Management of Phototherapy Side Effects — MCQs
Peau d’orange appearance is due to -
Which of the following statements about Bowen's disease is correct?
PUVA therapy is used in all except:
A term neonate, with a birth weight of 2700 g, who is otherwise well, and is exclusively breastfed, presents for routine evaluation. His total serum bilirubin is found to be 14mg/dl on day 5. What is the management?
A patient given digoxin started having side effects like nausea and vomiting. The serum concentration of digoxin was 4 ng/mL. The plasma therapeutic range is 1-2 ng/mL. If the half-life of digoxin is 40 hours, how long should one wait before resuming the treatment?
Which muscle relaxant is primarily excreted by the kidneys?
When an outcome is compared with intended objectives, it is called as -
Which of the following is NOT a side effect of digitalis?
What is the preferred treatment option for a 21-year-old college girl with mild endometriosis?
A 3-week-old infant presents with a cough and sore throat. The mother reports that the infant develops a paroxysm of cough followed by apnea. The total leucocyte count is >50,000 cells/μL. Based on these symptoms, which of the following drugs is the most appropriate treatment for this patient?
Management of Phototherapy Side Effects Indian Medical PG Practice Questions and MCQs
Question 1: Peau d’orange appearance is due to -
- A. Intra-epithelial cancer
- B. Vascular embolization
- C. Lymphatic permeation (Correct Answer)
- D. Sub-epidermal cancer
Explanation: ***Lymphatic permeation*** - **Peau d'orange**, or "orange peel" appearance, is characteristic of advanced breast cancer and is caused by **edema of the skin** due to **blockage of subcutaneous lymphatic drainage**. - The skin over the affected area becomes rigid and swollen, accentuating the hair follicles and leading to a dimpled appearance similar to an orange peel. *Intra-epithelial cancer* - **Intra-epithelial cancer**, such as ductal carcinoma in situ (DCIS), is confined to the epithelium and does not typically directly cause diffuse skin changes like **peau d'orange**. - It involves proliferation of malignant cells within the ducts or lobules without invasion of the **basement membrane**. *Vascular embolization* - **Vascular embolization** refers to the blockage of blood vessels by an embolus, which would cause ischemia or infarction, not diffuse skin edema with a dimpled appearance. - While cancer can spread via blood vessels, this mechanism does not directly result in the specific **peau d'orange** phenomenon. *Sub-epidermal cancer* - **Sub-epidermal cancer** might refer to a tumor lying beneath the epidermis, but this term is not standard for describing the cause of peau d'orange. - The appearance is due to lymphatic obstruction and edema, not merely the presence of a tumor in a specific layer, unless that tumor is causing the **lymphatic blockage**.
Question 2: Which of the following statements about Bowen's disease is correct?
- A. Chronic sun exposure is a known risk factor.
- B. It is more common in fair-skinned individuals.
- C. There is a link between HSV infection and Bowen's disease.
- D. It is a form of squamous cell carcinoma in situ. (Correct Answer)
Explanation: ***It is a form of squamous cell carcinoma in situ.*** - **Bowen's disease** is, by definition, **squamous cell carcinoma in situ (SCC in situ)**. - It is characterized by full-thickness epidermal atypia of keratinocytes **without invasion through the basement membrane**. - This statement is **definitional** and represents the fundamental nature of what Bowen's disease is, making it the **best answer** among the options. *Chronic sun exposure is a known risk factor.* - This statement is **medically accurate**. Chronic UV exposure is indeed a well-established risk factor for Bowen's disease. - However, this describes a **risk factor** rather than defining what the condition is. - Other risk factors include **arsenic exposure**, **ionizing radiation**, **immunosuppression**, and **HPV infection** (particularly in anogenital sites). - While true, this is not as fundamental as the definitional statement. *It is more common in fair-skinned individuals.* - This statement is also **medically accurate**. Bowen's disease occurs more frequently in fair-skinned individuals (Fitzpatrick skin types I-II). - Fair skin provides less melanin protection against UV damage, increasing susceptibility to various forms of skin cancer including Bowen's disease. - However, this describes **epidemiology** rather than defining the condition itself. *There is a link between HSV infection and Bowen's disease.* - This statement is **incorrect**. There is **no established association** between Herpes Simplex Virus (HSV) and Bowen's disease. - **Human Papillomavirus (HPV)**, particularly high-risk types 16 and 18, is associated with Bowen's disease, especially in anogenital locations. - This represents a common confusion between HSV and HPV.
