Pharmacology

Question 1

1. Mother brings in her 2 kids and wants them to get the intranasal flu shot. Daughter is age 12 months and healthy. Son is age 4 and on inhaled corticosteroids for asthma, had an admission 1 month ago requiring 5 days of oral steroids. What do you do?
   a) Neither child can have the intranasal flu shot
   b) Both kids can have the intranasal flu shot
   c) Only the daughter can have it
   d) Only the son can have it

Answer 1

Only son can have it

Contraindications to intranasal flu vaccine

1. <2yo
2. Current wheezing or medically attending wheezing in the past 7d or currently on oral or high-dose ICS
3. immunocompromised
4. pregnancy
5. receiving chronic ASA
6. Within 48H of antiviral agents active against influenza
7. Defer if nasal congestion

Question 2

2. A 15 yo boy with depression and conduct disorder presents to emergency with confusion and agitation. His vitals are T 38.9, P 110, BP 145/95. He has lead pipe rigidity and tremor. Glucose, electrolytes, Ca, Mg, PO4 are normal. CK is elevated (8900). What is the most likely cause?
A. Serotonin syndrome
B. Alcohol ingestion
C. Neuroleptic malignant syndrome
D. Amphetamine overdose

Answer 2

NMS

RIGIDITY!

Fever
Autonomic instability
Rigidity
Mental status changes

SS

• serotonergic agents
• Onset usu <12H
• increased tone
• HYPERREFLEXIA
• CLONUS
• DILATED PUPILS
• HYPERACTIVE BS
• Tx: cyproheptadine

NMS:

• dopaminergic antagonists (antipsychotics, antiemetics)
• onset usu 1-3d
• LEAD PIPE RIGIDITY
• hyporeflexia
• normal pupils
• normal or decreased BS
• Increased CK, WBC
• Tx: benzo, dantrolene, bromocriptine

BOTH

• Fever
• Autonomic instability
• Mental status changes

Question 3

3. 10 month girl recently immigrated to Canada from a refugee camp in Turkey. She’s had 3 doses of oral polio vaccine and 4 doses of DAT (diptheria, pertussis, tetanus). What vaccine do you recommend now?
   a. Pneumococcal conjugate and Hib
   b. Pneumococcal, HIB and IPV
   c. DTap-IPV-Hib and pneumococcal
   d. No vaccines needed

Answer 3

Pneumococcal, Hib, IPV

WHO recommends that all countries using only OPV to add at least 1 dose of IPV given after 14wk of age

Question 4

11. A 16 year old girl is on multiple medications and develops headaches with blurred optic discs bilaterally. Which of the following is most likely to be responsible?
    a. Methylphenidate
    b. Calcium
    c. Fluoxetine
    d. Minocycline

Answer 4

Minocycline

• tetracycline derivative
• infections + acne
• ADR
  1. Idiopathic intracranial hypertension
  2. DRESS
  3. Tooth discoloration
  4. N/V/D
  5. SJS
  6. Lupus-like syndrome
  7. Anemia, thrombocytopenia, neutropenia

Question 5

6. Child described with Unilateral facial weakness, and vesicles in ear canal. Best management
   a) Acyclovir and steroids
   b) Acyclovir alone
   d) steroids alone

Answer 5

Acyclovir + steroids

Ramsay Hunt

• Herpes zoster oticus with facial paralysis
• Herpes vesicles in ear canal + pinna
• Facial paralysis + pain
• May have other CN involvement (esp CN 8)
• Up to 50% do not complete recover facial nerve fxn

Question 6

7.  8yo male. Duodenal ulcer. What is treatment? (Note: none of them listed a PPI)
A. amox + clarithro 
B. clinda + clarithrO
C. metronidazole + clinda
D. bismuth subsalicylate + metronidazole

Answer 6

Amox + clarithro + PPI
If think H pylori

For PUD, can just use PPI or H2RA

Question 7

8. What is the most common side effect of cephalosporins?
   a. Rash
   b. Fever
   c. Arthritis
   d. Diarrhea

Answer 7

Diarrhea

Question 8

9. We no longer use codeine for post-operative pain due to several children who died as a result of this medication. What was the reason for these fatalities?
   a. Some children are ultra fast metabolizers of codeine
   b. Some children are slow metabolizers of codeine
   c. Some children are allergic to codeine

