Em Flashcards by Simon Evans

A 55-year-oldmanhas recently beendiagnosed with stage 2 hypertension. His other medical conditions includetype 2 diabetes and depression. He has no known medication allergies. His current medication includes: Atorvastatin 20mg ONMetformin 1g BDSertraline 50mg OD Which antihypertensive should this patient be started on first line?
Amlodipine
Doxazosin
Indapamide
Ramipril
Bisoprolol

Rationale: According to NICE guidance,an ACE inhibitor(ramipril in this case), would be first line for hypertension inthis patient,becausehe has type 2 diabetes.Note that if he didn’thave type 2 diabetes, a calcium channel blocker (such as amlodipine), would be first line due to his age of 55 years

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A 72-year-old lady has recently been started on alendronic acid for osteoporosis. Before
handing out the prescription to the patient, you decide to counsel her to ensure that they use
the medication safely and correctly.
Which of the following statements is incorrect?
o Alendronic acid 70mg should be taken once daily at the same time each
morning.
o Alendronic acid should be taken with a full glass of water, at least 30 minutes before
food, other drinks or medication.
o Alendronic acid tablets must be swallowed whole.
o Alendronic acid can increase the risk of atypical femoral fractures
o Alendronic acid is contraindicated in hypocalcaemia

Alendronic acid 70mg should be taken once daily at the same time is incorrect. It should be once weekly.

All the other statements are correct

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A woman comes into the community pharmacy and asks for your advice on what
paracetamol dose she should give her 2-year-old child for fever.
What dose of paracetamol is appropriate for a 2-year-old child?
- 60mg every 4-6 hours (max QDS)
- 120mg every 4-6 hours (max QDS)
- 180mg every 4-6 hours (max QDS)
- 240mg every 4-6 hours (max QDS)
- 360mg every 4-6 hours (max QDS)

180mg every 4-6 hours (max QDS)

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You are working in a community pharmacy and a patient hands you a script for diazepam.
You are checking its legality.
How long from the appropriate date is a prescription for diazepam valid?
o 7 days
o 28 days
o 30 days
o 6 months
o 12 months

28 days

Diazepam is a CD which belongs to SCH 4.1 Prescriptions for CD sch2-4 are valid for 28 days.

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A GP requests that you do an emergency supply of a POM for a patient.
Which statement is not true regarding emergency supply at request of the prescriber?
 The patient does not need be interviewed
 The prescriber must provide a prescription within 48 hours
 You must be satisfied that the prescriber is unable to provide a prescription
immediately due to an emergency
 An entry needs to be made in the POM register on the day of supply, or if impractical,
the following day
 Usual label requirements for POMs apply

The prescriber must provide a prescription within 48 hours. For emergency supply at the request of the prescriber, the prescriber must provide a prescription within 72 hours.

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You a working as a practice pharmacist in a GP surgery. You are counselling one of the
patients on starting atorvastatin.
Which of the following statements is correct?
o The usual dose for primary prevention is 80mg ON
o A blood test for creatinine kinase should be carried before starting the statin, and
then within 3 months and at 12 months
o Rhabdomylosis is a common side effect of atorvastatin
o Atorvastatin and amlodipine should not be taken together
o Atorvastatin can be taken in the morning

Unlike some other statins, atorvastatin can be taken in the morning. Note that rosuvastatin can also be taken in the morning. The usual dose of atorvastatin for primary prevention is 20mg OD (80mg OD is the secondary prevention dose). A blood test for liver function(LFTs)should be carried out before starting the statin, then within3 months andat12 months.Atorvastatin can be taken with amlodipine (note simvastatin interactswith amlodipine). Rhabdomylosis is a rare side effect of atorvastatin

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You are conducting a medication review for a patient at your practice. Their medical
history includes the following:
Depression/anxiety (diagnosed 2018)
Asthma (diagnosed 2007)Heartburn (diagnosed 2015)
Nocturnal leg cramps (diagnosed 2018)
Hypertension (diagnosed 2 days ago)
Their medication list is below:
Acute Medication:
28 x Losartan 50mg OD (issued 2 days ago)
28 x Diazepam 2mg TDS PRN (issued 6 months ago)
1 x Salbutamol inhaler (last issued 7 months ago)
Repeat medication: (all have been issued monthly for the past 12 months)
28 x Priadel (lithium) 400mg OD (last issued 1 week ago)
28 x Lansoprazole 30mg OD (last issued 1 week ago)
28 x Fostair 100/6 inhaler - 1 puff BD (last issued 1 week ago)
Based on the information provided, which potential issue are you are most concerned
about, and should act upon first?
o There is a drug interaction
o You are concerned about compliance
o One or more of the medications is not recommended long term
o You are concerned about her asthma control
o The dose of one of the medications is inappropriate

Drug interaction between the patient’s newly prescribed losartan and lithium. Lorsartan is an ARB which can increase lithium concentration -> increasing the risk of toxicity

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You are working as ahospital pharmacistand a foundation doctor asks for your advice regarding antibiotic treatment for community acquired pneumoniain a child.The doctor assessed that symptoms were non-severe. You check the patient’s record (listed below) and checkthe NICE guidance,which your hospital trust uses for their formulary. The patient is a 7 year old who weighs 25kg and is allergic to flucloxacillin.