Question 3: PUVA therapy is used in all except:
- A. Psoriasis
- B. Vitiligo
- C. Mycosis fungoides
- D. Melasma (Correct Answer)
Explanation: ***Melasma*** - **PUVA (Psoralen plus UVA) therapy** is contraindicated in melasma due to its potential to worsen hyperpigmentation and cause paradoxical darkening. - Melasma is best managed with topical agents like **hydroquinone**, **tretinoin**, and chemical peels, along with strict **sun protection**. *Psoriasis* - **PUVA therapy** is a well-established and effective treatment for moderate to severe psoriasis, especially for patients with widespread plaques. - It works by inhibiting DNA synthesis and cell proliferation in rapidly dividing keratinocytes, leading to a reduction in psoriatic lesions. *Vitiligo* - **PUVA therapy** is a common treatment for vitiligo, stimulating melanocyte activity and promoting repigmentation in affected areas. - Psoralen sensitizes melanocytes to UVA light, which then encourages melanin production. *Mycosis fungoides* - In its early stages, **mycosis fungoides**, a cutaneous T-cell lymphoma, can be effectively treated with **PUVA therapy**. - PUVA induces apoptosis of malignant T-cells in the skin, leading to remission of skin lesions.
Question 4: A term neonate, with a birth weight of 2700 g, who is otherwise well, and is exclusively breastfed, presents for routine evaluation. His total serum bilirubin is found to be 14mg/dl on day 5. What is the management?
- A. No active treatment required (Correct Answer)
- B. Stop breastfeeding for 2 days
- C. Phototherapy
- D. Exchange transfusion
Explanation: ***No active treatment required*** - A total serum bilirubin of **14 mg/dL** on day 5 in an otherwise well, exclusively breastfed term neonate (birth weight 2700g, which is >2500g) falls within the **physiologic jaundice range** and below thresholds for intervention. - This level is considered **normal for breastfed infants** at this age and does not warrant medical intervention as per current guidelines. *Stop breastfeeding for 2 days* - This intervention, known as **breast milk jaundice interruption**, is usually reserved for higher bilirubin levels or if there is concern for significant breast milk jaundice, which is not indicated here. - Temporarily stopping breastfeeding can disrupt the establishment of breastfeeding and is generally discouraged unless strictly necessary. *Phototherapy* - **Phototherapy** is indicated for bilirubin levels typically >15-18 mg/dL in a healthy term neonate on day 5, depending on risk factors, which this infant does not meet. - It works by converting unconjugated bilirubin into water-soluble isomers that can be excreted more easily. *Exchange transfusion* - **Exchange transfusion** is reserved for severe hyperbilirubinemia, usually with bilirubin levels approaching or exceeding 20-25 mg/dL, especially if there are signs of **acute bilirubin encephalopathy**. - This level is far below the threshold for such an invasive procedure.
Question 5: A patient given digoxin started having side effects like nausea and vomiting. The serum concentration of digoxin was 4 ng/mL. The plasma therapeutic range is 1-2 ng/mL. If the half-life of digoxin is 40 hours, how long should one wait before resuming the treatment?
- A. 120 hours
- B. 140-180 hours
- C. 1 half-life (40 hours)
- D. 80 hours (Correct Answer)
Explanation: ***80 hours (2 half-lives)***- Current digoxin level is **4 ng/mL**, which is **twice the upper therapeutic limit** (2 ng/mL), causing toxicity with nausea and vomiting [1]- After **1 half-life (40 hours)**: concentration reduces to 2 ng/mL (upper therapeutic limit) [2]- After **2 half-lives (80 hours)**: concentration reduces to 1 ng/mL (mid-therapeutic range) [2]- **Clinical rationale**: While 2 ng/mL is technically within range, waiting for 2 half-lives ensures the level is comfortably in the **middle of the therapeutic window** (1 ng/mL), providing a **safer margin** before resuming treatment in a patient who just experienced toxicity- This conservative approach minimizes risk of recurrent toxicity, especially important given the patient's recent symptoms at 4 ng/mL*1 half-life (40 hours)*- After 1 half-life, digoxin level would be 2 ng/mL, which is at the **upper limit** of the therapeutic range- While technically within the therapeutic range, this leaves **minimal safety margin** in a patient who just experienced toxicity- Starting treatment immediately at this level carries higher risk of recurrent side effects*120 hours (3 half-lives)*- After 3 half-lives, the concentration would be **0.5 ng/mL**, which is **below the therapeutic range** (1-2 ng/mL)- This is overly conservative and would **unnecessarily delay** resumption of essential cardiac medication- Could lead to inadequate control of the underlying condition (heart failure or atrial fibrillation)*140-180 hours (3.5-4.5 half-lives)*- This would reduce digoxin to **0.25-0.35 ng/mL**, well below therapeutic levels- This **excessive delay** is not clinically justified and could worsen the patient's cardiac condition- No standard protocol recommends waiting this long before resuming digoxin therapy
Question 6: Which muscle relaxant is primarily excreted by the kidneys?