Answer 8

Some children are ultra fast metabolizers of codeine

• Codeine is metabolized by liver CYP2D6 to morphine
• poor, extensive + ultra-rapid metabolizers
• Rapid-metabolizers (7%) convert codeine quickly to morphine, resulting in high conc’n of morphine in the blood -> overdose or death
• Watch for unusual sleepiness, confusion, noisy or laboured breathing

Question 9

10. A mother wants to use topical nasal decongestants in her 4 year old child. You recommend against it because:
    a. Rebound congestion
    b. Irritability
    c. Dystonic reaction

Answer 9

Rebound congestion

Intranasal decongestants (oxymetazoline + phenylephrine) should be used <5d. Should not be repeated more than 1X/mo to avoid rebound nasal congestion

Overdose can have sympathomimetic findings: High HR, BP, mydriasis, diaphoresis, agitation

Question 10

11. A 16 year old girl is on multiple medications and develops headaches with blurred optic discs bilaterally. Which of the following is most likely to be responsible?
    a. Methylphenidate
    b. Calcium
    c. Fluoxetine
    d. Minocycline

Answer 10

Minocycline

Idiopathic intracranial hypertension

Question 11

31. Why is diazepam rarely used as a sedative/anticonvulsant in infants?
    a. Increased distribution of liquid
    b. Decreased hepatic clearance (or something like that)
    c. Something about renal clearance
    —————
    Why do we not give diazepam to preterm infants?
    a. Small volume of lipid distribution
    b. Large volume of liquid distribution
    c. Immature hepatic metabolism
    —————
    The reason diazepam is not used in neonates is:
    a. increased distribution of liquid
    b. decreased distribution of lipids
    c. decreased hepatic function
    d. decreased renal clearance

Answer 11

Decreased hepatic function or clearance

Question 12

12. A 7 yo boy is on inhaled corticosteroids for poor asthma control. Mom is concerned about the effect of corticosteroids on his height. What do you tell her?
    a. he will lose 1 cm in height
    b. he will be significantly shorter than his genetic potential
    c. his growth velocity will be decreased, but his final adult height will not be affected
    d. he will have a significant catch-up period once he comes off the steroids

Answer 12

He will lose 1cm in height

Question 13

13. A child has CF. Family wants to use alternative medicine. Homeopathy has been proven effective for which condition:
    a) Diarrhea
    b) ADHD
    c) Allergies

Answer 13

Diarrhea

Question 14

14. Teratogenic effects of carbamazepine
    a) Neural tube defect
    b) Cleft lip and palate

Answer 14

Neural tube defects

Recommend level 2 U/S + fetal ECHO for women being treated with CBZ during pregnancy

Question 15

15. Asthmatic needs sedation, med to worry about giving causing histamine release:
    a) Morphine
    b) Fentanyl

Answer 15

Morphine

Assoc’d with hypotension + bronchospasm from histamine release (use with caution in asthma)

Preanesthesia evaluation
HIghest risk of complications:
1) admitted to hospital within previous year for asthma
2) In ED in last 6mo
3) admitted to ICU
4) Treated with parenteral steroids
Pre-op steroids if receiving asthma therapy currently or in past year
Active wheezing is indication to cancel elective surgery

Question 16

16. What is the most common side effect of diazepam in neonate?
    a. Respiratory depression

Answer 16

Resp depression

Question 17

31. Why is diazepam rarely used as a sedative/anticonvulsant in infants?
    a. Increased distribution of liquid
    b. Decreased hepatic clearance (or something like that)
    c. Something about renal clearance
    —————
    Why do we not give diazepam to preterm infants?
    a. Small volume of lipid distribution
    b. Large volume of liquid distribution
    c. Immature hepatic metabolism
    —————
    The reason diazepam is not used in neonates is:
    a. increased distribution of liquid
    b. decreased distribution of lipids
    c. decreased hepatic function
    d. decreased renal clearance

Answer 17

Decreased hepatic function or clearance

Lipophilic drug, high volume of distribution
Metabolized by liver. Half life prolonged in preterms > neonates > infants > children

