Recommendations:
● Undertake stool tests to ascertain the cause of watery stools, whether bacterial, viral, or
parasitic, before prescribing antibiotics.
● Prioritize rehydration through ORS or intravenous fluids to manage dehydration associated
with diarrhea.
● Consider alternative antibiotics based on identified pathogens, considering the patient's age
and antibiotic sensitivity.
● Exercise caution with chloramphenicol due to its severe side effects, especially in pediatric
patients, using it only when specifically indicated and under close monitoring.

(c ) A 8 year old boy was brought with severe abdominal pain, constipation and vomiting of one day
duration. He passed round worms a day prior to the onset of symptoms. He was a known case of
epilepsy receiving gardenal daily.

The following were found on examination:

Weight : 20 Kg.
Afebrile, not dehydrated, not toxic
Per abdomen: Soft, no tenderness, no rigidity, a vague mass was felt to the right of umbilicus.

Treatment:
Siquil inj. 1ml i.m. stat
Baralgan inj. 1ml i.m. stat
I.V. fluids
Piperazine citrate 2 tsp at bed time.

There are several issues and concerns with the provided treatment for the 8-year-old boy with
abdominal pain, constipation, vomiting, and a history of passing roundworms:

● Siquil inj. and Baralgan inj.: These medications are not standard or commonly used, and it's
crucial to avoid unverified medications in pediatric cases to prevent potential harm.
● I.V. fluids: While intravenous fluids are standard for managing dehydration, their type and
volume should be adjusted based on the child's condition.
● Piperazine citrate: Used for worm infections, but its administration in children should be based
on weight and specific infection type.

Alternate Choices:
 ● Acetaminophen or Ibuprofen could be considered for abdominal pain relief in appropriate
pediatric doses.
● Opt for oral medications or recognized formulations rather than unspecified injectable ones for
pain relief.
● Anthelmintic drugs like Mebendazole or Albendazole, typically used for roundworm infections
in children, could be considered after evaluation by a healthcare professional.

4. (a) A 8 year old boy came with history of fever and right sided chest pain which exaggerated on
coughing. PA view of x-ray chest showed right sided consolidation. He was diagnosed as a case of
pneumococcal pneumonia based on clinical and laboratory investigations.
He was subsequently prescribed:

Dexamethasone tab. 1 tab. x 2 days

Paracetamol tab. 500 mg t.d.s x 5 days
Mix. cough expectorant 1 oz s.o.s. x 5 days
Calmpose tab. 5mg at bed time
Terramycin solution 50mg t.d.s. x 5 days

There are some concerns and potential issues with the prescription provided for the 8-year-old boy
diagnosed with pneumococcal pneumonia:

● Dexamethasone - While controversial, using dexamethasone in pneumonia treatment for

children requires assessment of severity and underlying conditions justifying its use.
● Paracetamol (Acetaminophen) - Suitable for managing fever and pain with a dosage of 500 mg
thrice daily for five days
● Mix. Cough Expectorant - Caution advised in prescribing expectorants without evident mucus
production in children with pneumonia due to uncertain benefits and potential side effects.
● Calmpose (Diazepam) - Using diazepam in pneumonia treatment for children isn't a standard
practice and should be avoided without specific indications due to the risk of respiratory
depression.
● Terramycin Solution - Not recommended for treating pneumococcal pneumonia; antibiotics like
amoxicillin or amoxicillin-clavulanate are typically preferred as first-line treatments due to
efficacy against Streptococcus pneumoniae and lower resistance concerns.
●
Alternate Choices
● Amoxicillin or Amoxicillin-Clavulanate are commonly preferred as initial antibiotics for treating
pneumococcal pneumonia in children.
● A pediatrician might select an antibiotic regimen considering the child's weight, severity of
symptoms, and local antibiotic resistance profiles, if needed.
● In case of a bothersome cough affecting sleep or causing considerable discomfort, cough
suppressants could be an option instead of expectorants.

(b). An one year old boy had persistent vomiting and watery diarrhoea. He had not passed urine for 2
days.
On Examination:
Weight: 9 Kg.
Dehydration 10%

Treatment:
Siquil inj. 1ml i.m. stat
Chlorostrep suspension 1 tsf x 6 hrly
Lomotil tab. 1 t.d.s.
Electral forte orally.

There are several concerning issues and potential improvements that can be made in the provided
prescription for the one-year-old boy with persistent vomiting, watery diarrhea, and signs of
dehydration:

● Siquil inj. 1ml i.m. stat - The medication is unfamiliar and raises safety concerns, particularly
for a child. Clarification and verification of its appropriateness for pediatric use are necessary.*
● Chlorostrep suspension 1 tsf x 6 hrly - Clarity on the specific drug is required to evaluate its
suitability for a child with gastrointestinal issues.
● Lomotil tab. 1 t.d.s. - Not recommended for children under 2 years old due to potential side
effects like respiratory depression. Its use in a one-year-old might not be safe.
● Electral forte orally - This oral rehydration solution is appropriate for managing dehydration
caused by vomiting and diarrhea. However, monitoring the child's intake and response to
treatment is crucial.

Recommended Adjustments

● Immediate medical attention is crucial due to signs of dehydration and lack of urine output.
Hospitalization for intravenous fluid administration might be necessary.
● Continuation of oral rehydration therapy with an age-appropriate electrolyte solution while
closely monitoring the child's hydration status.
● Avoidance of anti-diarrheal medications like Lomotil due to safety concerns in young children.
Prioritize supportive care, fluid replacement, and identifying the underlying cause of diarrhea.

