B22

Question 1

A 34-year-old male has recently been prescribed citalopram for depression. He also has epilepsy but had been
seizure free for several years until last week.
Which of the following is most likely to have caused the seizure?
o Hypercalcaemia
o Hyperkalaemia
o Hypoglycaemia
o Hypomagnesaemia
o Hyponatraemia

Answer 1

Citalopram is an SSRI, and SSRIs are known to increase the risk of hyponatraemia, especially due to syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Hyponatraemia lowers the seizure threshold, which could explain why the patient, previously seizure-free, had a recent seizure.

Question 2

You are working in a community pharmacy on Boxing Day and a 30-year-old patient with epilepsy has asked if
you can give an emergency supply of their epilepsy medication as they have run out. You do not have a locally
commissioned emergency supply service, so you consider if they could have an emergency supply at the
request of a patient.
Which of the following drugs would you not supply as an emergency supply at the request of a patient?
o Carbamazepine
o Gabapentin
o Lamotrigine
o Phenobarbital
o Sodium Valproate

Answer 2

Gabapentin (sch 3)

Question 3

A 54-year-old male has been taking the following medication for the past four years:
* Amlodipine 10 mg tablets – Take one daily
* Cetirizine 10 mg tablets – Take one daily when required
* Indapamide 2.5 mg tablets – Take one daily
* Ramipril 10 mg capsules – Take one daily
* Paracetamol 500 mg tablets – Take two tablets four times a day when required
The patient rings the pharmacy and tells you that they have been suffering with diarrhoea and vomiting that
started this morning.
Which one of these medicines would you recommend that they stop for 1 - 2 days until they recover?
o Amlodipine
o Cetirizine
o Indapamide
o Ramipril
o Paracetamol

Answer 3

Ramipril (ACE inhibitor)
Can cause or worsen acute kidney injury (AKI) in dehydrated patients.
Vomiting and diarrhoea can lead to dehydration and reduced kidney perfusion.
Stopping Ramipril temporarily (a “sick day rule”) reduces the risk of AK

Question 4

2-year-old child has been prescribed ibuprofen 100mg/5ml for pain from an ear infection.
What dose is he most likely to receive?
o One 2.5 ml spoonful three times a day
o One 2.5ml spoonful four times a day
o One 5 ml spoonful three times a day
o One 5 ml spoonful and one 2.5 ml spoonful three times a day
o Two 5 ml spoonful’s three times a day

Answer 4

One 5ml spoonful three times a day

Question 5

A 55-year-old woman enquires about hormone replacement therapy (HRT). She is in good health and is not
on any other medication but has recently started suffering with night sweats and irritability. She will be
speaking to her GP about treatment but wants to know more about the risks of HRT treatment.
Which of the risks listed are NOT associated with Hormone Replacement Therapy?
o Alopecia
o Breast cancer
o Ovarian cancer
o Stroke
o Venous thromboembolism

Answer 5

Alopecia

Question 6

A 40-year-old man is diagnosed with Helicobacter Pylori infection. He has no allergies.
Which of the following would be the most suitable treatment regime for this gentleman?
o Lansoprazole 30mg capsules B.D, Amoxicillin 500mg capsules three times a day and Clarithromycin
500mg tablets twice daily
o Lansoprazole 30mg capsules B.D, Amoxicillin 1g capsules twice daily and Clarithromycin 500mg tablets
twice daily.
o Lansoprazole 60mg capsules B.D, Amoxicillin 1g capsules twice daily and metronidazole 400mg tablets
twice daily
o Lansoprazole 30mg capsules B.D, Amoxicillin 500mg capsules three times a day and metronidazole
400mg tablets three times a day.
o Lansoprazole 30mg B.D, Clarithromycin 500mg twice daily and Metronidazole 400mg twice daily.

Answer 6

Lansoprazole30mgcapsulesB.D,Amoxicillin1gcapsulestwicedailyandClarithromycin500mg
tablets twice daily.

Question 7

It is a cold winter’s morning and a 9-year-old girl is being reviewed at an asthma clinic. During the review she
is complaining of increased breathlessness at breaktimes when playing outside and when she goes for bike
rides with her family at the weekend when the weather is cold. She is currently on a salbutamol inhaler which
she needs to use daily. Her PEFR is 78% at best. She is on no other medication.
Which of the following is the most appropriate to add to her current medication?
o Clenil modulate 100 micrograms one puff twice daily
o Clenil modulate 200 micrograms one puff twice daily
o Flixotide evohlaer 250 micrograms one puff twice daily
o Pulmicort turbohaler 400 micrograms one puff twice daily
o Symbicort turbohaler 200 micrograms one puff twice daily

Answer 7

This child has asthma symptoms that are not well controlled (daily salbutamol use and cold-induced breathlessness). According to the British Thoracic Society (BTS) & NICE Asthma Guidelines, the next step in asthma management for children aged 5–12 years who are not well controlled on a short-acting beta-agonist (SABA) alone is the addition of a low-dose inhaled corticosteroid (ICS).