Contraindications

1. Infants <6mo (PO)
2. Severe resp impairment
3. Severe hepatic impairment

Question 18

17. Which antiepileptic causes bilateral renal calculi?
    a. Topiramate
    b. Dilantin
    c. Valproic acid
    d. Carbamazepine
    e. Keppra
    f. Lamotrigine

Answer 18

Topiramate

Calculus is a TOPic
Stoned on top of the world

1. Brain fog (cognitive dysfunction)
2. wt loss/decreased appetite
3. calcium phoshate renal stones
4. Glaucoma
5. Metabolic acidosis

Question 19

19. 8yr old child is status post renal transplant and was diagnosed with an AOM. He was started on clarithromycin. He had normal cyclosporine levels initially however 3 days later his cyclosporine levels are elevated. What is the MOST likely explanation?
    a. As he started to feel better, he started to refeed and this caused increased absorption of the cyclosporine.
    b. Impaired renal clearance
    c. Clarithromycin affects the p450 enzyme and lead to decreased metabolism of the cyclosporine.

Answer 19

Clarithromycin inhibits CYP450 enzyme activity and leads to decreased metabolism of the cyclosporine

Question 20

20. 9y boy on phenytoin and valproic acid for epilepsy. Mom notices gum swelling (describing gum hyperplasia). What should you advise?
    a. Decrease phenytoin
    b. Stop phenytoin
    c. Decrease valproic acid
    d. Stop valproic acid

Answer 20

Decrease phenytoin

(Probably better than stopping b/c pt probably needs the anti-epileptic on board)
Pheny -> gummy
Purple glove syndrome

Dose dependent: sedation, visual blurring
Idiosyncratic: rash (SJS/TEN rare)
Chronic: gingival hyperplasia, folate deficiency
Rare: DRESS, SLE-like syndrome

Question 21

21. How would you know if teenager was using anabolic steroids?
    a. Hirsutism
    b. Testicular atrophy

Answer 21

Testicular atrophy

• In men: testicular atrophy, gynecomastia
• In women: hirsutism, acne, deepening of voice, clitoral hypertrophy, male-pattern baldness
• Increased AST, ALT, LDH
• Increased total cholesterol, low HDL
• Thrombosis

Question 22

22. Kid with otitis media given Amox/Clav in 4:1 dose. Presents with diarrhea and vomiting. Cause?
    a. Wrong clavulin dose
    b. Viral gastro

Answer 22

Wrong clavulin dose

Should give 7:1 fomrulation b/c has most amox combined with least amount of clav

• 10mg/kg/d of clav is linked with higher risk for diarrhea
• To limit diarrhea: use BID, take with food

Question 23

23. During RSI, when is succinylcholine contraindicated?
    a. raised ICP
    b. muscular dystrophy

Answer 23

Muscular dystrophy
Risk of acute rhabdomyolysis + hyperkalemia

Sux is a short-acting, depolarizing neuromuscular blockage (only depolarizing agent currently in use)
- mimics ACh. Fasciculation phase -> neuromuscular paralysis

Contraindications of roc + sux
Hyperkalemia
Neuromuscular conditions
malignant hyperthermia
Acute phase injury following major burns, multiple trauma, extensive denervation of skeletal muscle

ADR of sux

• hyperkalemia
• increased intraocular pressure
• salivation
• HTN
• arrhythmias
• resp depression

Question 24

25. Kid with DM type I on clavulin (amox to clav ratio 4:1) for OM. On day 3 he develops vomiting and diarrhea. Most likely cause of vx/dx?
    a. Viral gastro
    b. Wrong clavulin dose
    c. Allergy to clavulin
    ————
    Young child has been treated with amoxicillin clavulin at 4:1 ratio. He has GI upset. What is the cause?
    a. Wrong clavulin dose
    b. C difficile

Answer 24

Wrong clavulin dose

Question 25

27. Best amnestic drug?
    a. midazolam
    b. ketamine
    c. fentanyl
    d. chloral hydrate

Answer 25

Midazolam

Question 26

29. Young boy’s mother wishes counseling about the risk of drug dependency with ADHD medications
    a. decreases risk of developing drug dependency
    b. risk actually increases
    c. “one of the stimulants” has been shown to decrease the risk more than others

Answer 26

Decreases risk of developing drug dependency

CPS
“Compared to those without ADHD, children with ADHD have a higher risk of substance abuse. However, children with ADHD who are treated with medication have a lower risk of substance abuse than children with ADHD who are not treated.”

