Pakistan Society of Chemical Pathologists
Distance Learning Programme in Chemical Pathology
Name of the Participant:
Date of Sending Answers:
(Answers without NAME and Date will not be accepted)
Lesson No 17
Toxicology
By
Prof Dilshad Ahmad Khan
Consultant Chemical Pathologist / Prof of Pathology,
AFIP Rawalpindi
&
Prof (Brig) Aamir Ijaz
Consultant Chemical Pathologist / Prof of Pathology,
AFIP Rawalpindi
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Answers will be sent to Prof Aamir Ijaz as usual
Any queries or comments regarding this lesson will also be routed through Prof
Aamir Ijaz
Before start attempting this lesson please read the instructions carefully:
1. Toxicology is a very important part of Chemical Pathology. Its two main branches
are Clinical Toxicology and Forensic Toxicology. Although these two branches
have different spheres of functioning, they may share same laboratories and
analytical techniques. In this lesson one SAQ is dedicated to introduction of the
branches of Toxicology so that our future Consultants could be sensitized about
these fields.
2. The lesson mainly comprises questions related to laboratory aspects of Toxicology
and competencies related to interpretation of lab data of Clinical Toxicology when
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3.
4.
5.
6.
7.
only scanty clinical information is available. Last two SAQs exemplify situations
when Chemical Pathologists are approached to provide guidance for selection of
appropriate laboratory tests in a particular toxidrome.
This lesson has two parts i.e. BCQs and SAQs.
You may find answers from books, internet or any other source. Please use red
colour font for selection of best answer of MCQs and writing answers of SAQs.
Final deadline for sending answer is midnight 8th Sep 2014 (Monday).
Key presentation (ppt) and award list will be sent by midnight 11th Sep Aug 2014
(Thursday). (Please note that it will NOT be on Wednesday).
You may discuss the ppt in your department after 8th Sep 2014 (Monday) but no
mutual consultation before this date.
8. Separate live session may not be possible on this lesson.
9. Two SKYPE Sessions will be held on this lesson as per following tentative
schedule:
a. 12th Sep 2014 (Friday) at about 1200 h.
b. 13th Sep 2014 (Saturday) at about 1000 h
You may join any Skype as per your convenience.
10.For gaining maximum benefit please don’t copy-paste answers from other sources
and please don’t share your answers with fellow colleagues. Be honest to yourself.
11.Lesson No 18 (Therapeutic Drug Monitoring) will be sent to you by 1800 h on 14th
Sep 2014 (Sunday)
Credit System for Lesson No 17
1.
2.
3.
4.
The lesson will be of 20 marks. One mark for each correct MCQ. Marks of SAQs
are given in parenthesis at the end of each question.
LAURELS will be given to those Participants who will secure 16 (80%) marks
before the deadline i.e. midnight 8th Sep 2014 (Monday).
Participant (s) with best performance will get 10 extra marks. So maximum marks
which can be gained in this lesson are 30.
Trainee Participant (s) with best performance in the whole course will be declared
as ‘Chemical Pathology Laureate’ after completion of all 20 lessons. Other high
performances will also be awarded.
Go for the Lesson now.
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Part I
MCQs (One Best Type)
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Select the best answers.
All options have been arranged in alphabetical order
1. Documents that track the location of evidence from collection to final disposition?
a.
b.
c.
d.
e.
Case file
Chain of custody
Laboratory raw data
Pathologist`s summary of test result
Physician`s drug request form
2. Which of the following indicators is most helpful in deciding whether you have a
case of poisoning or not?
a.
b.
c.
d.
e.
A witness saw the incidence
Brought in unconscious state in emergency
Laboratory analysis of drugs
Presence of the empty syringe/drug bottle besides poisoned person
Signs and symptoms of intoxication
3. While establishing Clinical Toxicology services in your lab, an urgent reporting
system is required for certain substances with turn-around-time of < 1 hour. All of
the following substances will be included in the list of such substances EXCEPT:
a.
b.
c.
d.
e.
Acetaminophen
Cannabinoids
Carboxyhaemoglobin
Ethanol
Ethylene glycol
4. Hypoglycaemia is an important biochemical finding in the toxicity of some drugs. All
of the following drugs are associated with hypoglycaemia in overdose EXCEPT
a.
b.
c.
d.
e.
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Oral hypoglycaemic
Phenytoin
Propranolol
Quinine
Sodium Valproate
5. In a Toxicology Laboratory the technique that separates the components of a mixture
of drugs / substances is?
a.
b.
c.
d.
e.
Atomic absorption
Chromatography
Colour test
Mass spectrometry
Spectrophotometer
6. A 31 year male has presented in the emergency with very high grade fever
(temperature: 1050 F). The lab investigation(s) most helpful to exclude salicylate
poisoning as a cause of pyrexia is /are:
a.
b.
c.
d.
e.
Ammonia
Arterial blood gasses
Ferric chloride test
Glucose
ALT
7. A 4 year old boy accidentally ingested a clear fluid, vomited twice then started to
cough with tachypnea; 24 hours later he developed fever of 39°C due to
bronchopneumonia. The possible diagnosis is:
a.
b.
c.
d.
e.
Ethanol toxicity
Kerosene toxicity
Methanol toxicity
Phenol toxicity
Salicylate poisoning
8. Alcohol intoxication leads to an increase in Serum Osmolality. Which of the
following alcohols leads to highest rise of serum osmolality (per mmol of alcohol):
a.
b.
c.
d.
e.