Clenil Modulite 100 mcg BD is a low-dose ICS, making it an appropriate first-line controller therapy for a child with worsening asthma symptoms.

Question 8

You are working on the oncology ward and a patient requires vincristine.
What route of administration should only be used when administering vincristine parenterally?
o Intravitreal
o Intrathecal
o Intravenous
o Subcutaneously
o Intramuscular

Answer 8

IV

Question 9

A 42-year-old patient has presented to their GP with a history of anxiety, weight loss, hyperactivity, and
difficulty sleeping. After routine blood tests, they have been diagnosed with hyperthyroidism and require
appropriate treatment.
Which of the following thyroid function test patterns is most likely to describe the patient?
o High TSH and normal T4
o High TSH and low T4
o Low TSH and high T4
o Low TSH and low T4
o Low TSH and normal T4

Answer 9

Low TSH and high T4

Question 10

A 16-year-old girl brings in a prescription for doxycycline to the pharmacy to treat her acute sinusitis. Her PMR
shows that this is her first time. You counsel the patient.
Which of the following is the most likely to be mentioned upon handout?
o Take on an empty stomach
o Do not take indigestion remedies, or medicines containing iron or zinc, 4 hours before or after you take
this medicine
o Protect your skin from sunlight – even on a bright but cloudy day. Do not use sunbeds.
o Take with a full glass of orange juice
o Stop taking the medication as soon as you feel better

Answer 10

Protect the skin

Question 11

A 35-year-old man has recently commenced opioid therapy for non-malignant pain relief. They are worried
about the potential for addiction as they have recently read a newspaper article about this.
Which of the following options would be the most appropriate advice to give?
o Even at therapeutic doses long term opioid therapy may lead to addiction and this should be discussed
with the patient’s prescriber.
o It is not possible for opioid medication to cause addiction when used for pain relief.
o Opioid therapy almost always results in addiction, the patient should find another option for pain
relief.
o The medication should be immediately discontinued, and only restarted after the patient has a chance
to discuss the potential of addiction with the prescriber.
o The risk of addiction from opioid therapy is only prevalent where there is a history of medication
abuse.

Answer 11

A

Question 12

A 45-year-old woman has been prescribed an antidepressant. She is concerned about weight gain.
Which of the following is most likely to cause weight gain?
o Amitriptyline
o Escitalopram
o Lofepramine
o Mirtazipine
o Venlafaxine

Answer 12

Mirtazapine is known to cause significant weight gain and increased appetite, likely due to its antihistaminergic (H1) and serotonergic (5-HT2C) effects.
It is commonly associated with increased cravings for carbohydrates and sedation, which can contribute to weight gain

Question 13

Sepsis is a life-threatening medical emergency.
Which of the following is least likely to be a common symptom of sepsis?
o Confusion
o Fever
o High blood pressure
o High heart rate
o Shortness of breath

Answer 13

Light-headedness due to low blood pressure is often experienced in patients with sepsis

Question 14

A 34-year-old woman comes in comes in the pharmacy complaining of recently experiencing nightmares and
sleep disturbances.
Which of the following beta blockers is she least likely to have been prescribed?
o Atenolol
o Propranolol
o Bisoprolol
o Metoprolol
o Nebivolol

Answer 14

Beta-blockers can cause nightmares and sleep disturbances due to their ability to cross the blood-brain barrier (BBB) and interfere with sleep architecture. However, atenolol is the least likely to cause these effects because:

Atenolol is hydrophilic (water-soluble) and does not readily cross the BBB, reducing its impact on the central nervous system (CNS

Question 15

A 21-year-old woman with type 1 diabetes visits your pharmacy for some advice. She is driving to see some
relatives tomorrow but is worried about her glucose levels on the long 6-hour drive.
Which is the most appropriate advice for this patient?
o Adjust her insulin dose before setting off on the journey
o Ensure her blood glucose concentration is below 8 mmol/L before driving
o Ensure she has a supply of long-acting carbohydrate in the vehicle
o Ensure she maintains her glucose levels at 5 mmol or more during the journey
o Ensure she tests her glucose less than 3 hours before driving

Answer 15

Ensure she maintains her glucose levels at 5mmol or more during the journey

Question 16

Flu season is approaching, and your pharmacy want to design a campaign to encourage the uptake of flu
vaccines in the community.
Which of the following patients is least likely to be eligible for an NHS flu vaccine?
o A 28-year-old man who works in children’s social care
o A 45-year-old woman who has newly been diagnosed with diabetes
o A lady who is 15 weeks pregnant
o A lady with a BMI of 22.5
o A person who is 66-year-old with two children at university

Answer 16

A lady with a BMI of 22.5

Question 17

A 4-year-old child has recently been prescribed montelukast 5 mg tablets one at night, for the prophylaxis of
his asthma. He is unable to use inhalers. On collection of his prescription his father informs you that his son’s
sleep patterns have been disrupted and he has started to stutter.
What is the most appropriate advice to give to the father?
o Advise the father to speak to GP or Asthma nurse for further advice as soon as possible
o Advise the father to discontinue treatment and to speak with the GP to switch to flixotide evohaler
o Advise the father that these are just side effects of the tablets and to continue as normal
o Advise the father to continue treatment but speak to GP or Asthma nurse about reducing the dose of
Montelukast tablets
o Advise the father to discontinue treatment and speak to GP about having a short acting beta agonist
instead

Answer 17

Advise the father to speak to the GP or Asthma nurse for further advice as soon as possible.

