Patient case history and interpretation MCQs With Answer

Introduction: Patient case history and interpretation MCQs With Answer is designed for M.Pharm students to strengthen clinical reasoning and pharmaceutical care skills. This collection emphasizes real-world case histories, requiring interpretation of symptoms, laboratory data, medication lists, and drug-related problems. Questions cover assessment of adverse drug reactions, dosing adjustments in renal/hepatic impairment, medication reconciliation, drug interactions, causality assessment tools, and prioritization of therapy. Each item is crafted to encourage application of pharmacokinetic, pharmacodynamic, and clinical knowledge rather than rote memorization. Working through these MCQs will help students prepare for clinical postings, exams, and practice as clinical pharmacists involved in patient-centered care.

Q1. A 68-year-old male with chronic kidney disease (eGFR 28 mL/min/1.73m2) is on metformin 500 mg twice daily, lisinopril 10 mg once daily, and ibuprofen as needed. He presents with new-onset confusion and lactic acidosis (serum lactate elevated). Which is the most appropriate immediate action regarding his medications?

• Continue metformin and stop ibuprofen
• Stop metformin immediately and discontinue ibuprofen
• Reduce metformin dose and continue lisinopril
• Discontinue lisinopril and continue metformin

Correct Answer: Stop metformin immediately and discontinue ibuprofen

Q2. A 55-year-old woman with atrial fibrillation on warfarin presents with INR 6.5 but no bleeding. What is the recommended initial management?

• Give vitamin K orally and omit 1–2 doses of warfarin
• Administer intravenous vitamin K and fresh frozen plasma immediately
• Continue warfarin and recheck INR in one week
• Switch to low molecular weight heparin

Correct Answer: Give vitamin K orally and omit 1–2 doses of warfarin

Q3. A 72-year-old female with heart failure and serum creatinine 2.0 mg/dL is on metolazone and furosemide. She has dizziness, low blood pressure, and potassium 2.8 mEq/L. Which intervention is highest priority?

• Increase furosemide dose
• Administer oral potassium supplementation and reassess diuretics
• Add spironolactone immediately
• Start intravenous albumin

Correct Answer: Administer oral potassium supplementation and reassess diuretics

Q4. A patient reports a new rash after starting amoxicillin. History reveals prior immediate urticaria with penicillin as a child. How should this allergic history be classified?

• Non-allergic adverse event
• Type I hypersensitivity — penicillin allergy
• Type IV hypersensitivity — contact dermatitis
• Drug intolerance without immune mechanism

Correct Answer: Type I hypersensitivity — penicillin allergy

Q5. A 60-year-old diabetic on glyburide has fasting glucose 60 mg/dL and is found confused. Which factor in his history most likely contributed?

• Recent addition of diltiazem
• Renal impairment reducing glyburide clearance
• Started high-fiber diet
• Switch from bed to chair exercise

Correct Answer: Renal impairment reducing glyburide clearance

Q6. A 45-year-old man presents with constipation after starting verapamil. Which mechanism explains this adverse effect?

• Beta-adrenergic blockade in gut smooth muscle
• Calcium channel blockade reducing intestinal smooth muscle contractility
• Increased serotonin leading to decreased motility
• Activation of opioid receptors in the gut

Correct Answer: Calcium channel blockade reducing intestinal smooth muscle contractility

Q7. A patient with chronic hepatitis and bilirubin elevated 3-fold is prescribed drug X primarily metabolized by hepatic CYP enzymes. What is the most appropriate initial approach to dosing?

• Start standard dose; monitor clinically
• Avoid drug X if safer alternatives exist and consider dose reduction
• Increase dose to overcome hepatic clearance
• Administer loading dose followed by same maintenance dose

Correct Answer: Avoid drug X if safer alternatives exist and consider dose reduction

Q8. A 50-year-old on simvastatin develops new muscle pain with CK moderately elevated (3× ULN). Which step is most appropriate?

• Continue simvastatin and re-evaluate in 6 months
• Stop simvastatin and switch to a lower-risk statin such as pravastatin
• Increase simvastatin dose to relieve symptoms
• Add fibrate therapy to reduce muscle symptoms

Correct Answer: Stop simvastatin and switch to a lower-risk statin such as pravastatin

Q9. A 30-year-old woman is prescribed oral terbinafine for onychomycosis and presents after 3 weeks with dark urine, jaundice, and ALT 12× ULN. What is the correct pharmacist recommendation?

• Continue therapy and recheck labs in 2 weeks
• Stop terbinafine immediately and refer for urgent hepatic evaluation
• Reduce dose of terbinafine by half
• Add hepatoprotective herbal supplements and continue

Correct Answer: Stop terbinafine immediately and refer for urgent hepatic evaluation

Q10. A patient taking warfarin is started on trimethoprim-sulfamethoxazole (TMP-SMX). INR increases significantly. What is the likely mechanism?