- A. Vecuronium
- B. Pancuronium
- C. Gallamine (Correct Answer)
- D. Atracurium
Explanation: Everything in nature is balanced. ***Gallamine*** - **Gallamine** is predominantly cleared from the body through **renal excretion** (>90%), with very low hepatic metabolism. - Due to its high reliance on kidney function for elimination, **gallamine** is contraindicated in patients with **renal impairment**. [2] - **Note**: Gallamine has limited current clinical use and has been withdrawn from many markets, but remains important for understanding muscle relaxant pharmacokinetics. *Pancuronium* - **Pancuronium** has significant renal elimination (~40-50%), along with hepatic metabolism and biliary excretion. - While renal excretion is clinically important for **pancuronium** (making dose adjustment necessary in renal impairment), gallamine has a higher percentage of renal excretion. - Among **currently used** muscle relaxants, pancuronium shows the greatest dependence on renal function. *Vecuronium* - **Vecuronium** is mainly eliminated by **hepatic metabolism** (60-80%) and **biliary excretion**, with only a small fraction (10-25%) excreted renally. [1] - Its intermediate duration of action is attributed to rapid redistribution and hepatic metabolism, making it relatively safer for patients with renal dysfunction. [1] *Atracurium* - **Atracurium** undergoes unique elimination via **Hofmann degradation** (non-enzymatic chemical breakdown at physiological pH and temperature) and **ester hydrolysis**, independent of organ function. [3] - This makes it the preferred choice in patients with **renal** or **hepatic failure** as its metabolism does not rely on these organs. [3]
Question 7: When an outcome is compared with intended objectives, it is called as -
- A. Network analysis
- B. Evaluation (Correct Answer)
- C. Input-output analysis
- D. Monitoring
Explanation: ***Evaluation*** - **Evaluation** is a systematic process of comparing actual outcomes against predefined objectives to assess their effectiveness, efficiency, and impact. - It involves making judgments about the **worth** or **significance** of a program, project, or policy. *Network analysis* - **Network analysis** is a technique used to understand the relationships and connections within a system, often focusing on communication or collaboration. - It does not primarily involve comparing outcomes to objectives but rather mapping and measuring interactions between entities. *Input-output analysis* - **Input-output analysis** is an economic technique that studies the interdependence between different sectors of an economy by tracing inputs and outputs. - It is concerned with resource allocation and production linkages, not the comparison of outcomes to explicit objectives. *Monitoring* - **Monitoring** involves the continuous tracking of activities and progress against plans to ensure things are on track. - While it collects data on actual performance, its primary purpose is to observe and report as events unfold, not to make judgments about overall success against original goals.
Question 8: Which of the following is NOT a side effect of digitalis?