Explanation:
Montelukast, a leukotriene receptor antagonist, is used to help prevent asthma symptoms, but it can be associated with side effects, particularly in children. These side effects include sleep disturbances, mood changes, and in some cases, behavioral changes such as stuttering. The most serious side effects could be neuropsychiatric effects such as aggression, agitation, or other behavioral changes, which require medical attention.

Given the concerns about the child’s sleep disruption and the new onset of stuttering, the most appropriate step is to consult the GP or asthma nurse. They can assess whether montelukast is the cause of these symptoms and consider alternative treatments or adjustments.

Question 18

A 3-year-old child weighing 14 kg has come into your pharmacy with their mother with a prescription for
nitrofurantoin 25 mL/ 5 mL suspension at a dose of 10.5 mg four times a day for 7 days for an acute urinary
tract infection.
Three days later the mother returns with her child concerned that her child is passing urine of yellow-brown
colour.
What is the most appropriate advice to give to the mother of the child?
* The child can continue to take nitrofurantoin, but the GP must be notified of the discoloured urine within
24 hours.
o The urine can sometimes turn yellow brown in colour with nitrofurantoin and this is a harmless side effect.
It is therefore safe for the child to continue taking nitrofurantoin.
* The child can stop taking the nitrofurantoin as long as the symptoms have resolved
* The child needs to drink more water
▪ The child needs to stop taking the abx and attend A+E

Answer 18

The urine can sometimes turn yellow brown in colour, this is a harmless effect

Question 19

A 5-year-old girl is brought to your attention in the pharmacy by her mother who explains she is feeling “really
itchy all over”. You see a rash on the child’s arm and neck and her speech is impaired suggesting her tongue
has started to swell. Her mother explained that the symptoms have just started after lunch which she had 10
minutes ago.
What is the most appropriate advice for the mother of the child?
o Call 999 immediately
o Explain this is self-limiting and will improve over the next hour
o Refer to GP within the next three days
o Refer to local walk-in centre within the next 24 hours
o Sell chlorphenamine solution (Piriton) and advise the monitor their child over the next few days

Answer 19

call 999

Question 20

A man returns his 62-year-old wife’s unused Oxynorm liquid to your pharmacy.
Which of the following is the most appropriate course of action?
o Enter the returned volume into the CD register in the quantity obtained section and store in a segregated
area in the CD cabinet.
o Explain to the patient that they must return the unused supply to their GP.
o Retain the bottle in the yellow DOOP bin, in preparation for denaturing and disposal.
o Store in a segregated area of the CD cabinet before rendering irretrievable.
o The liquid must be denatured and witnessed by an authorised person.

Answer 20

Store in a segregated area of the CD cabinet before rendering it irretrievable

Question 21

While checking an ‘owing’, you identify that the medicine was supplied the previous day with an incorrect
dose.
Which of the following actions needs to take place first?
o Identify improvements in the pharmacy processes to prevent this error from reoccurring.
o Inform the patient of the error
o Inform the pharmacy team of the error
o Investigate as to why the error was made
o Report the error

Answer 21

Inform patient of error

Question 22

A 47-year-old female is currently taking an oral-only regimen for pain management. On an average day she
will have four additional doses for breakthrough pain. She is recently finding it more difficult to swallow the
tablets and her consultant would like her to switch to an equivalent dose of fentanyl via a 72-hour patch.
Current Oral Regimen
* MST 30 mg tablets – Take ONE twice a day
* MST 15 mg tablets – Take ONE twice a day
* Oramorph 10 mg/5 ml solution – Take 5 ml for breakthrough pain when required
Which patch would be most appropriate?
o Fentanyl 12 patch
o Fentanyl 25 patch
o Fentanyl 50 patch
o Fentanyl 75 patch
o Fentanyl 100 patch

Answer 22

Fentanyl 50

Question 23

A 75-year-old man has been prescribed glyceryl trinitrate 2 % ointment for the prophylaxis of angina
How much glyceryl trinitrate is required to produce 60 g of the ointment?
o 120 mg
o 200 mg
o 1200 mg
o 2 g
o 12 g

Answer 23

2g in 100g -> 2000mg in 100g
1200mg in 60g

Question 24

A 66-year-old man has been discharged with a diuretic.
Which of the following thiazide or thiazide related diuretics are appropriate for a patient with an eGFR 27
mL/minute/1.73m2?
o Bendroflumethiazide
o Chlortalidone
o Cyclopenthiazide
o Indapimide
o Metolazone

Answer 24

Metaolazone

Question 25

A 30-year-old male presents with the following rash. He explains it was tingling in the area a few days before the rash presented and is now itchy and painful. He tells you that he has the some more spots and localised tracking around to his back, and only on one side of his body. He has no other symptoms Which of the following conditions is the patient likely to have? o Contact Dermatitis o Measles o Psoriasis o Ringworm o Shingles

Answer 25

Shingles is caused by the reactivation of the varicella-zoster virus (the same virus that causes chickenpox). It typically presents with: Pain and tingling (often described as a burning or itching sensation) in a specific area before the rash appears. A unilateral, localized rash that usually appears in a dermatomal pattern (affecting one side of the body). The rash consists of clusters of fluid-filled blisters, which can be very painful. The rash commonly appears on the torso, face, or neck, often following the nerve paths (hence the term "tracking").