• TMP-SMX induces hepatic warfarin metabolism
• TMP-SMX competes for vitamin K binding sites, increasing warfarin effect
• TMP-SMX inhibits CYP2C9-mediated warfarin metabolism causing increased INR
• TMP-SMX promotes GI absorption of vitamin K

Correct Answer: TMP-SMX inhibits CYP2C9-mediated warfarin metabolism causing increased INR

Q11. A hospitalized patient’s medication list shows both insulin sliding scale and scheduled basal insulin orders leading to recurrent hypoglycemia. Best pharmacist intervention?

• Recommend discontinuation of basal insulin only
• Clarify regimen and propose elimination of sliding scale in favor of scheduled basal-bolus regimen
• Advise doubling the sliding scale doses
• Remove all insulin orders and substitute oral hypoglycemics

Correct Answer: Clarify regimen and propose elimination of sliding scale in favor of scheduled basal-bolus regimen

Q12. A 70-year-old with Parkinson’s disease is on selegiline and starts sertraline for depression. After a week he develops agitation, hyperreflexia, and fever. What is the most likely diagnosis?

• Serotonin syndrome due to MAOI-SSRI interaction
• Neuroleptic malignant syndrome from selegiline
• Benign akathisia from sertraline
• Worsening Parkinsonism due to drug interaction

Correct Answer: Serotonin syndrome due to MAOI-SSRI interaction

Q13. A 65-year-old on chronic opioid therapy reports new anticholinergic symptoms after adding amitriptyline. Which sign most strongly suggests anticholinergic toxicity?

• Pinpoint pupils
• Diarrhea and salivation
• Dry mouth, urinary retention, and constipation
• Bradycardia and increased sweating

Correct Answer: Dry mouth, urinary retention, and constipation

Q14. A patient with suspected drug-induced liver injury is evaluated using RUCAM scale. Which of the following findings increases the RUCAM score and supports causality?

• Onset of liver injury 6 months after starting drug
• Dechallenge resulting in improvement after drug cessation
• Presence of multiple other hepatotoxic medications
• History of chronic alcohol use

Correct Answer: Dechallenge resulting in improvement after drug cessation

Q15. A 78-year-old on multiple medications has falls and confusion. Using STOPP criteria, which drug is most likely inappropriate and should be reviewed?

• Low-dose aspirin for primary prevention without cardiovascular disease
• Short-acting insulin for postprandial control
• Topical emollient for dry skin
• Levothyroxine for documented hypothyroidism

Correct Answer: Low-dose aspirin for primary prevention without cardiovascular disease

Q16. A 40-year-old with epilepsy is on carbamazepine and reports oral contraceptive failure with breakthrough bleeding. What is the pharmacological explanation?

• Carbamazepine inhibits estrogen receptor function
• Carbamazepine induces hepatic CYP3A4 increasing estrogen metabolism reducing contraceptive efficacy
• Carbamazepine causes malabsorption of oral contraceptives
• Carbamazepine increases sex hormone binding globulin levels

Correct Answer: Carbamazepine induces hepatic CYP3A4 increasing estrogen metabolism reducing contraceptive efficacy

Q17. In adverse drug reaction causality assessment using the Naranjo algorithm, which element increases the score most significantly toward a definite ADR?

• Previous conclusive reports on this reaction
• Occurrence of reaction after the suspected drug was administered
• Improvement after drug discontinued (dechallenge)
• Reaction reappeared on re-administration (rechallenge)

Correct Answer: Reaction reappeared on re-administration (rechallenge)

Q18. A patient with atrial fibrillation and CrCl 18 mL/min is being considered for dabigatran. What is the most appropriate pharmacist recommendation?

• Use full-dose dabigatran as usual
• Avoid dabigatran and consider alternative anticoagulation due to renal impairment
• Double the dabigatran dose to achieve therapeutic effect
• Change to dabigatran and no monitoring needed

Correct Answer: Avoid dabigatran and consider alternative anticoagulation due to renal impairment

Q19. A 58-year-old presents with new-onset cough after starting an ACE inhibitor. What is the mechanism of this adverse effect?

• Bradykinin accumulation due to ACE inhibition causing cough
• Direct irritation of airway by ACE inhibitor particles
• Allergic IgE-mediated bronchospasm
• ACE inhibitor-induced bacterial bronchitis

Correct Answer: Bradykinin accumulation due to ACE inhibition causing cough

Q20. A patient on multiple psychotropics becomes febrile, rigid, and with elevated CPK. He is recently started on high-dose haloperidol. Which diagnosis fits best and immediate action?

• Serotonin syndrome — give cyproheptadine
• Neuroleptic malignant syndrome — stop antipsychotic and initiate supportive care with possible dantrolene
• Malignant hyperthermia — give succinylcholine
• Sepsis — start broad-spectrum antibiotics immediately

Correct Answer: Neuroleptic malignant syndrome — stop antipsychotic and initiate supportive care with possible dantrolene

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