Which antibiotic regimen below would you advisefor this patient?
- Amoxicillin 500mg TDS for 5 days
- Clarithromycin 500mg BD for 5 days
- Erythromycin 250mg QDS for 5 days
- Co-amoxiclav -10mL of 250/62 suspension TDS for 5 days
- Clarithromycin 187.5mg BD for 5 days

Patient has an allergy to flucloxacillin. Clarithromycin is the correct answer

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A father presents to the pharmacy with his 2-year-old son. He tells you that his son
developed a spotty rash across his body, which then turned into itchy fluid filled blisters.
Some of these vesicles are now starting to crust over to form scabs. The patient also
experienced loss of appetite and general malaise.
Based on this presentation, what is the most likely diagnosis?
o Chickenpox
o Scarlet fever
o Measles
o Rubella
o Contact dermatitis

Chickenpox

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A trainee pharmacist asks you to go through the topic of ‘sick day rules’ with them.
Which of the following medications is most appropriate to omit during periods of
diarrhoea and vomiting?
o Basal insulin
o Clopidogrel
o Indapamide
o Oxycodone IR
o Amlodipine

Indapamide (diuretic) should be admitted during periods of diarrhoea and vomiting due to the risk od dehydration and AKI

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The GP provides a male patient with a prescription for nitrofurantoin to treat a lower
urinary tract infection.
How many 50mg nitrofurantoin capsules would you expect to dispense to provide the
full course of treatment?
- 7 capsules
-12 capsules
-21 capsules
-29 capsules
- 9 capsules

For lower urinary tract infections in men, the usual dose of nitrofurantoin is 50mg QDS (so 4 x 50mg capsulesper day), and the usual course duration is 7 days in men, so you would expect to dispense 28 capsules(7 days x 4 capsules per day = 28 capsules

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A patient hands you a prescription for fentanyl.
Which of the following statements is correct?
o This prescription can be put on a repeatable prescription
o This prescription is valid for 30 days from the appropriate date
o It is strongly recommended that no more than 28 days supply can be prescribed on
the prescription
o It is strongly recommended that no more than 30 days supply can be prescribed on
the prescription
o You cannot dispense more than 30 days supply

Fentanyl is a schedule 2 controlled drug. It is strongly recommended that no more than 30 days supplyis prescribed of schedule 2, 3 or 4 controlleddrugs.The other statements above are incorrect.Consult the MEP for more information on this

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Which of the following statements is true regarding edoxaban?
o A patient is prescribed edoxaban for prevention of stroke and systemic embolism in
non-valvular atrial fibrillation. Their body weight is 58kg. Their renal function is
normal. For this patient, the recommended dose of edoxaban is 60mg OD
o Dose reduction to edoxaban 30mg OD is required for patients on concomitant
amiodarone
o Anaemia is a common side effect of edoxaban
o eGFR is the most appropriate measure of renal function to use when reviewing
edoxaban
o The dose of edoxaban should be reduced to 30mg OD in patients greater than 80
years old

Anaemia is a common side effect of endoxaban

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A mother presents to the pharmacy with her 5-year-old son, who has had cough and cold
symptoms for the past 3 days. The main symptom is a dry tickly cough.
Which of the following is the most appropriate action?
o Refer to GP
o Sell guaifenesin syrup
o Sell dextromethorphan syrup
o Sell glycerol and sucrose syrup
o Sell ibuprofen

There are no red flags listed in the presentation so a referral to the GP is not necessary at this stage. OTC dextromethorphan and guaifenesin is not suitable for this patient due to his age. Guaifenesinis also indicated for productive coughs rather than dry coughs, as it is an expectorant. Ibuprofen may help with fever and pain but is unlikely to help with the cough which is the patient’s main symptom.Glyceryl and sucrose syrup is the most appropriate option for this patient

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You are conducting a revision session for trainee pharmacists regarding osteoarthritis
and pain management.
Which of the following statements regarding osteoarthritis is correct?
o Regular paracetamol should be routinely recommended to patients for long term pain
management for osteoarthritis
o Exercise should be avoided in osteoarthritis
o Glucosamine should be recommended in osteoarthritis
o Morphine or oxycodone is recommended for pain management in osteoarthritis only
if co-codamol is ineffective or not tolerated
o Acupuncture should not be recommended for symptom relief in osteoarthritis

Simple analgesiafor osteoarthritisshould only be used infrequentlyand short term.Exercise is recommended in osteoarthritis.Strong opioids should not be prescribed for pain management in osteoarthritis.Glucosamine and acupuncture should not be recommended for symptom reliefin osteoarthritis (this is due to the lack of evidence base –see the NICE CKS topic on osteoarthritis)