Question 26

A 3-year-old girl has recurrent urinary tract infections and the paediatrician has recommended trimethoprim prophylaxis at a dose of 2 mg/kg at night. She weighs 12.5 kg and trimethoprim suspension is available as 50 mg/5 mL What is the most appropriate volume of suspension the child’s mother should give her every evening? o 0.25 mL o 2.5 mL o 25 mL o 5 mL o 10 mL

Answer 26

2mg x 12.5 =25mg 50mg in 5ml 25mg is 2.5mg

Question 27

One of your regular patients has been diagnosed with gastro oesophageal reflux disorder (GORD). She has been prescribed Omeprazole 20mg capsules and would like to know if it is safe to take this with her other medication Which of her current medication has a significant interaction with omeprazole? o Atenolol o Clopidogrel o Metformin o Ramipril o Simvastatin

Answer 27

Omeprazole is a proton pump inhibitor (PPI) that works by reducing stomach acid production. However, it can inhibit the CYP2C19 enzyme, which is involved in the activation of clopidogrel, an antiplatelet drug used to prevent blood clots. Clopidogrel is a prodrug, meaning it needs to be converted into its active form by CYP2C19 in the liver. When omeprazole inhibits this enzyme, it can reduce the effectiveness of clopidogrel, potentially increasing the risk of cardiovascular events. This interaction is particularly important for patients who are at high risk for heart attacks or strokes, where clopidogrel is used as part of secondary prevention.

Question 28

A 55-year-old man, has been newly prescribed Ramipril and would like to know more information. Which of the following is least likely to be a side effect of Ramipril? o Angioedema o Constipation o Dizziness o Dry persistent cough o Hypokalaemia

Answer 28

Hypokalaemia

Question 29

A 48-year-old female patient is being treated for advanced ovarian cancer with cisplatin and paclitaxel. This is her third round of chemotherapy and she has suffered with nausea and vomiting in her previous treatments. Prior to being diagnosed with ovarian cancer she was generally well. The only medication she took was Stugeron prior to travelling. Which of the following is most appropriate to treat her chemotherapy induced nausea and vomiting? o Aprepitant o Dexamethasone o Ondansetron o Ondansetron and Dexamethasone o Ondansetron, aprepitant and dexamethasone

Answer 29

Chemotherapy-induced nausea and vomiting (CINV) is a common and potentially debilitating side effect of chemotherapy, especially with cisplatin and paclitaxel, which are highly emetogenic (likely to cause nausea and vomiting). For optimal control, a combination of antiemetic agents is often used. The typical regimen includes: Ondansetron (a 5-HT3 receptor antagonist) is the standard treatment for acute nausea and vomiting associated with chemotherapy. It works by blocking serotonin receptors in the gut and brain, preventing nausea and vomiting. Aprepitant (a NK1 receptor antagonist) is effective for delayed nausea and vomiting that can occur up to several days after chemotherapy. It works by blocking substance P, which plays a role in vomiting. Dexamethasone (a corticosteroid) is commonly used in combination with other antiemetics to enhance efficacy. It is effective in delayed CINV and also helps to reduce inflammation in the gut, which may contribute to nausea.

Question 30

A 67-year old man has been recently diagnosed with mild Parkinson’s disease dementia. Which of the following is most likely to be prescribed? o Co–careldopa o Pergolide o Rivastigmine o Ropinirole o Co-beneldopa

Answer 30

Rivastigmine is a cholinesterase inhibitor, which is commonly used in the treatment of dementia associated with Parkinson's disease. It works by increasing the levels of acetylcholine in the brain, which can help improve cognitive function and manage symptoms of dementia. It is particularly used for mild to moderate dementia in Parkinson's disease patients to help with symptoms like memory loss, confusion, and difficulties with thinking. Why not the other options? Co-careldopa and Co-beneldopa: These are combinations of levodopa and carbidopa, which are used to treat the motor symptoms of Parkinson’s disease, such as tremors, rigidity, and bradykinesia. They do not directly treat dementia symptoms. Pergolide: This is a dopamine agonist that was used for Parkinson's disease but is no longer commonly prescribed due to its association with serious side effects, including heart valve issues. It is not typically used to treat dementia. Ropinirole: Another dopamine agonist, used to treat the motor symptoms of Parkinson’s disease, but not for dementia

Question 31

You are a pharmacist working in a specialist mental health unit, you have been asked to check the understanding of a 23-year-old patient on the ward about their new medication, lithium, prior to their discharge. Which statement would be incorrect advice about Lithium treatment? o The signs of lithium toxicity are vomiting, visual disturbances, fine tremor. o If a dose is missed they should take it as soon as possible and if yesterday's dose was missed then they should double today's dose. o Avoid taking over-the-counter non-steroidal anti-inflammatory drugs. o That episodes of diarrhoea or vomiting, or any form of dehydration, will lead to sodium depletion and therefore increased plasma lithium levels. o To carry a lithium card.