- A. Nausea and vomiting
- B. Ventricular Bigeminy
- C. Vasodilatation (Correct Answer)
- D. Ventricular tachycardia
Explanation: **Vasodilatation** - **Digitalis**, primarily digoxin, is known for its **positive inotropic effect**, increasing myocardial contractility, and for its **vasoconstrictive properties** at higher doses due to sympathetic activation and direct smooth muscle effects, not vasodilatation. - While it can indirectly improve cardiac output and thus tissue perfusion, its direct vascular effects do not typically include widespread vasodilatation. *Ventricular tachycardia* - **Digitalis toxicity** can lead to various arrhythmias, including **ventricular tachycardia**, which is a potentially life-threatening side effect. - This occurs due to increased automaticity and delayed afterdepolarizations in ventricular myocytes. *Nausea and vomiting* - **Gastrointestinal symptoms** such as **nausea and vomiting** are common early signs of digitalis toxicity. - These effects are thought to be mediated by the drug's action on the chemoreceptor trigger zone in the brainstem. *Ventricular Bigeminy* - **Ventricular bigeminy**, characterized by alternating normal and premature ventricular beats, is another classic manifestation of **digitalis toxicity**. - This arrhythmia results from enhanced automaticity and altered conduction properties in the ventricles.
Question 9: What is the preferred treatment option for a 21-year-old college girl with mild endometriosis?
- A. Cyclical OC pill
- B. Continuous OC pill (Correct Answer)
- C. Progesterone only pill
- D. Danazole
Explanation: ***Continuous OC pill*** - For **mild endometriosis** in a young woman, **continuous oral contraceptive pills (OCP)** are the **first-line medical treatment** according to current evidence-based guidelines (ACOG, ESHRE). - Continuous OCP use provides better suppression of endometriosis by creating a **stable hormonal environment** that prevents cyclic menstrual bleeding and retrograde menstruation, which can worsen endometriosis. - This approach effectively manages symptoms like **dysmenorrhea** and **pelvic pain** while preserving future fertility, and is well-tolerated in young women with the added benefit of menstrual suppression. *Cyclical OC pill* - While cyclical OCPs can help manage endometriosis symptoms, they are **less effective** than continuous OCPs because they allow withdrawal bleeding, which may perpetuate retrograde menstruation and endometrial implant stimulation. - Cyclical OCPs may still provide symptom relief but are considered a **second-line option** when continuous use is not acceptable to the patient. *Progesterone only pill* - **Progesterone-only pills (POP)** can suppress endometriosis by inducing amenorrhea and decidualization of endometrial implants, but they may cause **irregular bleeding patterns**, especially in the first few months. - While effective, they are generally considered when combined OCPs are contraindicated (e.g., migraine with aura, thrombotic risk) rather than as first-line for uncomplicated mild endometriosis. *Danazole* - **Danazol** is an androgenic agent that creates a hypoestrogenic environment, leading to atrophy of endometrial tissue, but it is **rarely used today** due to significant androgenic side effects. - Common side effects include **acne**, **hirsutism**, **weight gain**, and **voice deepening**, which are often unacceptable for a 21-year-old woman, making it an obsolete option for first-line management of mild endometriosis.
Question 10: A 3-week-old infant presents with a cough and sore throat. The mother reports that the infant develops a paroxysm of cough followed by apnea. The total leucocyte count is >50,000 cells/μL. Based on these symptoms, which of the following drugs is the most appropriate treatment for this patient?
- A. Azithromycin (Correct Answer)
- B. Amoxicillin
- C. Cotrimoxazole
- D. Erythromycin
Explanation: ***Azithromycin*** - This infant's symptoms are highly suggestive of **pertussis** (whooping cough), characterized by **paroxysmal coughs** followed by **apnea** in young infants, along with **marked leukocytosis**. - **Macrolides** are the treatment of choice due to their effectiveness against *Bordetella pertussis*; **azithromycin** is preferred in infants due to better tolerability and a shorter course compared to erythromycin. *Amoxicillin* - **Amoxicillin** is a penicillin-class antibiotic primarily effective against various bacterial respiratory infections, but it has **no activity against *Bordetella pertussis***. - Using amoxicillin for pertussis would lead to **treatment failure** and a worsening of the infant's condition. *Cotrimoxazole* - While **cotrimoxazole** (trimethoprim-sulfamethoxazole) can be used as an alternative for pertussis in patients **allergic to macrolides**, it is **not the first-line treatment** in infants. - It carries a risk of **kernicterus** in newborns and young infants due to displacement of bilirubin from albumin, so it is generally avoided. *Erythromycin* - **Erythromycin** is a macrolide and is effective against *Bordetella pertussis*, but it is **associated with a higher incidence of infantile hypertrophic pyloric stenosis** when given to young infants. - Due to this adverse effect, **azithromycin** is generally preferred over erythromycin in infants for pertussis treatment.
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