Clinical Pharmacotherapeutics Past paper 2012 9th Semester University of Lahore

THE UNIVERSITY OF LAHORE-ISLAMABAD CAMPUS

SCHOOL OF PHARMACY

Subject: Clinical Pharmacotheraputics	Session:                 Pharm-D IX-Semester
Total Marks:  25	Date: 13/11/2012
Time Allowed:  2.hrs	Paper:                    Mid-term
Name:	Roll No.

A 56-year-old man with a history of hypertensionand cigarette smoking is admitted to the intensive careunit after 1 week of fever and nonproductive cough. Imagingshows a new pulmonary infiltrate, and urine antigentest for Legionella is positive. Each of the following islikely to be an effective antibiotic except

A. azithromycin

B. aztreonam

C. levofloxacin

D. tigecycline

E. trimethoprim/sulfamethoxazole

A 79-year-old man has had a diabetic foot ulceroverlying his third metatarsal head for 3 months but hasnot been compliant with his physician’s request to offloadthe affected foot. He presents with dull, throbbingfoot pain and subjective fevers. Examination reveals aputrid-smelling wound notable also for a pus-filled 2.5cm wide ulcer. A metal probe is used to probe thewound and it detects bone as well as a 3-cm deep cavity.Gram stain of the pus shows gram-positive cocci inchains, gram-positive rods, gram-negative diplococci,enteric-appearing gram-negative rods, tiny pleomorphicgram-negative rods, and a predominance of neutrophils.Which of the following empirical antibioticregimens is recommended while blood and drainagecultures are processed?

A. Ampicillin/sulbactam, 1.5 g IV q4h

B. Clindamycin, 600 mg PO tid

C. Linezolid, 600 mg IV bid

D. Metronidazole, 500 mg PO qid

E. Vancomycin, 1g IV bid

A 30-year-old healthy woman presents to the hospitalwith severe dyspnea, confusion, productive cough, and fevers.She had been ill 1 week prior with a flulike illnesscharacterized by fever, myalgias, headache, and malaise.Her illness almost entirely improved without medical interventionuntil 36 h ago, when she developed new rigorsfollowed by progression of the respiratory symptoms. Oninitial examination, her temperature is 39.6°C, pulse is 130beats per minute, blood pressure is 95/60 mmHg, respiratory

rate is 40, and oxygen saturation is 88% on 100% face mask. On examination she is clammy, confused, and verydyspneic. Lung examination reveals amphoric breathsounds over her left lower lung fields. She is intubated andresuscitated with fluid and antibiotics. Chest CT scan revealsnecrosis of her left lower lobe. Blood and sputum culturesgrow Staphylococcus aureus. This isolate is likely to beresistant to which of the following antibiotics?

A. Doxycycline

B. Linezolid

C. Methicillin

D. Trimethoprim/sulfamethoxazole (TMP/SMX)

E. Vancomycin

In the inpatient setting, extended-spectrum-lactamase(ESBL)-producing gram-negative infections aremost likely to occur after frequent use of which of the followingclasses of antibiotics?

A. Carbapenems

B. Macrolides

C. Quinolones

D. Third-generation cephalosporins

A 22-year-old recent immigrant to the Pakistan has never been vaccinated for tetanus.He sustains a minor, but soil-contaminated, injury. Which of the following statements iscorrect?

(A) tetanus usually develops within 2 weeksfollowing exposure

(B) tetanus always develops within 4 hoursfollowing exposure in patients whohave not been previously immunized

(C) tetanus may develop many months oryears following exposure in susceptibleindividuals

(D) the usual incubation period for tetanusis 48 hours

(E) tetanus may be prevented withPenicillin

Which of the following is the next mostcommon cause of blood transfusion-relatedhepatitis after hepatitis B?

(A) hepatitis A

(B) Epstein-Barr hepatitis

(C) hepatitis C

(D) hepatitis D

(E) HIV hepatitis

A 34-year-old man is seen for asymptomaticelevations in his AST and ALT. He appears welland the physical examination is normal. Thereis no prior history of intravenous drug use, bloodtransfusions, or multiple sex partners.His hepatitis serology is positive for the virus, most likely to lead to chronic infection.

(A) hepatitis A virus

(B) hepatitis B virus

(C) hepatitis C virus

(D) hepatitis D virus

(E) hepatitis E virus

A38-year-old woman is worried about a recentpotential exposure to an individual with activeviral hepatitis. She is seeking treatment for viralhepatitis for which passive immunotherapycan provide some protection.

(A) hepatitis A virus

(B) hepatitis B virus

(C) hepatitis C virus

(D) hepatitis D virus

(E) hepatitis E virus

A 49-year-old man comes to your office, requesting testing for hepatitis C. He recently attended his 25-year college reunion, where he heard from a mutual acquaintance that an old friend was seriously ill with cirrhosis due to hepatitis C. The patient became very concerned because he had "partied" with this friend during a brief period of experimentation with injection drugs while in college. The patient is otherwise healthy and denies any symptoms except for occasional fatigue after a long day at work. Physical examination of the patient is unremarkable. There are no stigmata of chronic liver disease.Which of the following is the most appropriate course of action?

A)Check a quantitative HCV PCR ("viral load").

B)Order a recombinant immunoblot assay (RIBA).

C)Order an HCV antibody test (enzyme immunoassay).

D)Order a qualitative HCV PCR.

The patient's liver biopsy shows mild to moderate inflammatory activity and portal and periportal fibrosis (Stage 2). He is relieved to find out that he does not have cirrhosis, but remains very concerned about his hepatitis and wants to do everything possible to "get rid of" the hepatitis C. He asks about treatment for his HCV.You tell him which of the following?