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A 49-year-old patient presents to the pharmacy with heartburn. They have already tried
omeprazole over the counter, but it hasn’t helped their symptoms. They mention that they
have lost over a stone in weight over the past few months, but they haven’t made any
changes to their diet or lifestyle, so they’re not sure why.
What is the most appropriate action?
o Refer patient to GP
o Refer patient to A&E
o Sell patient Gaviscon to help with symptoms, to take in addition to omeprazole
o Sell patient Gaviscon to help with symptoms, to take instead of omeprazole
o Provide diet and lifestyle advice

This patient should be referred to the GP to investigate due to the red flag of weight lossand the fact that the PPI hasn’t helped their symptoms. The GP is the most appropriateroute of referral, and they should be seen promptlyby the GP.

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You are working in a community pharmacy. A patient presents to the pharmacy holding
their nose with a tissue. On discussion, they tell you that they have a heavy nosebleed which
will not stop, and this has lasted over 30 minutes so far. You find out that they are on
warfarin. The patient feels otherwise well.
- Refer to GP
- Refer to A+E
Explain that this is likely a side effect of warfarin, and advise the patient to come back
to the pharmacy if the nosebleed has not resolved within the next hour
o Advise them to temporarily stop their warfarin and book an INR clinic appointment
within the next 2-3 days to make sure their INR is within range
o Advise them to keep taking their warfarin and book an INR clinic appointment within
the next 2-3 days to make sure their INR is within range

The patient is taking warfarin which increases the risk of bleeding. Thepatientshould be referred to A&Edue to the duration of this nosebleed. The other options and referral time frames are not appropriate.

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A 17-year-old girl presents to the pharmacy with symptoms of vaginal thrush. She tells
you that she has had an episode of vaginal thrush once before around 11 months ago,
which was diagnosed by a GP. The treatment she had for this was effective. These
symptoms are the same as her last episode of thrush. She has no other medical history and
is on no regular medication. She is not sexually active. She has not yet tried any medication
to manage this episode of thrush. She is requesting medication for it, and she states that she
would prefer a cream formulation as treatment as she doesn’t like taking tablets or capsules.
What is the most appropriate action?
o Refer patient to GP
o Refer patient to sexual health clinic for STI testing
o Sell the patient clotrimazole internal and external cream
o Sell the patient fluconazole capsule and clotrimazole external cream
o Provide lifestyle advice only to manage their symptoms

This patient can be treated OTC so there is no need to refer elsewhere. There are no red flags or referral criteria stated. The patient has toldyou that she doesn’t like taking capsules so the clotrimazole internal and external cream is the best option for this patient.She is over16 years old so clotrimazole cream is licensed OTC for her.

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A patient in hospital is prescribed gentamicin as a multiple daily dose regimen. The
foundation doctor has asked for your advice regarding the blood results, as the trough level
of gentamicin has come back high. The peak level was normal.
What is the most appropriate advice?
o The interval between doses should be increased
o The interval between doses should be decreased
o The dose should be increased
o The dose should be decreased
o The dose and the dosing interval should be altered

The interval between doses should be increased

The trough level came back high, which means the interval between the doses should be increased. If the peak level was high, the dose should be decreased. Consult the gentamicin monograph in the BNF for more information on this.

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You are working as a GP practice pharmacist and are conducting a COPD medication
review for a patient. The patient continues to be breathless and have exacerbations. There
are no asthmatic features or features suggestive of steroid responsiveness.
Their medication list is as follows: Salbutamol inhaler PRN

If following NICE guidance, what would the initial recommendation be if a step up of
treatment is required?
o Add a LAMA only
o Add a LABA only
o Add an ICS only
o Add a LAMA and LABA
o Add a LABA and ICS

The patient is currently prescribed a SABA. According to NICE guidance, the next step-up in treatment of COPD for patients without asthmatic features or features suggesting steroid responsiveness, is to add a LABA and a LAMA

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A patient is prescribed clozapine for schizophrenia, and you are counselling them about
potential side effects.
Under which circumstance should they seek immediate medical advice?
o Diarrhoea
o Constipation
o Insomnia
o Hypersalivation
o Galactorrhoea

Patients taking clozapine should be advised to seekimmediate medical advice if they become constipated. This is due to the potentially fatal risk of intestinal obstruction, faecal impaction and paralytic ileus. This was an MHRA alert in 2017

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A patient is suffering from opioid induced constipation since he started taking Zomorph
20mg BD. He has not tried any laxatives yet. The GP is asking your advice on what laxatives
to prescribe.
Of the options below, which would be the first line treatment?
o Naloxegol
o Laxido and senna
o Loperamide
o Ispaghula husk and docusate
o Lactulose and ispaghula husk

Laid and Senna

Of the options above, Laxido (an osmotic laxative) and senna(a stimulant laxative)would be first line for opioid induced constipation. Consult the BNF section on constipation for more information about this. Ispaghula husk is a bulk forming laxative, which should be avoided in opioid induced constipation.Loperamide is indicated for diarrhoea, not constipation. Naloxegol is not first line –it can be used for opioid induced constipationif other laxatives have been tried but have not given an adequateresponse