Answer 31

Missed dose take asap etc is incorrect

Question 32

A 62-year-old patient has recently been admitted to the hospital after a non-ST-elevation myocardial infarction (NSTEMI). As part of their management, they have undergone an angiogram and had two stents inserted. Previously only taking amlodipine for hypertension, the GP has been asked to prescribe the following in addition to amlodipine: * Aspirin 75 mg once daily * Clopidogrel 75 mg once daily (for 12 months) * Bisoprolol 2.5 mg once daily * Ramipril 2.5 mg once daily * GTN 200 mcg spray when required They have no known drug allergies. Which of the following would be the most appropriate to lower cholesterol as secondary prevention as per NICE guidance? o Atorvastatin 40mg once daily o Atorvastatin 80mg once daily o Ezetimibe 10mg once daily o Simvastatin 20mg once daily o Simvastatin 40mg once daily

Answer 32

Atorva 80mg

Question 33

Thrush is a common yeast infection that affects both men and women and can be treated with over the counter antifungal medicines. It is not always safe to treat, and some patients need referral to their GP or sexual health clinic. Which one of the following patients can be safely treated through a community pharmacy? o A 61-year-old woman who suffered from thrush 6 months ago. She reports she has high blood pressure and takes atenolol. o A 47-year-old man who has had thrush for the first time. o A 15-year-old girl, who was first diagnosed with thrush six months ago by her GP. She is a type 1 diabetic. o A 23-year-old woman, who is 30 weeks pregnant. Her midwife diagnosed thrush at 12 weeks pregnant. It cleared up but has now come back. o A 35 year-old-man who had thrush 5 years ago. He reports burning around the head of the penis. He smokes and takes citalopram 10mg daily for the treatment of depression.

Answer 33

A 35 year old man who has had thrush 5 years ago. Patients over 60 or diabetic or pregnant or experience thrush for the first time or repeatedly within 6 months of treatment should be referred to a doctor.

Question 34

A 57-year-old artist comes to the pharmacy to seek advice from you. Two weeks ago, he noticed that his hands have started to shake, his movement has slowed and his muscles seem to be quite rigid. You ask him whether he has recently started to take any other medicines and he tells you that he has started a new medicine one month ago to reduce nausea and vomiting. Which one of the following medicines is most likely to be the cause of the patient’s symptoms? * Cyclizine * Domperidone * Droperidol * Hyoscine * Ondansetron

Answer 34

Droperidol is an antipsychotic and antiemetic that belongs to the class of butyrophenones, which can cause extrapyramidal symptoms (EPS), including tremors, rigidity, and bradykinesia. These symptoms are consistent with Parkinsonism, which the patient is experiencing. Droperidol can lead to drug-induced parkinsonism as part of its side effect profile

Question 35

A 35 year old patient has been taking carbimazole for an overactive thyroid for 3 months and their TSH level is now in the reference range. Which of the following is not true concerning carbimazole? o Blood tests should be carried out every 6 months o If the patient has a sore throat it should be investigated without delay o It can be taken with or without food o It can be used for Graves’ disease o They should discuss with their doctor if they are pregnant or trying for a baby

Answer 35

the incorrect answer is blood tests should be carried out every 6 months

Question 36

The doctor added Symbicort 100/6 to a patients drug regimen as he was experiencing an exacerbation of his COPD. The pharmacist counselled the patient and checked his inhaler technique. Which of the following presentations would be a sign of poor inhaler technique? o Hair loss o Mouth ulcers o Oral thrush o Stained teeth o Swollen lips

Answer 36

Oral thrush

Question 37

A 15 year-old-female is presenting with signs of anaphylaxis. What is the correct dose of adrenaline to administer? o 150 micrograms IM repeated as needed every 15 minutes o 300 micrograms IM repeated as needed every 5 minutes o 300 micrograms IM repeated as needed every 15 minutes o 500 micrograms IM repeated as needed every 5 minutes o 500 micrograms IM repeated as needed every 15 minutes

Answer 37

500mcg IM repeated as needed every 5mins

Question 38

You are undertaking a medication review with a 72-year-old man, who was admitted to hospital the previous evening following a fall at their home. They are stabilised on warfarin at a dose of 3.5mg on Tuesdays and Fridays and 3mg on the remaining 5 days a week. During their review, they discuss their diet, lifestyle, and other medicines they take, with you. Which of the following is LEAST likely to affect the patient’s INR control whilst on warfarin? * Addition of clarithromycin for a respiratory tract infection * Chronic diarrhoea * Drinking grapefruit juice every morning * Increase in levels of kale and spinach in diet * Taking a multivitamin supplement each day

Answer 38

Warfarin has multiple interactions including Vitamin K, clarithromycin and cranberry but not grapefruit. Grapefruit usually interacts with some statins.