(c) A 45 year old lady suffering from hypertension was put on reserpine (0.5 mg/b.i.d.) and
hydrochlorthiazide (25mg o.d.). She developed diarrhoea. Stool examination and culture were
inconclusive.

She was prescribed:

Mix. Kaolin 1 oz t.d.s x 7 days
Ampicillin cap. 500 mg q.i.d. x 7 days
Metronidazole tab. 800 mg t.d.s. x 7 days

The prescription provided for the 45-year-old lady with hypertension who developed diarrhea after
taking reserpine and hydrochlorothiazide raises some concerns and requires analysis:

● Kaolin Mixture - Prescribing kaolin for seven days might not be necessary without a confirmed
cause of diarrhea and could potentially lead to constipation and nutrient absorption issues due
to prolonged use.
● Ampicillin - While effective against bacterial infections, prescribing ampicillin for nonspecific
diarrhea without evidence of a bacterial cause may contribute to antibiotic resistance and is not
ideal.
● Metronidazole - Its use for nonspecific diarrhea without clear evidence of a specific infection
may not be justified, as it targets certain bacterial and protozoal infections and should be used
selectively.

Alternatives to consider:
● Loperamide - Useful for symptomatic relief in acute diarrhea but should not mask underlying
causes. Consider short-term use for symptom relief instead of immediate antibiotic
prescription.
 ● Probiotics - Instead of immediate antibiotic use, consider probiotics to restore gut flora
disturbed by diarrhea, particularly if the cause is not confirmed as bacterial.
● Clostridium difficile Testing - Given inconclusive stool examination and culture, testing for
Clostridium difficile infection might be considered, as it commonly causes antibiotic-associated
diarrhea. Specific antibiotics like Vancomycin or Fidaxomicin might be appropriate if confirmed.

5 (a) A 7 year old boy was brought by his mother with infected scabies. He was prescribed
Inj. Procaine Penicillin 2 lacs im daily for four days. The mother volunteered that other siblings too
had similar lesions.

The prescription of Inj. Procaine Penicillin 2 lacs IM daily for four days for a 7-year-old boy with
infected scabies might not be the most appropriate choice.

● Administering Inj. Procaine Penicillin 2 lacs IM daily for four days for a 7-year-old boy with
infected scabies might not be the optimal treatment as scabies is caused by mites, not
bacteria, making antibiotics like penicillin ineffective.
● Scabies is usually treated with topical agents like Permethrin or Oral medications such as
Ivermectin, rather than antibiotics.
● The use of penicillin injections in this case could be unnecessary and potentially harmful due to
the risks associated with unnecessary antibiotic use and possible adverse effects of penicillin.

Considering the involvement of other siblings with similar lesions, appropriate treatment with topical
permethrin or oral ivermectin should be considered to address potential spread within the family.
● Topical Permethrin is generally effective and safe for treating scabies, while Oral Ivermectin
may also be considered, especially when dealing with widespread infestation among family
members.

(b) A 20 year old woman accidentally cut herself with a kitchen knife while preparing food. She was
prescribed

Inj. Tetanus toxoid 0.5ml im stat

Cap. Amoxycillin 250 mg t.d.s X 7 days

The prescription for the 20-year-old woman who accidentally cut herself includes:

● Inj. Tetanus toxoid 0.5ml im stat: Administered as a single intramuscular dose, the tetanus
toxoid injection is essential to prevent tetanus infection in cases of injury or wound
contamination, particularly when the tetanus vaccination status is uncertain or outdated.
● Cap. Amoxicillin 250 mg t.d.s X 7 days: Prescribed as a seven-day course, the oral antibiotic
amoxicillin, taken at 250 mg three times daily, serves as a preventive measure against
potential bacterial infections at the wound site, especially for skin or soft tissue injuries.
● Antibiotic prophylaxis might not always be necessary for minor, clean wounds, unless specific
risk factors exist (e.g., immunocompromised status, deep or contaminated wounds). In such
cases, healthcare providers may opt for alternative strategies like proper wound care and
vaccination.
● Consideration for alternative antibiotics, such as cephalosporins or macrolides, might be
necessary in case of allergies to penicillin-based antibiotics like Amoxicillin.

(c) A 24 year old woman with rheumatic heart disease was to undergo extraction of her third molar
tooth. She was not receiving any prophylaxis. After the extraction she was prescribed
Inj. Gentamicin 80 mg im daily for 7 days
The prescription of intramuscular (IM) Gentamicin 80 mg daily for 7 days after a dental extraction for
a 24-year-old woman with rheumatic heart disease raises some concerns:

● Gentamicin is not typically used as prophylaxis for dental procedures or routine post-tooth
extraction care, despite its effectiveness against bacterial infections.
● The duration of 7 days for Gentamicin after a dental extraction without signs of infection is
excessive, potentially increasing the risk of adverse effects like kidney damage or hearing loss,
especially with intramuscular administration.
● The prescription of Gentamicin for post-extraction prophylaxis in a young woman with
rheumatic heart disease seems inappropriate due to its unconventional use, potential side
effects, and unclear necessity after dental procedures.

Alternate Drug Suggestions

● Amoxicillin or Clindamycin are commonly recommended for prophylaxis after dental
procedures in patients with cardiac conditions like rheumatic heart disease, but their use
should align with guidelines and the patient's specific health status to prevent bacterial
endocarditis.