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You are reviewing the patients on your ward and come across a patient who has been
recently diagnosed with bacterial vaginosis.
Which antibiotic would be most suitable for treatment of bacterial vaginosis?
o Co-amoxiclav
o Metronidazole
o Nitrofurantoin
o Erythromycin
o Clarithromycin

Metronidazole is indicated for bacterial vaginosis.Metronidazole covers anaerobic bacterial infections such as bacterial vaginosis

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You are discussing antibiotic counselling points with a trainee pharmacist.
Which antibiotic requires monitoring for new or worsening respiratory symptoms?
o Nitrofurantoin
o Amoxicillin
o Clarithromycin
o Doxycycline
o Meropenem

Nitrofurantoin carries a risk of pulmonary adverse effectsand patients should be counselled to report any new or worsening pulmonary symptoms. This is based off a 2023 MHRA alert.

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You are working in a GP practice, and you receive a letter from a consultant requesting that a patient is started on a non-selective beta-blocker. Which of the following is a non-selective beta blocker? o Nebivolol o Bisoprolol o Atenolol o Metoprolol o Propranolol

Propranolol is a non-selective betablocker.The other betablockers listed above are relatively cardio-selective.

A 16-year-old girl comes into the community pharmacy requesting emergency hormonal contraception on a Thursday morning at 10am. She tells you she had UPSI at 11pm on Sunday night. She does not want the copper coil fitting. She has no medical conditions and takes no regular medications. Her BMI is 23. What is the most appropriate action? o Provide a tablet of EllaOne o Provide a tablet of Levonelle o Explain that it is too late to take emergency hormonal contraception and refer her to the GP or sexual health clinic to get the copper coil fitted o Explain that you cannot provide emergency hormonal contraception due to her age and refer to GP or sexual health clinic o Provide a double dose of Levonelle

It is appropriate to provide EllaOne as it is within the time frame of 5 days(120 hours)since UPSI.Levonelle is not appropriate as greater than 3 days(72 hours)has passed since UPSI. The other statements are incorrect.

You are processing a hospital discharge summary for an 82-year-old lady. She has dementia and was recently admitted to hospital following a fall. One of her medications has been stopped due to its high anticholinergic burden. Based on this information, which medication is most likely to have been stopped? o Amitriptyline 30mg ON o Atorvastatin 20mg ON o Doxazosin 16mg OD o Mirabegron 50mg OD o Memantine 20mg ON

Amitriptyline has a high anticholinergic burden which could increase the risk of falls

A patient presents to the community pharmacy with symptoms of acute stroke. What is the most appropriate initial action? o Ring 999 for an ambulance o Ring NHS 111 for advice o Give 300mg aspirin o Give 75mg aspirin o Put the patient in recovery position

Stroke is a medical emergency so ringing 999 is the most appropriate option. It is not appropriateto give aspirin for suspected stroke in the communityas it first needs to be established in hospitalif it is ischaemic or haemorrhagic stroke

A patient has been admitted to hospital with NSTEMI. He has been advised that one of his medications will only be prescribed for 12 months after the NSTEMI, after which it can be stopped. Which medication is being referred to? o Aspirin o Clopidogrel o Atorvastatin o Glyceryl trinitrate o Ramipril

For secondary prevention of NSTEMI, dual antiplatelet therapy should be offered for the first 12 months. Aspirin should then be continued indefinitely, andthe second antiplateletstopped after 12 months (in this instance, clopidogrel). AnACE inhibitor (eg. ramipril), and statin (eg. atorvastatin), would normally be continued long term. The GTN spray is for PRN use.

You are working as a GP practice pharmacist. You receive a prescription query from the local community pharmacy regarding a medication that must always be dispensed in the manufacturer’s original full pack, except for in exceptional circumstances. Which medication is being referred to? o Apixaban o Warfarin o Ciclosporin o Oxycodone o Sodium valproate

Sodium Valproate

A 15-year-old girl presents to the pharmacy, requesting analgesia for period pain. Which is the least appropriate analgesia option for this patient? o Aspirin o Paracetamol o Ibuprofen o Co-codamol o Naproxen

Aspirin is least appropriateoptionfor a 15-year-oldgirl for period pain becauseaspirin is contraindicated in children less than 16 years old(unless specifically indicated eg. for Kawasaki disease), due to the risk of Reye’s syndrome

A patient is requesting information regarding eligibility criteria for free prescriptions, as they want to check if they are eligible. Which of the below patients is eligible for free prescriptions, based on the information provided? o A 17-year-old in full time education o A 16-year-old who has left education, with a full-time job o A 50-year-old patient with hypertension o A 22-year-old patient, who gave birth 21 months ago o A 48-year-old woman on HRT