Question 27

30. Teenage female presents with headaches that wake her from sleep. On exam, has bilateral papilledema. Currently on OCPs and minocycline for acne. CT normal. What is the most likely diagnosis?
    a. Pseudotumour cerebri
    b. Migraines
    c. Stroke
    d. Tumor
    ————–
    Teen with bad morning headaches. Takes OCP and minocycline for acne. In ER, exam is normal except bilateral papilledema. Normal CT and MRI. Diagnosis:
    a. migraine
    b. pseudotumor cerebri

Answer 27

Benign intracranial hypertension

Question 28

32. What are the main differences between a neonate and an adolescent with respect to drug dosing?
    a. Increased distribution of liquid
    b. Increased distribution of lipid
    c. More rapid renal clearance
    d. More rapid liver metabolism
    —————-
    How is a neonate different than a teenager (the answer I wanted to give wasn’t here!)
    a. better liver function
    b. increased renal excretion
    c. bigger fluid volume
    d. bigger lipid volume
    —————-
    Which is higher in neonates compared to adolescents?
    a. Volume of liquid distribution
    b. Volume of lipid distribution
    c. Hepatic metabolism
    ————–
    Compared with an adult, a newborn has:
    a. increased distribution of liquid
    b. increased distribution of lipids
    c. decreased hepatic function
    d. increased renal function

Answer 28

Increased distribution of liquid

TBW decreases with age
Higher TBW content in neonates than teens

Body fat increases with age
- Note: lipid content is high in the brain
Renal function improves with age. Formation complete by 36wk. Functionally immature with GFR ~1/2 of adult value at birth. Typically mature at 1y.
Hepatic metabolism improves with age

Question 29

33. 16 yr old comes complaining of daily morning headaches, nausea, and occasional vomiting. Otherwise systemically well. She is on an acne medication but still gets teased regarding her acne at school. She is academically doing well at school. Which one of her acne medications will cause her symptoms:
    a. minocycline
    b. oral contraceptive pills
    c. clindamycin
    d. topical tretinoin

---------------
Girl with acne. Which of the following gives you pseudotumour cerebri:
a. Minocycline
b. OCP
c. Topical retinoid
---------------
Kid with signs of increased ICP, teased at school because of obesity and acne. PE reveals papilledema, MRI head normal. No sexual activity. What is the most likely cause?
a. oral contraceptive
b. minocycline

Answer 29

Minocycline

Question 30

34. Child has received anthracycline as part of chemotherapy. Which long term side effect should he be tested for:
    a. Hearing
    b. Vision
    c. Renal
    d. Cardiac
    —————
    Long term effect of anthracyclines?
    a. Cardiomyopathy
    —————
    You are a rural doc seeing a child who had just completed chemotherapy. What are the side effects of anthracyclines -what do you need to monitor for?
    a. hearing test
    b. cardiac echo
    c. thyroid function
    d. renal function

Answer 30

Cardiac for dilated cardiomyopathy/cardiotoxicity

Doxorubicin is anthracycline
Increased risk of toxicity by concomitant radiation therapy

Question 31

39. Doxorubicin causes?
    a. dilated cardiomyopathy
    b. hypertrophic cardiomyopathy
    c. restrictive cardiomyopathy
    d. pericarditis
    ————–
    Complication of doxorubicin?
    a. Restrictive cardiomyopathy
    b. Dilated cardiomyopathy
    c. Hypertrophyic cardiomyopathy
    d. Pericarditis
    ————–
    Doxorubicin causes
    a. DCM
    b. HCM
    c. Restrictive CM

Answer 31

Dilated cardiomyopathy

Question 32

35. Most amnestic drug?
    a. Midazolam
    b. Chloral hydrate
    c. Morphine
    d. Fentanyl
    —————
    Which has amnesia effects?
    a. midazolam
    b. chloral hydrate
    c. fentanyl
    d. morphine
    —————
    Most amnestic drug:
    a. Fentanyl
    b. Morphine
    c. chloral hydrate
    d. Midazolam

Answer 32

Midazolam

• anixolytic + amnesia + sedation
• no analgesia

Question 33

36. Teen on OCP. What is the side effect of excess estrogen?
    a. Mood swings
    b. Breast tenderness
    c. Weight gain
    d. Acne
    —————
    The estrogen part of the OCP causes what?
    a. moodiness
    b. salt and water retention
    c. Acne

How does combined OCP work?
What are the advantages?
What are the SE?