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Acetone
Ethylene glycol
Ethanol
Isopropanol
Methanol
9. A 34 y male has been brought in the A&E of a hospital with the charge of driving
under ethanol intoxication. His Serum Osmolality Gap was found to be 3 mOsmol/L
(Ref Value < 4). Sample was sent for Serum Ethanol estimation. Its result received
next day showed his serum ethanol 123 mg/dl (26.2 mmol/L). These results puzzled
the treating physician. The most probable cause of this discrepancy (normal
osmolality gap with high serum ethanol) could be:
a.
b.
c.
d.
e.
Inappropriate sample collection using ‘spirit swab’
Patient has concomitant diarrhea
Patient has concomitant methanol intoxication
Patient has diabetic ketoacidosis
Vapor pressure depression method used for osmolality
10. A state-of-the-art analytical technique is used in a semi-automated, medium throughput and rapid analyser which is capable of testing nearly 50 drugs /substances in one
sample in a few minutes. This technique is:
a.
b.
c.
d.
e.
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Atomic Absorption
Biochip array technology
Chemiluminescence
HPLC
Immunoturbimetery
Part II
Short Answer Questions:




Please be brief in your answers.
Write your answers in RED Font Colour beneath each sub-component.
When specified number of responses are asked, restrict yourself to the number e.g. if
THREE causes are asked, give only three. The fourth cause in such a question will not
be considered.
Marks carried by each component are given in parenthesis.

Copied and shared answers will NOT be accepted.
11. Toxicology is mainly divided into two major branches i.e. Clinical Toxicology and
Forensic Toxicology. Please answer following questions related to Toxicology:
a. Compare the requirements in Clinical Toxicology and Forensic Toxicology in
following terms (0.5 marks each):
i. Specificity
ii. Sensitivity
iii. Speed of analyses
iv. Analytical instrumentation
b. What are the THREE sub-branches of Forensic Toxicology? Please give
examples of situations and laboratory samples dealt by these sub-branches?
(One mark).
c. Forensic Drug Chemistry is also an important branch related to Forensic
Toxicology. Which types of samples are dealt in a Forensic Drug Chemistry
Laboratory? (One mark).
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12. A 21-year-old female presents to the emergency department with a history of nausea,
vomiting, abdominal pain, tinnitus, oliguria and stupor.
Her emergency lab tests result were as following:
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pH :
7. 40
HCO3 :
14
mmol/L
Base Excess
-7.4
PO2:
108 mmHg
PCO2:
22
mmHg
Na :
141
mmol/L
K :
4.8 mmol/L
Cl :
106 mmol/L
Urea :
9.2 mmol/L
ALT:
23
U/L
Serum Osmolality Gap: 2.7 mOsmol/L
Urine Trinder Spot test: Purple colour
(7.35 – 7.45)
(23 – 28)
<+3- -3
(80 – 110)
(35-45)
(135–150)
(3.5 – 5.0)
(98-108)
(3.3 – 6.6)
(< 32)
Please answer following questions related to this patient (One mark each)
a. What is the most likely class/drug used in this patient?
b. Write TWO most important indications for haemodylasis in this
patient
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13. A 34 year female presents with nausea, vomiting and abdominal pain.
Her emergency lab tests result were as following:
•
•
•
•
•
•
•
•
•
•
•
•
pH :
7 . 31
HCO3 :
17
Base Excess
-3.4
PO2:
112
PCO2:
33
Na :
139
K :
4.5
Cl :
105
Urea :
6.9
ALT:
532
Serum Osmolality Gap: 1.8
Urine Trinder Spot test:
mmol/L
mmHg
mmHg
mmol/L
mmol/L
mmol/L
mmol/L
U/L
mOsmol/L
Negative
(7.35 – 7.45)
(23 – 28)
<+3- -3
(80 – 110)
(35-45)
(135–150)
(3.5 – 5.0)
(98-108)
(3.3 – 6.6)
(< 32)
Please answer following questions related to this patient (One marks each)
a. What is the most likely class/drug used in this patient?
b. What is the stage of drug toxicity this patient is suffering from?
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14. A 29-year-old agitated male arrives in an Emergency Department after having two
seizures at home. According to family members, he has no prior history of seizures.
He tried suicide attempt (tried to cut wrists) four days ago.
Physical Examination revealed
Not-oriented in time and space
Skin of axilla completely dry
Pupils: Dilated and sluggishly reacting to light
Temp: 39o C; Heart Rate: 112 beat per minute, regular
Resp Rate: 22 breaths per minute BP: 180/100 mm Hg
Pulmonary: Clear to auscultation.
CVS: Tachycardia without murmur.
Abdomen: Soft and non-tender.
Bowel sounds: markedly diminished.
Neurologic: Myoclonus.
What is the most likely class/drug used in this patient? (One mark)
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15. A 25-year-old male body builder presents to your emergency department after
ingesting some “white powder” given to him by Hakime in his village for
improving his muscles. He has developed diarrhea, vomiting and weakness.
Physical Examination revealed
Semi-conscious
Garlic-like smell coming from the patient
Pupils: Normally reacting to light
Temp: 37o C; Heart Rate: 122 beats per minute, regular;
Resp Rate: 24 breaths per minute BP: 90/70 mm Hg
Pulmonary: Clear to auscultation.
CVS: Tachycardia without murmur.
Abdomen: Soft and non-tender.
Bowel sounds active.
Neurologic: GCS 15. Neurologic exam is normal.
What is the most likely class/drug used in this patient? (One mark)
For queries and comments: Prof Aamir Ijaz, (0300-5203194)
ijaz_aamir@hotmail.com
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