A patient who is 17 in full time education

During a medication review, a patient asks you about the timing of their medication in relation to when they eat. Which of the following should not be taken with food? o Aspirin 75mg OD o Rivaroxaban 20mg OD o Lansoprazole 30 mg OD o Prednisolone 5mg OM o Ferrous sulfate 200mg OD

Lansoprazole should be taken at least 30 minutes before food. Aspirinand prednisoloneshould be taken with food to reducethe risk of GI side effects. Rivaroxaban 20mg should be taken with food to ensure adequate absorption.Ferrous sulfatecan be taken either before meals or during meals, depending on tolerance. Note that ferrous sulfate is absorbed better on an empty stomach, but it can be taken with food to minimise the risk of GI side effects

A pregnant women is asking advice regarding OTC vitamin supplements. Which of the following should be avoided in pregnancy ? A D E K C

A- Due to its potential teratogenic affect

Which of the following statements is incorrect regarding Rybelsus? o Rybelsus is a black triangle drug o The active ingredient is semaglutide o The maximum recommended daily dose of Rybelsus is 28mg o The shelf life of Rybelsus tablets is 24 months o The tablet contains magnesium stearate as an excipient

Use the SPC to answer this question. The maximum recommended daily dose of Rybelsusis 14mg.The other above statements are correct

A patient asks you if their medication needs to be prescribed by brand. In which circumstance would the same brand of product normally need to be maintained? o A patient prescribed primidone for essential tremor o A patient prescribed levetiracetam for epilepsy o A patient prescribed lacosamide for epilepsy o A patient prescribed phenytoin for epilepsy o A patient prescribed carbamazepine for trigeminal neuralgia

Phenytoin, carbamazepine,primidone are category 1 antiepileptics which should be prescribed by brand if used for epilepsy.Note that it only needs to be prescribed for brand if for epilepsy, not for other indications such as essential tremor or trigeminal neuralgia

You are working on an oncology ward. The consultant wants to confirm with you – by what route should vinblastine be given? o Intramuscular o Intravenous o Intrathecal o Subcutaneous o Transdermal

Vinblastine is forINTRAVENOUS ADMINISTRATIONONLY; it is a vinca alkaloid. Incorrect administration can cause fatal neurotoxicity

A patient comes into the pharmacy asking for advice regarding her contraception. She tells you that she is 11 hours late taking her dose of Microgynon 30 and wants your advice. She has not missed any other doses. Which advice is most appropriate? o She should omit the dose and continue taking as normal when next tablet due, no additional contraceptive measures are required o She should omit the dose and continue taking as normal when next tablet due, additional contraceptive measures are required for the next 7 days o She should take the dose now, and then continue tablet taking as normal when next due, and no additional contraceptive measures are required o She should take the dose now, then continue tablet taking as normal when next due, and additional contraceptive measures are required for the next 7 days o She should take the dose now, then continue tablet taking as normal when next due, and additional contraceptive measures are required for the next 2 days

She should take thedose now, and then continue tablet taking as normal when next due, and no additional contraceptive measures are required

A patient reports having experienced a flare up of gout following initiation of a new medication. Which medication below is most likely to exacerbate gout? o Naproxen o Indapamide o Amlodipine o Diazepam o Diltiazem

Indapamide is a thiazide like diuretic which can exacerbate gout

You are clinically checking a prescription that you have received for an adrenaline autoinjector. Which adrenaline autoinjector is suitable for a 7-year-old child for emergency treatment of anaphylaxis? - 100mcg -150mcg -300mcg -500mcg -1000mcg

Consult the BNFfor children–a 300 microgram adrenaline autoinjectoris appropriate for a child aged 6-11 years old

A patient asks for your advice regarding acid reflux. You exclude any red flags and sell the patient Gaviscon. In addition to medication, you offer the patient some advice to help manage their reflux symptoms. Which of the following is the least appropriate advice? o They should limit their alcohol consumption o They should eat larger meals and eat less frequently o They should try to relax and reduce stress o They should avoid clothes that are tight fitting around the waist o They should raise the head of the bed to help symptoms at night

They should try to eat smaller, more frequent meals rather than eating larger meals. The other statements are correct.

A nurse asks for your advice regarding which blood tests a patient requires as monitoring for their medication. Their medication list is: Candesartan 16mg OD for migraine prophylaxis Levothyroxine 125 microgram OD for hypothyroidism Which blood test option below needs to be checked as monitoring these medications? o Renal function, serum electrolytes, HbA1c o Renal function, serum electrolytes, thyroid function tests o Thyroid function tests, HbA1c o Renal function, serum electrolytes, full blood count, liver function tests o HbA1c, thyroid function tests, liver function tests

Renal function, serum electrolytes and thyroid tests

You are working in a community pharmacy and the dispenser is putting away stock following the morning delivery. They ask for your advice regarding which items need to be stored in the fridge. Which of the following does not need to be stored in the fridge before use? o Fostair Nexthaler o Fostair MDI o Insulin Glargine o Insulin Aspart o Chloramphenicol eye drops