How does progestin only work?
What are the SE?

Answer 33

Breast tenderness

Combined OCP
E2
- disrupts ovum transport
- slows tubal mobility
- inhibits sperm's ability to fertilize egg

PE2

• thickens cervical mucus
• inhibits ovulation
• induces endometrial atrophy

Advantages

• decreases PID risk
• decreases ectopic pregnancy risk
• decreases menstrual blood loss
• decreases acne

SE
1. breakthrough bleeding
2. nausea
3. H/A
4. breast tenderness
(no sig risk of mood changes or wt gain)

Progestin only

• thickens + decreases cervical mucous
• inhibits ovulation
• atrophies endometrium

SE

1. irregular bleeding
2. breast tenderness
3. depression

Question 34

45. 15 y/o wanting OCP. What is contraindication?
    a. undiagnosed vaginal bleeding
    b. seizure disorder
    c. mod HTN
    d. diabetes mellitus
    —————-
    Which of the following is a contraindication to the OCP?
    a. Undiagnosed vaginal bleeding
    b. Moderate hypertension
    c. Seizures
    d. Diabetes
    —————-
    Contraindications to OCP?
    a. Undiagnosed vaginal bleeding
    b. Headaches
    c. Diabetes
    d. Mild hypertension

What are the 12 absolute contraindications?

What are the 8 relative contraindications?

Answer 34

Undiagnosed vaginal bleeding

What are absolute contraindications?

1. <6wk postpartum if breastfeeding
2. Smoking >35yo (>=15 cig/d)
3. HTN (SBP >=160 or DBP >=100)
4. Current or past Hx of VTE
5. Ischemic heart disease
6. Hx of cerebrovascular accident
7. Complicated valvular heart disease (pulm HTN, afib, Hx of SBE)
8. Migraine H/A with focal neuro Sx
9. Current breast cancer
10. Diabetes with retinopathy/nephropathy/neuropathy
11. Severe cirrhosis
12. Liver tumour (adenoma or hepatoma)

What are relative contraindications?

1. Smoker >35yo (<15cig/d)
2. Adequately controlled HTN
3. HTN (SBP 140-150, DBP 90-99)
4. Migraine H/A > 35
5. Currently symptomatic gallbladder disease
6. Mild cirrhosis
7. Hx of combined OCP-related cholestasis
8. Users of meds that may interfere with combined OCP mechanism

What are other contraindications?

• Undiagnosed vaginal bleeding
• Pregnancy

Question 35

38. Which of the following effects of ketamine make it not a preferable drug to use in brain injury for RSI:
    a. sympathomimetic effect
    b. negative inotrope -
    c. induces respiratory depression
    —————
    Child with head injury. Which of the following is a reason for why ketamine should not be used in this child?
    a. it has sympathomimetic properties
    b. it has negative inotropic properties
    c. it causes respiratory suppression

What are the effects of ketamine?
What are the SE?
When is it contraindicated?

Answer 35

Sympathomimetic effect

Ketamine
1-3mg/kg IV, lasts 15-30min
NMDA receptor antagonist in CNS
- dissociative analgesic
- amnestic
- increase HR + BP

• Can give IV, IM, SC, IN, PO
• bronchodilator - useful for asthma

SE

1. causes sialorrhea (consider atropine or glycopyrrolate)
2. may be assoc’d with laryngospasm
3. high doses leads to loss of airway reflexes, apnea + resp depression
4. increases myocardial O2 demand, use cautiously if impaired myocardial O2 delivery or cardiac outflow tract obstruction
5. decreases sz threshold
6. increases intracranial + intraocular pressure
7. Postanesthetic hallucinations

Absolute contraindications

1. <3mo (airway complication risk)
2. Schizophrenia
3. Hypersensitivity reaction to drug or any of its components

Relative contraindications
- in pts in whom elevated BP is dangerous (increased ICP, HTN, thyrotoxicosis, aneursysms, CHF)