Question 39

A 30-year-old female patient has been taking lithium for bipolar disorder for the past 18 months. She is currently prescribed Priadel 400 mg at night and her lithium levels have been stabilised at 0.8 mmol/L. Test results eGFR = 77 (previous results 6 months ago = 82, 12 months ago = 85) Creatinine = 85 (range 45 – 84 µmols/ Litre) Which is the most appropriate action? o Decrease Lithium dose o Increase Lithium dose o Monitor kidney function again in 6 months o Monitor Lithium plasma concentration levels more frequently and assess deterioration of renal function o Stop lithium and switch to sodium valproate

Answer 39

Monitor lithium plasma levels more frequently and assess detonation of renal function

Question 40

A 30-year-old woman comes into the pharmacy and speaks to you about her options for contraception. Following a check on her records you notice she is taking Carbamazepine 400mg tablets twice a day for epilepsy Which is the most suitable contraceptive for this patient? o Depo-Provera (medroxyprogesterone acetate 150 mg/1 mL) deep intramuscular injection o Desogestrel 75 mcg tablets o Ethinylestradiol 35 mcg, Norgestimate 250 mcg tablets o Etonogestrel 68 mg subdermal implant o Norelgestromin 6 mg, ethinyl estradiol 600 mcg transdermal patch

Answer 40

Carbamazepine is an enzyme-inducing antiepileptic drug (AED). It can reduce the effectiveness of hormonal contraceptives, particularly those containing ethinylestradiol (like combined oral contraceptives and the patch), as it increases the metabolism of hormones through CYP450 enzyme induction. Therefore, methods of contraception that do not rely on estrogen (which is metabolized by the liver) are preferred. The progestin-only options, such as the Depot-Provera injection, Desogestrel (a progestin-only pill), and the Etonogestrel implant, are effective options. However, Depot-Provera (a progestin-only method) is often recommended for women on enzyme-inducing drugs like Carbamazepine, as it does not involve estrogen and provides effective long-term contraception.

Question 41

A 30-year-old woman has approached you for advice on constipation. She is 33 weeks pregnant. She has tried dietary changes, but they have not resolved the issue. She does not take any other medication and does not have any other medical conditions. Which of the following would be most suitable to recommend? o Bisacodyl o Glycerin suppositories o Ispaghula husk o Loperamide o Senna

Answer 41

Ispaghula husk is a bulk-forming laxative, which is the first-line treatment for constipation in pregnancy, as it is safe and mimics natural dietary fiber. It increases stool bulk and stimulates bowel movements in a gentle manner. Dietary modifications (e.g., increased fiber, fluids, and exercise) are always recommended first, but since these have not worked for her, ispaghula husk is the next best option

Question 42

The local primary school has noticed a recent rise in the number of children suffering with asthma and requiring a salbutamol inhaler. The headteacher has contacted your store by phone to place an order for six Ventolin inhalers. What will be the information you need to tell the headteacher? * A signed order on appropriately headed notepaper is required before supply can be made * Only secondary school head teachers can make this request * The signed order must have a named pupil(s) so the inhalers can be labelled correctly * They cannot obtain a supply for the school without a prescription from the doctor * You can only supply a maximum of four inhalers to the school in any one year

Answer 42

Correct Answer: A signed order on appropriately headed notepaper is required before a supply can be made

Question 43

A 65-year-old male has gout and has been purchasing ibuprofen and paracetamol over the counter. Upon inspection, you advise the patient to see his GP for further advice. Which of the following medicines is most likely to be prescribed to treat an acute attack of gout? o Amitriptyline o Colchicine o Morphine sulphate o Paracetamol o Tramadol

Answer 43

Colchicine

Question 44

A GP calls you for support with an NSAID audit that is being conducted in the practice. She is looking into correlation between NSAIDs and gastro-intestinal issues. Specifically, she is looking at patients aged between 20 and 50 years with no previous gastro-intestinal issues. Which of the following NSAIDs is most likely to cause gastro-intestinal problems in this patient group? o Ibuprofen o Indometacin o Naproxen o Piroxicam o The risk is the same for all NSAIDs in patients with no previous GI issues

Answer 44

Piroxicam has the highest gastrointestinal (GI) risk among the NSAIDs listed. It is associated with a higher incidence of GI ulcers, bleeding, and perforation compared to other NSAIDs. Because of this, its use is restricted, and it is generally only prescribed when other NSAIDs are ineffective or unsuitable.