Foster Nexthaler

A patient is admitted to the emergency department with iron salt poisoning. Which agent can be used in iron salt poisoning? o Flumazenil o Naloxone o Acetylcysteine o Desferrioxamine mesilate o Dicobalt edetate

Desferrioxamine mesilate can be used in iron salt poisoning. Flumazenil is for benzodiazepine poisoning. Naloxone is for opioid poisoning. Acetylcysteine is for paracetamol poisoning. Dicobalt edetateis for cyanide poisoning

A patient takes 5mL QDS of Oramorph 10mg/5mL solution. The prescriber asks for your advice as they want to switch the Oramorph to an equivalent dose of tramadol. What total daily dose of oral tramadol in milligrams should be prescribed? o 40mg o 120mg o 200mg o 400mg o 800mg

5mL x 4 times a day = 20mL per day of Oramorph oral solutionOramorph is 10mg/5mLWhich is 2mg / 1mLWhich is 40mg / 20mLSothe total daily dose of oral morphine is 40mgLooking at the conversion table, 10 mg of oral morphine sulfate is equivalent to 100mg of tramadolSo 40mg oral morphine sulfate is equivalent to 400mg of tramadol

A patient is taking ferrous sulfate as treatment for iron deficiency anaemia. Which blood test would you expect to be carried out as monitoring for this medication? o Liver function tests o Full blood count o Urea and electrolytes o HbA1C o Troponin

FBC

You are legally checking a prescription. Which of the following is not a legal prescription writing requirement for POMs? o Age of the patient if under 18 years o Valid date o Name of patient o Address of patient o Address of the prescribe

Age of the patient is only a legal requirement for prescription writing if the patient is under the age of 12

A medical student asks you to explain the mechanism of action of amoxicillin. What is the mechanism of action of amoxicillin? o Inhibits bacterial dihydrofolate reductase (DHFR) o It is bacterostatic and inhibits protein synthesis o Inhibits 30s subunit o Inhibits 50s subunit o Inhibits peptidoglycan synthesis, which weakens the bacterial cell wall

Inhbits peptidoglycan synthesis, which weakens the bacterial cell wall

You are conducting an audit on the appropriate prescribing of antibiotics. Which antibiotic below carries the highest risk of C. Difficile? o Vancomycin o Clindamycin o Erythromycin o Trimethoprim o Flucloxacillin

Of the options listed above, clindamycin carries the highest risk of C. Difficile. C. Difficile is associated with broad-spectrum antibiotics.Cephalosporins and quinolones are also associated with a risk of C. Difficile.

During a patient’s hypertension annual review, you are discussing a patient’s blood test results and lifestyle with them. Their QRISK came back as 27% and their cholesterol was raised. Which statement is appropriate? o It is recommended that they start taking aspirin 75mg OD as their QRISK is > 10% o In a room of 100 people, 27 people like them would be predicted to have an event such as heart attack or stroke within the next 6 months. o They should aim to do at least 150 minutes of exercise a week They should increase their saturated fat intake and reduce their unsaturated fat intake o They should avoid eating oily fish

NHS guidancerecommend at least 150 minutes of moderate intensity exercise each week.Aspirin is not indicatedfor primary prevention so the first statement is incorrect (although a statin should be considered based on the QRISK). The second statement is incorrect because the QRISK predicts the risk of heart attack or stroke over the next 10-yearperiod. The fourth statement is incorrect as the guidance is to reduce saturated fat intake.The last statement is incorrect as oily fish is recommended as part of a balanced diet

The practice nurse is conducting a diabetes review and asks for your advice regarding a patient’s target HbA1c. They have type 2 diabetes. Their medication list is as follows: Metformin 1g BD Gliclazide 80mg OD Clopidogrel 75mg OD Atorvastatin 80mg OD What is their target HbA1c? o 48 mmol/mol o 53 mmol/mol o 58 mmol/mol o 63 mmol mol o 70 mmol/mol

As thispatient is prescribed gliclazide (a sulfonylurea), which is associated with hypos, the target HbA1c would usually be 53 mmol / mol.The target would also usually be 53 mmol / mol because they are prescribed 2 antidiabetic medications

You measure a patient’s blood pressure as they have recently started losartan to manage their hypertension. They also have stage 3 CKD with proteinuria (ACR above 70 mg/mmol). They are 50 years old. According to NICE guidelines, what is their blood pressure target? o < 150/90 o < 140/90 o < 130/90 o < 130/80 o < 135/85

According to NICE guidance, because they have CKD andan ACR of 70 mg/mmol or more, their BP target is less than 130/80 mmHg.