Of note, new evidence shows that weak evidence of ketamine elevating ICP
No evidence that ketamine causing harm in TBI
Ketamine’s hemodynamic stability may actually benefit pt with TBI requiring RSI

Question 36

39. Contraindication of OCP?
    a. moderate HTN
    b. undiagnosed vaginal bleeding
    c. smoker
    —————–
    Which is an absolute contraindication to birth control pill:
    a. Migraine headaches
    b. Smoking
    c. Moderate Hypertension
    d. Undiagnosed vaginal bleeding

Answer 36

Undiagnosed vaginal bleeding

Question 37

40. Transplant pt on cyclosporine. Normal drug levels. Admitted and put on clarithromycin. Cyclosporine level now toxic. Why?
    a. not compliant prior to admission
    b. clarithromycin causes decreased metabolism of cyclosporine
    c. clarithromycin causes decreased renal excretion
    —————-
    An 8 year old girl with a renal transplant is on cyclosporine. She is admitted to the hospital for pneumonia and receives clarithromycin. On admission her cyclosporine level is normal and three days later it is above the normal range. What is the reason for this?
    a. Poor compliance with medication prior to arrival
    b. Clarithromycin decreases the renal clearance of cyclosporine
    c. Clarithromycin decreases the metabolism of cyclosporine
    —————–
    Cyclosporine at start of treatment and high levels 3 days into treatment. Patient started on clarithromycin. Reason?
    a. renal transplant
    b. clarithro inhibits renal excretion of cyclosporine
    c. better compliance
    d. clarithromycin

Answer 37

Clarithro decreases the metabolism of cyclosporin

Clarithro inhibits hepatic CYP450 3A4
Cyclosporine clearance largely depends on CYP450 3A4 enzyme metabolism

Question 38

41. Mother is concerned about her son who has asthma. He has been on daily moderate dose inhaled steroids for the last few years. She has noticed that he seems to be growing slowly. What can you tell her based on the knowledge that we currently have?
    a. He will be slightly shorter than his genetic potential
    b. There will be no significant difference in his height
    c. He will be significantly shorter than his predicted height
    d. There will now be a significant catch up period of growth

Answer 38

He will be slightly shorter than his genetic potential

But 1 cm….

Question 39

42. Management of postoperative pain in children aged 6-10 years:
    a. use BP and HR as a guide for when to give pain medications
    b. give regular doses of pain meds in the first 24 hours as they cannot reliably report pain
    c. use facial expression as an indication of pain
    d. patient can use a visual analog pain scale to describe their pain

Answer 39

Patient can use a visual analog pain scale to describe their pain

> =4yo
Faces Scales

> =6-8yo
Visual analog scale
Likert Scale

All ages
Behavioural or combined behavioural-physiologic scales (e.g. FLACC) - can be used in infants + nonverbal children
Autonomic measures

Question 40

43. Succinylcholine is contraindicated in which of the following
    a. DMD
    b. Hypothyroidism
    c. Increased ICP

Answer 40

DMD

Question 41

44. ADHD long term side effects of stimulant meds
    a. tics
    b. depression
    c. appetite
    —————
    Which of the following is a late-onset side effect of stimulants?
    a. Tics
    b. Depression
    c. Hypertension
    d. Weight loss

Answer 41

Depression

Question 42

46. Mom concerned about the risk of dependency in her child, whom you have recently prescribed long-acting Ritalin. What do you tell her:

a. treatment with stimulant medications decreased risk of drug dependency
b. treatment will result in no change in the risk of dependency
c. there is an increase in risk of dependency in those who are treated
d. there is only a decreased risk of dependency with methylphenidate

Answer 42

Treatment with stimulant decreases risk of drug dependency

Note: if have substance abuse or dependence, should avoid Dx of ADHD until pt is in recovery.

Question 43

48. How long after IVIG should you wait before giving live vaccines.
    a. 6 months
    b. 9 months
    c. 3 months
    d. 11 months

Answer 43

11 months

• give live vaccine at least 14d prior to Ig preparation or blood product
  OR delay live vaccine until antibodies in the Ig preparation or blood product have been degraded => dose dependent effect. Wait 3-11 mo depending on dose. To maximize immunization effectiveness
• If cannot meet this requirement, then repeat dose after the recommended interval

Should wait 11mo after IVIG at the 2g/kg IV dose given before giving live vaccine.

