CENTRAL NERVOUS SYSTEM

1. Parkinson's disease

R
Fixed dose combination
of tab Levodopa + Carbicdopa (100 mg + 25 mel
8
half tablet TDS
To follow up after 15 days for dose evaluation and dose
adjustment jf
necessary.
Dr. ABC
Reg. No.
Important Points
Dose of levodopa can be increased to maximum of 2
Treatment of Parkinson's has to continued life
gm per day.
long.
Instead of Levodopa, Tab Benzhexol, Tab Selegiline, Amantadine
may be used.
2. Drug-induced Parkinsonism

R
Tab Benzhexol (Trihexyphenidyl) 2 mg 1/4th tablet TDS daily
increased to maximum 1 tabletTDS.
Dr. ABC
Reg. No.:
Important Points
Instead of Tab Benzhexol, Tab
TabPromethazine can be used.
Trihexyphenidyl, or Tab Biperiden or

Acute dystonic reaction after

Inj Metoclopramide.
Inj Promethazine 25 mg TDS.
3. Generalized tonic-clonic seizures
(Grand mal Epilepsy)
R
.Tab Phenytoin Sodium 100 mg BD after food for 15 days (maximum
dose 600 mg/day)
OR
Tab
Carbamazepine 200 mg BD for 15 days (maximum 1200
To follow
up after 15 days
for evaluation and dose mg/day)
sary. adjustment neces
if

Dr. ABC

mportant Points Reg. No.

The dose of phenytoin has to be
control seizures. increased gradually to a dose tha
 p h e n y t o i n 1s 600 mg per day.
dose ol
um
Tab Carbamazepine, or Tab Phenobarbitor
nstead
of Phenytoin
been continued for at least 5 years.
can t for epilepsy has
child (absence selzures)
in 3-year-old
a l seizures
4. Per

BD 15days.
Ethosusinmide
250 mg/ml/5 ml
.r after 15 days for evaluation and dose adjustment if necessary.
Dr. ABC
Reg. No.:

Important Points

can de increased to a maximum of 1 gm per

Dose of ethosuximide
day. with caution for the fear of causing
should be u s e d
Sodium valproate
children.
in
fatal hepatitis alternative.
can be u s e d a s
Lamotrigine

mal Epilepsy
3. Petit

200 mg TDS gradually increase at weekly interval

Tab sodium valproate
to
maximum of 800 mg/day.
Dr. 4ABC
Reg. No.:

6. Insomnia

R:
at bedtime.
Tab Diazepam 5 mg once

or

'lab Zolpidem 5 mg once at bedtime (Hs)

Dr. ABC

Reg. No.

Important Points
'lhe cause
of Insomnia has to be investi8ated.
'Hypnotics are best used only intermittentuy.
a Benzodiazepine is used for more than 15 days the dose should be

tapered slowly.
7. Status Epilepticus

R
L.0razepam
10 ninutes. 4
mg IV at the ratee of
ot 21ug/min, repeated once alter
 Proscriptions49

In Diazepam 10 mglN. slowly every 15 minutes upto maximum ot 0

mg till convulsions are controlled.
Inj Phenytoin sodium 15
of 20 mg/min.
nng/kg to be given as IV infusion at the rate

Dr. ABC
Reg. No.:
mportant Points
After convulsions stop change over to Tab Phenytoin 100 mg TDS tor
15 days.
Dose of diazepam be
can
repeated 4 hourly, to maximum 100 mg8
day.
Instead of lnj
Phenytoin, Inj Phenobarbitone, inj Fosphenytoin
can be administered.
8. Acute attack of
moderate migraine
R
Tab Ergotamine caffeine ( 1 mg+ 100 mg) 1 tab immediately at the
+

onset of headache. Then 1/2 tab

every half hourly.
Dr..ABC
Reg. No.
Important Points
-The max dose of ergotamine that can be used for the acute attack is
6 tablets.
-

Instead of Ergotamine, Tab Aspirin,

Tab Ibuprofen, Inj Sumatriptan
may be used at the onset of headache.
After the attack subsides start
acute
prophylaxis with Tab Propranolol
40 mg BD for 6 weeks is given.

9. Acute attack of severe

migraine
R
Sumatriptan (6 mg/0.5ml). 6 mg SC may be repeated after 1 hour.
(Max 12 mg/day).
Inj Metoclopramide 10 mg I.M.
Followed by prophylaxis with Tab Flunarizine 10 mg OD.
Dr..ABC
Reg. No.:
Important Point
If the acute attacks are recurrent then start prophylaxis with Tab
Propranolol 40 mg BD for 6 weeks. Maximum dose of Propranolol is
300 mg/day.
10. Prophylaxis of Migraine (>4 attack/month)
Tab Flunarizine (10 mg) 1 tablet OD at bed time