Question 45

It was a busy Thursday evening. On Friday morning when you arrive in the dispensary you notice that the 60 flu vaccinations that had been delivered on Thursday evening had not been put in the fridge and left on the stockroom shelf overnight. What is the best course of action to take? * Check the expiry dates and place the vaccines in fridge immediately * Check the temperature of the packaging. If this is cold, place the vaccines in the fridge immediately. * Discard the vaccines immediately. * Identify who received the stock and put them under disciplinary action to make sure they do not do this again * Phone the manufacturer and find out how long the vaccines can be out of the cold chain

Answer 45

Fridge line medication/vaccines can be left outside of the fridge for a specified period of time before it is considered unsafe to use. The manufacturer will be able to provide the required details

Question 46

A man presents at the healthcare counter with his 3-year-old son. His son has been experiencing intense itching around his bottom and it seems to be worse at night. His son is irritable, and the itching is disturbing his sleep. Which of the following options is the most appropriate action? o No actions are needed as this is a self-limiting condition o Refer to the GP. A 3-year-old cannot be treated over the counter. o Treat him with a single dose of mebendazole. The dose may need to be repeated in 2 weeks if infection persists. o Treat him and any household contacts with mebendazole unless contraindicated. The dose may need to be repeated in 2 weeks if infection persists o Treat him and any household contacts with mebendazole unless contraindicated and advise rigorous hygiene measures for 2 weeks. The dose of mebendazole may need to be repeated in 2 weeks if infection persists

Answer 46

o Treat him and any household contacts with mebendazole unless contraindicated and advise rigorous hygiene measures for 2 weeks. The dose of mebendazole may need to be repeated in 2 weeks if infection persists

Question 47

A 36-year-old man comes into the pharmacy and asks to speak to the pharmacist. He tells you that he has been passing more frequent and watery stools than is normal for him over the last 24 hours and is worried that he may become dehydrated. You inform the patient that an oral rehydration solution will help to prevent him from getting dehydrated and he decides to buy Dioralyte® sachets. The patient needs to dissolve the contents of each sachet in 200 mL of drinking water. Each sachet contains 300 mg of sodium. The molecular weight of sodium is 23. How many millimoles of sodium ions will he have per sachet, to the nearest millimole? o 3 millimoles o 12 millimoles o 13 millimoles o 14 millimoles o 23 millimoles

Answer 47

Moles = mass/mr 300/23 = 13

Question 48

A patient presents having recently started digoxin. Which of the following is NOT a sign of digoxin toxicity? o Dizziness o Increased appetite o Nausea o Visual disturbances o Vomiting

Answer 48

Increased apepitiee

Question 49

A 72-year-old woman is stabilised on co-careldopa therapy, however, she regularly experiences “off episodes”. Which of the following is most likely to be prescribed for when she experiences these? o Amantadine o Apomorphine o Bromocriptine o Cabergoline o Ropinirole

Answer 49

Apomorphine is a dopamine agonist used for the rapid relief of "off" episodes in patients with Parkinson’s disease who are already stabilised on levodopa (such as co-careldopa) but experience motor fluctuations. It is administered subcutaneously and acts quickly to reduce freezing and immobility during "off" episodes.

Question 50

A mother calls you to ask for your advice regarding her 12-year-old daughter who was diagnosed with type 1 diabetes 18 months ago. She has managed her condition using basal-bolus insulin injections and is able to adjust her insulin dose depending on her blood glucose results. She is currently feeling unwell and has a fever. What is the most appropriate advice that you would give to the mother? o Continue usual blood glucose monitoring o Decrease frequency of blood glucose monitoring o Increase frequency of blood glucose monitoring o Reduce the frequency of the insulin injections o Stop insulin injections

Answer 50

When a patient with type 1 diabetes is unwell, their blood glucose levels can become unpredictable due to stress hormones, infection, or fever. Illness can lead to hyperglycaemia and increase the risk of diabetic ketoacidosis (DKA), so closer monitoring is essential. The patient should continue taking insulin, even if they are eating less, and adjust the dose if necessary.

Question 51

A trainee pharmacist asks you to go through the different types of studies conducted in research in order to produce reliable evidence. Which of the following studies is most likely to produce reliable results? o Case-control studies o Cohort studies o Expert opinions o Randomised Controlled trials o Systematic Reviews

Answer 51

Hierarchy of Evidence (from most to least reliable): 1️⃣ Systematic Reviews – Combine results from multiple studies (including RCTs) to give the best evidence. 2️⃣ Randomised Controlled Trials (RCTs) – The gold standard for individual studies; participants are randomly assigned to groups, reducing bias. 3️⃣ Cohort Studies – Follow groups over time to compare outcomes based on exposure to a factor. 4️⃣ Case-Control Studies – Compare patients with and without a condition retrospectively; more prone to bias. 5️⃣ Expert Opinions – The least reliable as they are based on personal experience rather than systematic evidence

Question 52

A 35-year-old woman has recently started a new medication and is now suffering from facial flushing. Which of the following is this patient most likely to have been initiated on? o Amlodipine o Carvedilol o Diltiazem o Enalapril o Moxonidine

Answer 52

Amlodipine

Question 53

A 36-year-old male has been feeling persistently sad for weeks. He has a loss of appetite and sleep disturbance. He has just been diagnosed with moderate depression. Which anti-depressant is most likely to be prescribed as first line treatment? o Amitriptyline o Citalopram o Lofepramine o Mirtazapine o Venlafaxine