Which vaccine has this patient (5 year old boy) not yet received, if the routine immunisation schedule has been followed? o HPV vaccine o MMR vaccine o Meningococcal group B vaccine o Diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae type B vaccine o Rotavirus vaccine

HPV vaccine is offered at the age of 11-14 years old

A doctor asks for your advice regarding ibuprofen dosing for a 10-year-old child. What dose of ibuprofen is appropriate for a 10-year-old child? o 100mg TDS o 150mg TDS o 200mg TDS o 300mg TDS o 400mg TDS

300mg TDS

A patient has been admitted to hospital with a UTI and AKI. You do a medication reconciliation and review the appropriateness of their medication. Considering their presentation, which of the following medications needs to be reviewed? o Metformin o Co-codamol o Felodipine o Ezetimibe o Folic acid

Metformin should be held in AKI

A patient comes into the community pharmacy for advice regarding her sodium valproate, as she tells you she is pregnant. Her method of contraception failed. She takes sodium valproate for her epilepsy, which is well controlled on this medication. She tells you that she has an upcoming midwife appointment in 6 weeks. Which is the most appropriate advice? o She should stop taking the sodium valproate immediately o She can continue taking the sodium valproate as normal during pregnancy o She should only take the sodium valproate if she gets a seizure o She should seek advice from her GP / specialist as soon as possible

You should not advise her to stop sodium valproate due to seizure risk which could harm both mother and baby. Aplan needs to be put in place with the specialistas sodium valproate is teratogenic.She should get this advice as soon as possible –it is not appropriate to wait until a midwife appointmen

A patient takes methotrexate for rheumatoid arthritis. She hands you the following prescription at the community pharmacy, which contains the following items: Methotrexate 10mg tablets – take ONE tablet once weekly on a Friday Methotrexate 2.5mg tablets – take TWO tablets once weekly on a Friday Folic acid 5mg tablets – take ONE tablet once a week, on a different day to methotrexate Which statement below is correct? o The methotrexate dose is an overdose o The total methotrexate dose should be prescribed as 2.5mg tablets alone o The methotrexate dosing interval is incorrect o Methotrexate should be prescribed by brand o Methotrexate tablets can only be dispensed in hospital pharmacies

Total methotrexate dose should be prescribed as 2.5mg tablets alone

You are working in a hospital on a surgical ward. A patient is suffering from acute pain and his pain requirement is likely to change soon following his surgery, when his analgesia will likely need to be titrated. The patient does not currently take any medication and has no known allergies. The foundation doctor asks for your advice regarding pain relief. Which of the following options is the least appropriate for the patient’s acute pain? o Bunov patch o Codeine o Paracetamol o Oramorph liquid o OxyNorm liquid

Bunovpatch is not appropriate for acute painor where pain relief requirements are rapidly changing

A 5 year old child has bullous impetigo. They have no known allergies. Which of the following antibiotics is most appropriate -AMOX -Co-Amox Flucloxacillin -Doxy -Clindamycin

Flucloxacillin is the first line antibiotic in bullous impetigo

A man presents to the pharmacy asking for advice regarding his daughter. This morning, he spotted headlice when combing her hair. Which of the following statements is incorrect? o Headlice prefer dirty hair o She can still attend school even though she has headlice o Herbal treatments are not recommended for the treatment of headlice o Wet combing is a method of detecting and systematically removing headlice o Resistance to Malathion aqueous liquid has been reported

There is no evidence that head lice prefer clean or dirty hair. The other statements are correc

You are counselling a patient on the potential side effects of his GTN spray. Which of the following is the most likely side effect of glyceryl trinitrate spray? o Headache o Hypertension o Constipation o Diarrhoea o Cyanosis

Headache is listed as a very common side effect ofglyceryl trinitratespray in the SPC. Note that hypotension isalso listed as a side effect (not hypertension)

A patient asks for your advice as she is experiencing symptoms of ankle swelling and she believes it is a side effect of one of her medications. Which medication below is most associated with the side effect of ankle swelling? o Isosorbide mononitrate o Aspirin o Pregabalin o Furosemide o Nifedipine

Nifedipine is a calcium channel blocker, which are associated with peripheral oedema, eg. ankle swelling.

You are preparing to start delivering the Pharmacy First Service. Which of the following is not included in the Pharmacy First Service? o Infected insect bite o Shingles o Sinusitis o Sore throat o Complicated urinary tract infections in men

The Pharmacy First Service includes uncomplicated urinary tract infections in women, not complicated urinary tract infections in men

You are counselling a child on how to use their spacer Which of the following statements is correct? o The spacer device should be replaced after 4 months of use. o With normal daily use, the spacer should be cleaned no more than once a month. o Inside the spacer should be rubbed with a cloth to clean it o Only one puff should be inhaled at a time o The spacer can be autoclaved

The spacer should be replaced after 12 months of use. It should be cleaned at least twice a week. Inside the spacer should not be rubbed with a cloth as this can create static. The spacer should not be autoclaved. This information can be found in the SPC

You receive a clinic letter from the hospital urology department requesting that one of your patients should be started on an alpha blocker for benign prostatic hyperplasia. Which of the following is an alpha blocker? o Finasteride o Tamsulosin o Mirabegron o Tadalafil o Solifenacin

Tamsulosin is an alpha blocker, indicated for benign prostatic hyperplasia. Finasteride is a 5-alpha reductase inhibitor. Mirabegronis abeta 3-adrenoceptoragonist. Tadalafil is a PDE5 inhibitor.Solifenacin is an antimuscarinic.