IVIG prepared from adult plasma donors. Predom IgG. Tested to ensure minimum Ab titres to diphtheria, HepB, measles + polio.

SE of IVIG

• infusion rate related (respond to decreasing rate): fever, H/A, myalgia, chills, N/V
• more serious rxns: anaphylaxis, VTE, aseptic meningitis, renal insufficiency

Question 44

49. A child on dilantin is given septra for an infection. She returns ataxic with abnormal speech. What is the mechanism of this interaction?

a. Septra increases absorption of Dilantin
b. Septra displaces dilantin from protein binding sites
c. Septa causes decreased metabolism of Dilantin
d. Septra causes decreased excretion of Dilantin

Answer 44

Septra causes decreased metabolism of Dilantin/phenytoin

TMP is a potent inhibitor of CYP450 2C8
Phenytoin metabolism catalyzed by CYP450 2C8, 2C9, 2C19.
Inhibition of the enzyme leads to phenytoin toxicity
- ataxia
- nystagmus
- purple glove syndrome

Question 45

51. 13 yr male in with his mother who is concerned about his growth as he has been on continuous moderate dose inhaled corticosteroid therapy. What can you tell her?
    a. his final height will not be affected
    b. he will have catch up growth in the next year
    c. puberty will be delayed
    d. he will be slightly shorter than his peers

Answer 45

He will be slightly shorter than his peers

Question 46

52. What is a late-onset side effect of Ritalin***Q
    a. difficulty sleeping
    b. decreased appetite
    c. tics
    d. depression

Answer 46

Depression

Question 47

53. You are developing a post-op pain management program for kids 7-12 years. How best to assess their pain?
    a. it’s not possible to assess their pain, so you have to guess
    b. self-reporting using a owie-face scale
    ————-
    Management of postoperative pain in children aged 6-10 years:
    a. give regular doses of pain meds in the first 24 hours as they cannot reliably report pain
    b. they can assess pain meds as required using self reporting
    c. use facial expression as an indication of pain
    d. use a visual analog pain scale

Answer 47

Self-reporting using visual analog pain scale

Question 48

55. What should be used for sedation while doing a CT scan in a patient with head injury?
    a. Midazolam
    b. Chloral hydrate
    c. Propofol

Answer 48

Propofol

Midaz not as helpful for CT scans compared to short acing barbiturates
Chloral is no longer recommended for diagnostic testing

Question 49

57. An 8 year old girl is in a motor vehicle accident and has had significant pain in her left upper extremity. Her symptoms are consistent with neuropathic pain. What treatment do you recommend?
    a. opioids
    b. gabapentin
    c. NSAIDs

What are 7 other meds that I can use to treat neuropathic pain?

Answer 49

Gabapentin

Tx of neuropathic pain

1. Gabapentin
2. Pregabalin
3. Lorazepam
4. Valproate
5. Carbamazepine
6. Phenytoin
7. Topiramate

Question 50

What causes sexual dysfunction in adolescents?

a) Calcium channel blockers
b) Antidepressants
c) Beta-2 agonists
d) Theophylline

Answer 50

SSRI (class effect)

• Fluoxetine: abnormal ejaculation + impotence
• Paroxetine: abnormal ejaculation, orgasm distrubance

CCB
- Amlodipine + nifedipine: male sexual dysfunction

Question 51

60. A teen in your practice has been on fluoxetine and risperdal. He presents to your office with hyper-reflexia and tremor and ataxia and 5 or 6 more symptoms. What to do you do?
    a. Decrease fluoxetine
    b. Stop fluoxetine
    c. Increase fluoxetine
    d. Decrease risperdal

Answer 51

Stop fluoxetine

Serotonin Syndrome

Question 52

72. IVIG is used for all EXCEPT:
    a. ITP
    b. Guillaine-Barre
    c. Kawasaki disease
    d. bone marrow transplant
    e. nephrotic syndrome

Answer 52

Nephrotic syndrome

Question 53

3yo boy with CP presents with fever + tachypnea. On CXR there is an air collection surrounded by consolidation + significant pleural effusion on the LLL. What is the most appropriate management?