Answer 53

Citalopram

Question 54

A 45-year-old caucasian male patient presents with a prescription for an antihypertensive. Upon speaking to the patient, you establish that the prescription is for them and it is the first time they have been prescribed medication for high blood pressure. Which of the following would be the most appropriate antihypertensive for the doctor to have prescribed? o Amlodipine o Bendroflumethiazide o Doxazosin o Losartan o Ramipril

Answer 54

Rampiril

Question 55

A 2-month-old boy has been admitted to hospital with suspected bacterial meningitis Which is the most appropriate treatment for this patient? o Intravenous benzylpenicillin o Intravenous cefotaxime o Oral clarithromycin o Intravenous co-amoxiclav o Intravenous vancomycin

Answer 55

For a 2-month-old infant with suspected bacterial meningitis, IV cefotaxime is the most appropriate first-line treatment. Guidelines (UK-based): Neonates (<3 months old): IV cefotaxime + amoxicillin (to cover Listeria monocytogenes, which is more common in neonates). Infants ≥3 months old: IV ceftriaxone is preferred.

Question 56

A mother brings in prescriptions for her 6-year-old twins who have been prescribed different steroid inhalers for their asthma. What is the clinical difference between Clenil modulate and Qvar? o Qvar is twice as potent as Clenil o Clenil is twice as potent as Qvar o The potency is identical o They contain different active ingredients o Qvar must be kept in the fridge.

Answer 56

1️⃣ Qvar is twice as potent as Clenil Modulite This is because Qvar has extra-fine particles, which improves lung deposition and enhances its effect. As a result, half the dose of Qvar provides the same anti-inflammatory effect as Clenil

Question 57

Thrush is a fungal infection and can cause uncomfortable symptoms. What is the most appropriate advice for a pregnant woman who would like to buy a Canesten pessary for her thrush symptoms. o Canesten pessaries should not be used during pregnancy without seeking medical advice from her GP or midwife o To leave the vaginal thrush untreated until the pregnancy is over. o To not use the applicator found in the box. Instead, use your fingers. o Swallow the pessary o Use TWO pessaries instead of ONE

Answer 57

Canestan pessaries should not be used during pregnancy without seeking medical advice from GP or midwife

Question 58

A 14-year old boy comes in complaining of a sore tongue. Upon questioning, you identify he is suffering from oral thrush and supply daktarin oral gel. Which of the following medications is important to rule out before supplying daktarin gel? o Lisinopril o Ramipril o Sumatriptan o Warfarin o Zopiclone

Answer 58

Miconazole greatly increases the anticoagulant effect of warfarin. MHRA advises avoid unless INR can be monitored closely; monitor for signs of bleeding.

Question 59

Following a review, a 35-year-old male who is a type 1 diabetic and weighs 80 kg brings in a repeat prescription for isophane insulin 100 units/ml, which comes as 3 ml pre-filled pens. Their current daily dose equates to 0.8 units/kg. How many pens will be needed for a 30 day supply? o 2 o 5 o 6 o 7 o 10

Answer 59

7

Question 60

A 65-year-old woman is due to have a mechanical heart valve replacement in three days. The consultant cardiologist asks for your advice regarding anticoagulation for this patient post-surgery. Which of the following would be the most appropriate to give this patient? o Apixaban o Dabigatran o Edoxaban o Rivaroxaban o Warfarin

Answer 60

Warfarin

Question 61

A young couple approach you at the pharmacy counter asking for some advice regarding how much alcohol they should be drinking in a week. They also wanted to know if the limit was different between males and females. Which of the following is correct regarding recommended weekly alcohol units? o 14 units of alcohol for both spread across 3 or more days o 21 units of alcohol for males and 14 for females o 21 units of alcohol for both spread across 3 or more days o 28 units of alcohol for both spread across 3 or more days o 28 units of alcohol for males and 21 for females

Answer 61

14 units of alcohol for both spread across 3 days or more

Question 62

A 28-year-old woman comes into your community pharmacy for advice on symptoms they have been experiencing. Upon questioning, you identify that they take sertraline on prescription and for the last three months they have been using St John’s Wort that they bought from a health food store. You are concerned that they may be exhibiting signs of serotonin syndrome. Which of the following is unlikely to be a symptom of serotonin syndrome? o Confusion o Diarrhoea o Hypothermia o Tachycardia o Tremor

Answer 62

Hypothermia is not a symptom of SS

Question 63

A 60-year-old women is taking the following medication following recurrent deep vein thrombosis: * Amlodipine 10 mg tablets once daily * Apixaban 2.5 mg tablets twice daily * Atorvastatin 20 mg tablets once daily * Bendroflumethiazide 2.5 mg tablets once daily She has hypertension which is controlled by her medication. She presents with severe facial pain and is diagnosed with trigeminal neuralgia. She is to commence treatment with Carbamazepine 100 mg tablets twice a day for the pain. Which of her existing medicines, if any, should be avoided when taking carbamazepine? o Amlodipine o Apixaban o Atorvastatin o Bendroflumethiazide o None – patient should be monitored and doses adjusted accordingly

Answer 63

Carbamazepine is predicted to decrease the exposure to apixaban. Manufacturer advises use with caution or avoid.