A) Combination therapy with interferon and ribavirin results in sustained virologic responses (SVR) in 40-70% of patients treated.

B) Failure to attain a 2-log10 drop in the quantitative HCV PCR in the first 12 weeks of antiviral treatment is a predictor of treatment failure.

C) Combination therapy with interferon and ribavirin can cause numerous side effects, including cytopenias, flu-like symptoms, worsening of autoimmune conditions, depression, and hemolytic anemia.

D) The HCV genotype is a strong predictor of response to treatment.

E) All of the above.

Clinical Case (10-Marks)

Chief Complaint

“My family doctor told me that my liver function tests wereabnormal. I’ve been a little more tired than usual, but I thought thatwas because of menopause. I’ve also been retaining more fluid in mylegs, been dizzy and lightheaded at times, and having more headachesthan I did last year. I’ve lost some weight lately, too, but that’sgood, isn’t it?”

HPI

Linda Lane is a 49-year-old woman who has been referred by herfamily physician to the liver clinic for assessment of her abnormalliver enzymes. She reports remote use of recreational drugs inhigh school, including marijuana, alcohol, occasional amphetamines,and IV cocaine. She still drinks alcohol occasionally (2–4glasses of wine once or twice a week), but otherwise has been“drug free” since her mid-twenties when she was married. Shestates that she feels fine much of the time, but sometimes hasfatigue, fluid retention, headaches, and difficulty sleeping. She

tends to get dizzy on exertion at times. She has lost about 10pounds in the last 2 months, which she attributes to reducedappetite, since her activity level has diminished. She is premenopausal and has isolated episodes of hot flashes and flushes but stillmenstruates on a regular 25-day cycle. She has no past history ofliver problems.

PMH

IV drug abuse in high school,HTN,GERD,Early menopause

FH

No known family history of liver disease. Both parents are alive, stillliving independently, and doing reasonably well considering theyare in their early 80’s. Her father has HTN, her mother hashypothyroidism and a chronic “bathroom problem.” One olderbrother with DM Type 2, HTN, and GERD.

SH

Married for 24 years; two children in college. Non-smoker; deniesillicit drug or inhalant use; drinks two to four glasses of wine onceor twice weekly.

ROS

Denies any signs or symptoms of liver diseases except for nonspecificconstitutional symptoms such as fatigue and headaches. Nochanges in urine color. Recalls having icteric sclerae and a period ofsevere fatigue and nausea in high school, which she had thought tobe “mono.”

Meds

MVI 1 tablet po daily × 1 year

Calcium citrate with vitamin D 1 tablet po BID × 1 year

Protonix 40 mg po once daily × 2 years

Norvasc 10 mg po once daily × 5 years

Acetaminophen 500 mg 1–2 tablets up to 3 times daily PRN for

headaches and other body aches (averages 3–4 tablets per day)

Allergy

No known drug or food allergies

Physical Examination

Gen

Well-nourished woman

VS

BP 100/63, P 72, RR 17, T 37.0°C; Wt 61 kg, Ht 5'4''

Skin

No jaundice; no spider angiomata or palmar erythema

HEENT

Sclera anicteric; funduscopic exam normal

Neck/Lymph Nodes

Neck supple; no lymphadenopathy or thyromegaly; no carotidbruits

Lungs

Normal breath sounds

CV

S1, S2 normal; no S3 or S4

Abd

Liver span 11 cm; spleen not palpable; no evidence of ascites

MS/Ext

+1 edema in LE bilaterally; peripheral pulses 2+ throughout

Neuro

CN II–XII intact;

Labs:-Na 140 mEq/L Hgb 13.0 g/dL AST 177 IU/L HbsAg (–),K 4.0 mEq/L Hct 39.3 % ALT 198 IU/L Anti-HAV (–), Cl 100 mEq/L Plt 220 × 103/mm3 Alkphos 86 IU/L Anti-HCV (+), CO2 28 mEq/L WBC 6.7 × 103/mm3 T. bili 1.5 mg/dL HCV RNA (bDNA assay) 4.4 million copies/mL,

BUN 11 mg/dL 67% PMNS Alb 3.5 g/dLSCr 1.0 mg/dL 3% Bands PT 12.3 sec HCV genotype 1

Glu 111 mg/dL 20% Lymphs ANA (–) HIV (–),TSH 2.32 ìIU/mL10% Monos

Q.No.1)What physical findings, laboratory values, and medical history information suggest the presence of chronic hepatitis C virus (HCV) infection?

Q No 2)Design a Pharmacotherapeutic plan for this patient. Include thedrug, dose, schedule, and duration of therapy?

Q.No 3)With respect to the patient’s other drug therapy, are there anydrug related interventions that need to be made?

Q.No 4)Which baseline parameters of this patient have been suggestedas predictors of poor response to the treatment you recommended?

Q.No.5)How should the therapy you recommended for HCV infectionbe monitored for efficacy and adverse effects?

Q.No1) a) A Patient came in to the emergency department with Bloody diarrhea, high grade fever with chills and rigors. O/E He didn’t have any Respiratory, Urinary source of infection. You ordered Typhi dot test and found O" agglutinin antibody titer ≥1:80 and "H" ≥1:160.How will you treat this patient?

b)Write down the Critical phase of Dengue?(5-Marks)

OR

Q.No2) a) A 35-yr old patient came to the emergency department with LOC and severe dehydration which you checked by skin pinch test.Patient has history of 6-episodes of loose motion and 4 episodes of Vomiting since morning .There is no any H/O Hepatitis and other diseases.you suspect that patient hs Cholera. How ll you treat this patient?

b)Write down the Clinical features of Tetnus? (5-Marks)