Important Points
Tab Propranolol 40 mg BD or Amitriptyline can be prescribed.
Instead of Inj Ergotamine, Inj Sumatriptan can be given.
-Instead of Flunarizine, Propranolol, Amitriptyline can be prescribed.
11. Acute attack of Trigeminal neuralgla
R
Tab Carbamazepine (100) mg TDS, gradually increased to 200 mg
TDS within 3 weeks.
Dr. ABC
Reg. No.:
12. Motion sickness

R
Tab Promethazine 25 mg, the first dose taken one hour before the
start of the journey then QDS.
Dr. ABC
Reg. No.:

13. Headache

R
Tablbuprofen 200 mg stat as and when required.
Dr. ABC
Reg. No.:

Important Point
Instead of Ibuprofen, Tab Aspirin, Tab Paracetamol can be given.
14. Preanaesthetic medication

R
I n j Atropine 0.6 mg IM
.Inj Pethidine 50 mg IM/slow IV surgery
I n j Diazepam 5 mg/V
Inj. Promethazine 25 mg IM
Dr. ABC
Reg. No.:

15. Postoperative pain

R
I n j Diclofenac 75 mg IM 12 hourly.
Dr. ABC
Reg. No.:
 Postoperative pain (severe).
16.

R: IM every 6 hours or Inj

Pentaz0cine 0mg M
Pethidine 100 mg
Inj
every 6hours.
Dr. ABC
Reg No

17. Anxicty

R weeks. Review after 2 weeks for

(0.5 mg) BD for 2
T a b Alprazolam

dose adjustment. Dr. ABC

Reg. No.:

18. Febrile covulsions

retention
enema,
ifseizure
5 ml) 2.5 ml Rectallyas
Diazepam (10 mg after 10
minutes

does not stop. repeat

19. Post-herpetic Neuralgias

weeks.
(100 mg) TDS for 3
T a b Gabapentin

20. Vertigo for 2 weeks

Cinnarizine (25 mg) TDS
Tab

21. Acute Depression weeks

OD for 2
s e r a l i n e 50 mg
Tab

22 Schizophrenia
10 mg OD
for 7 days
T a b olanzapine
Follow-up for evaluation.

23. Acute Mania

10 mg OD for 7 days.
olanzapine
Tab
Diazeparm
5 ng twice daily
Important Point can also be given
haloprridol
risprridonr,
Others likr quetiapine,

alan
200 1ng
24. Bipolar depression werkly (AMax alose
Inerrase 25 mg
Lamotrigine
25
ng OD.
disorder)
disorder (Bipolar inereased to mav
25. Manic an he
09 ng/day.
Sodium valprnate

2000 mg/day.
 Criticism 73

(CENTRAL NERVOUS SYSTEMM)

1. Comment correct and rewrite the
following prescription for pat a
ient who complains of tremors of fingers, rigldity of faclal muscles
and mental depression diagnosed Parkinson's. Do not
as criticise
the format of the prescription.

Tab Levodopa 100

Tab
mg once daily.
Pyridoxine 10 mg twice daily.
Dr. ABC
Criticism:
Levodopa is the correct drug for treatment of this patient but it is never
given alone because 98% of it gets peripherally decarboxylated to
allow only 25% to reach the brain. It is available as fixed dose combi-
nation with carbidopa. Carbidopa prevents the peripheral decarbox-
ylation of Levodopa so that more is made available to cross the blood
brain barrier to reach the site of the action.
The dose given is incorrect. It is started with the combination of
(Levodopa Carbidopa) (100 mg + 25 mg) thrice daily to max of
Levodopa of 2 gm.
Pyridoxine is Vitamin B6, which is a co factor for enzyme for dopa
decarboxylase, Given along with levodopa it would increase the
peripheral decarboxylation, thereby decreasing the therapeutic
effect of Levodopa.
Note: Anti-Dopaminergics (Phenothiazines, Haloperidol, Metoclopr
amide but not Domperidone) also reverse the therapeutic effect
of Levodopa.
Corrected prescription:
Dr. ABC
Address
Date:

For Mr. XYZ

Age: Sex: Weight:
Address

R
.Tab Levodopa +Carbidopa (100 mg+25 mg)TDS
To follow up after 15 days for dose evaluation and dose adjustment if

necessary.
Dr. ABC
Reg. No.:
74 Practical Phamacology
or n

Comment and rewrlte the followlng prenerlptlon

correct
2 irnnd Mal selzure
old pregnant woman sufferlng from
28-year- formnt of the pre
(Generalized tonic clonic). Do not eritlelse the
scription.
R
Tab Phenobarbitone 60 mg thrice daily.
T a b Phenytoin 1 gm daily.
Dr. ABC

Criticism:
All antiepileptics are teratogenic when used in pregnaney. Pheno

barbitone is teratogenic causing Floppy baby SyndlroIne.