a) Clindamycin + gentamicin
b) ciprofloxacin
c) cefuroxime + azithromycin
d) ampicillin + gentamicin

Answer 53

Aspiration pneumonia

Previous Sick Kids guidelines
Amp + gent (hospital acquired)
vs clinda + gent (life threatening)

Sick Kids Formulary 2016 for empiric Tx of aspiration pneumonia: CFTX +/- clinda

Question 54

The mechanism of morphine for pain relief

a) works at only 1 type of receptor
b) reduces sensation of pain + emotional perception of pain (analgesic effect of subjective perception of pain + decreased emotional response)
c) IM route preferred over IV

Answer 54

Reduces sensation of pain + emotional perception of pain

Question 55

What are the acute adverse effects of marijuana?

Answer 55

1. Euphoria, distorted perception
2. Anxiety + panic
3. Psychotic symptoms
4. Impaired short term memory, performance of complex mental tasks, compromised motor skills + reaction times
5. Doubles risk of MVA

Question 56

What is Cannabis Use Disorder?

Answer 56

DSM5
Problematic use of cannabis leading to clinically significant functional impairment or distress within a 12mo period

• reduced academic performance
• truancy
• reduced participation + interest in extracurricular activities
• withdrawal from usual peer groups
• conflict with family

Question 57

What is Cannabis Withdrawal Syndrome?

Answer 57

DSM5
After cessation of heavy cannabis use (daily or nearly daily for at least a few mo)

At least 2/5 psychological Sx

1. Irritability
2. Depressed mood
3. Anxiety
4. Sleep disturbance
5. Appetite changes

At least 1/6 physical Sx

1. Fever
2. Chills
3. Shaking
4. Diaphoresis
5. H/A
6. Abdo pain

Withdrawal Sx occur 24-72H after last use, persist 1-2wks.
Sleep disturbance up to 1mo

Question 58

What are the long term risks of cannabis?

Answer 58

1. 50% of youth with cannabis related psychosis go on to develop psychotic disorder in the future
2. Chronic bronchitis + impaired resp function
3. Smoking 4d/wk x 6mo -> suppress plasma testoterone + spermatogenesis
4. Gynecomastia if >4X/wk

Question 59

[CPS] What are CPS recommendations for government + HCP about marijuana?

Answer 59

Governments should

1. Prohibit sale under legal age
2. Decrease concentration of THC in <25yo
3. Limit marketing to minors
4. Extend tobacco legislation (no smoking in public venues)
5. More roadside monitoring

HCP

1. screen everyone + educate on harm
2. Provide anticipatory guidance on risks

Question 60

[CPS] What is the major tenet of homeopathy?

Answer 60

Law of similars or “like cures like”
Substance can cure the same set of Sx that it can induces in a healthy individual

Given in diluted + shaken form

No effect of homeopathy

• Otitis media - pain, recurrence, hearing loss
• Adenoid hypertrophy - need for T+A
• Asthma
• Allergies
• Warts

Some improvements with homeopathy

• Diarrhea - sig decrease frequency of stools + duration of diarrhea (well designed studies)
• Chemo-induced stomatitis (++design problems)
• Post-op agitation (++methodological + reporting problems)
• ADHD (++methodological problems)

Question 61

What is pharmacodynamics?

Answer 61

How drug affects the body

One drug modulate pharmacodynamic effect of another: 1) additive, 2) synergistic, 3) antagonistic

Question 62

What is pharmacokinetics?

What are the 4 properties?

Answer 62

How body processes the drug

1. Absorption - food, GI motility, chelation, pH
2. Distribution - transport, protein binding
3. Metabolism - phase I (CYP450), phase II (conjugation)
4. Elimination - renal (GFR), tranport

Question 63

What are examples of CYP450 inhibitors?

Answer 63

3A4

• erythromycin, clarithromycin
• ketoconazole, itraconazole
• grapefruit juice (intestinal 3A4 only)

2D6

• fluoxetine, paroxetine
• codeine

Others

• VPA
• HIV protease inhibitors

Question 64

What are examples of CYP450 inducers?

Answer 64

1. Rifampin
2. Phenobarbital
3. Phenytoin
4. Carbamazepine
5. St. John’s Wort