Tab Phenytoin Sodium is teratogenic especially in the first
trimes:
ter of pregnancy. Since anti-epileptic drug treatment should not be
stopped. Phenytoin can be replaced with Tab Carbamazepine which
is lesser teratogenic than the two. But if the decision is to continue
Phenytoin then the dose should be adjusted to the minimum thera
peutically effective dose. Therapeutic drug monitoring (TDM) should
be done with all the antiepileptic drugs during pregnancy.
EXtra supplementation of Folic acid is required in epileptic preg-
nant women treated with Phenytoin as it causes megaloblastic
anemia.
Correct prescription:

Dr. ABC
Address
Date:
For Mr. XYZ
Age: Sex: Weight:
Address

R
Tab Phenytoin Sodium (100 mg) TDS
Tab Folic acid (5 mg) TDS
To review after 15
days.
Dr. ABC
Reg. No.
3. Criticize comment and rewrite the
following prescription for a
patient to be given lignocaine 2% plus adrenaline 1:10000 for a
con-
tused lacerated wound at the tip of the toe.
Rx:

Inj lignocaine 2 % plus adrenaline 1:10000

Dr. ABC
 Criticism:
-
The combination of lignocaine is of advantage as adrenaline beca
of the vasoconstricting action would increase the duration of the
action of the lignocaine and also decrease the systemic toxicity.
The combination of adrenaline for local anesthesia in dilution of
(1:50,000 or 1:200,000)) and in the dilution mentioned above.
At end arteries, i.e. tip of fingers, toes, pinna and penis this combi
nation would be contraindicated as there is no collateral circulation
and the area could rarely go in necrosis and turn gangrenous also.
Therefore at these places only lignocaine alone and no combination
with adre:raline should be done.

Correctprescription:
Dr. ABC
Address
Date:

For Mr. XYZ

Age: Sex: Weight:
Address

R
Lignocaine 2% injection at the site
Dr. ABC
Reg. No.:

4. Grand Mal Epilepsy:

R
1 Tab. 4 times a day if not controlled
Tab Phenytoin sodium (200 mg)
add SS.
T a b Phenobarbitone (25 mg) 1 Tab 2 times a day.
Dr. ABC
Reg. No.:

Criticism: is
correct but dose is incorrect. Phenobarbitone
Phenytoin drug is
added on as control if epilepsy not controlled by phenytoin.
on page 47 of chapter
2 (no. 3).
Corrected Prescription
for an Adult:
5. Preanesthetic Medication

IV
Inj Morphine (1 mg)
Inj Diazepam (10 mg) IV
IM.
Inj Atropine (50 mg) IV
Inj Promethazine (5 mg) Dr. ABC

Reg. No.
 Criticksm

Crad f Atropine, glycopyrrolate can be given.

n of elective surgery Diazepam can be given orally in the night,

st before surgery by parenteral

route.

ead of Promethazine, Metoclopramide can be given.

Promethazine
25 mg IM
Inj
Postoperative Pain (Moderate)
6.

R (50 mg) IM 8-12 hourly.

Inj Diclofenac
1 tab. tds.
.
Tab lbuprofen
Dr. ABC
Reg. No.:
Criticism:
.Parenteral NSAIDS any one can be given.

. Post-Operative Pain (Severe)

R
.Inj Pentazocine (30 mg) IV 6 hourly.
Inj Dextropropoxyphene (65 mg) every 4 hourly along with par-
acetamol (50 mg)
Dr. ABC
Reg. No.:
Criticism:
-Insevere Post-operative pain, opioids can be given to control the
pain. Dextropropoxyphene, paracetamol need not be
added to pen-
tazocine.
Corrected prescription on 51 of
page chapter 2 (no. 16).
8. Treatment of Acute Gout
R
Tab Aspirin (200 mg) 2 tabs. 3 times a day as
long as
Tab
Allopurinol (200 mg) 1 tab. 3 times a day for 10 there is pain.
days.
Dr. ABC

Criticism: Reg. No.

Aspirin as anti-inflammatory dose may decrease pain and
on but retention of uric acid agEgravates gout.
causes inflamma.
a-

Allopurinol is drug of choice for prophylaxis

ot gOut, dose inco
OTrected Prescription on page 68 of chapter 2 (no. 1).
 Criticism77
9. Parkinsonism:

R
Inj L-dopa 10 mg/1V. stat.
Tab B-complex 1 tab. twice daily.
lab Benzhexol 2.5 mg increased up to 300 mg/day in divided
initialy
doses.
Dr. ABC

Reg. No.:

Criticism: carbidopa
combination with
Levodopa is given orally, and always in
or Benserazide.
(Pyridoxine) which increases the peripheral
B complex B,
contains
increasing synthesis dopa decarboxylase
m e t a b o l i s m of Levodopa by

enzyme. induced
Parkinsons caused by
of choice in drug
Benzhexol is drug can also be given in mild par-
( C h l o r p r o m a z i n e / m e t o c l o p r a m i d e ) ,

kinsonism.
of chapter 2 (no. 1).
Prescription
on page 47
Corrected