A patient is 4 years old and is a type 1 diabetic. He is brought to A&E as he is confused and complains of increased thirst and urination. He also complains of stomach pain and has been vomiting. Based on this presentation, which is the most likely diagnosis? o Hypoglycaemia o Diabetic ketoacidosis o Anaphylaxis o Appendicitis

Symptoms of diabetic ketoacidosis can include confusion, increased thirst and urination, vomiting and stomach pain, and this patient is type 1 diabetic, making diabetic ketoacidosis the most likely diagnosis. By contrast, symptoms of hypoglycaemia may includeconfusion,feelinghungry, sweating, shaking and dizziness

You are doing a presentation to trainee pharmacists about antibiotic resistance and antimicrobial stewardship. Antibiotics should be reviewed within a certain timeframe and considered for being stepped down to oral antibacterials where possible and clinically appropriate. Within what timescale should intravenous antibacterials be reviewed? o 24 hours o 48 hours o 72 hours o 96 hours o 120 hours

48 HRS

You are making some inhaler switches as part of asthma reviews at the GP practice that you work at. You are switching pressurized metered dose inhalers to dry powder inhalers where clinically appropriate, to reduce carbon footprint. What advice regarding inhaler technique should be given to patients who are switched to dry powder inhalers? o Inhalation should be forceful and deep o Inhalation should be gentle and deep o Inhalation should be forceful and shallow o Inhalation should be gentle and shallow o Inhaler technique is the same for dry powder inhalers as it is for pressurized MDIs

With dry powder inhalers, inhalation should be forceful and deep. By contract with aerosol inhalers, inhalation should be slow and steady

A patient has heart failure with reduced ejection fraction. The heart failure nurse has requested that a patient is optimised on the four pillars of heart failure treatment. Recent bloods came back as satisfactory. BP: 135/82 mmHg Pulse: 70 bpm Which of the following medications is least appropriate to start in this patient? o Bisoprolol o Diltiazem o Spironolactone o Ramipril o Dapaglifozin

The four pillars of heart failure treatment are: ACEi/ARB/ARNI, beta-blockers, MRAs, SGLT2 inhibitors. Therefore, bisoprolol (betablocker), spironolactone (MRA), ramipril (ACEi), and dapagliflozin (SGLT2 inhibitor),would potentially be appropriate options for this patient. Diltiazem is a rate-limiting calcium channel blocker–the BNF advises that this should be avoided in patients withheart failure with reduced ejection fraction, so this would be the least appropriate answer

You are working as a GP practice pharmacist. A 15-year-old girl is prescribed Equasym XL (methylphenidate) for ADHD. There is a shared care agreement in place between the specialist and the GP. Her mum rings up the surgery and tells you that she has rung around several pharmacies and no pharmacies have any brand of methylphenidate in stock. The mum tells you that they have lisdexamphetamine in stock. What is the most appropriate course of action? o Change the prescription to lisdexamphetamine o Change the prescription to atomoxetine as this is not a controlled drug o Contact the ADHD specialist and ask them to review the patient’s treatment o Tell the patient that they will have to just wait until it is back in stock as there are no other alternatives o Ask the patient if she would like to try mirtazapine instead

You should contact the ADHD specialist and ask them to review the patient’s treatmentas treatment should be initiated by the specialist and only transferred over to the GP oncethe patient is stable.The other options are not appropriate

You are teaching one of the foundation doctors about the different classes of diuretics. Which of the following is an example of a loop diuretic? o Bumetanide o Metolazone o Indapamide o Amiloride o Eplerenone

Bumetanide is an example of a loop diuretic. Indapamide and metolazone are thiazide-like diuretics. Amiloride is a potassium-sparing diuretic. Eplerenone is amineralocorticoid receptor antagonist

A patient comes into the pharmacy requesting to buy two boxes of Benadryl Allergy Relief Plus Decongestant Capsules (this contains 60mg pseudoephedrine per capsule and 8mg acrivastine per capsule). Each box contains 12 capsules. He has symptoms of allergic rhinitis. What is the most appropriate course of action? o Decline the sale as you cannot sell this quantity of pseudoephedrine o Decline the sale as you cannot sell this quantity of acrivastine o Sell the products that the patient has requested o Report the patient to the GPhC o Ring the police

The patient is trying to buy two boxes; each capsule contains 60mg pseudoephedrine and there are 12 capsules per box, so 2 boxes would be 24 capsules. Total quantity of pseudoephedrine = 24x 60mg = 1440mg.The sale should be declined because it is against the law tosupply any product that containsover 720 mg pseudoephedrine or over 180 mg ephedrine without a prescription

Mr Timms takes Uniphyllin Continus (theophylline) for COPD. He tells you he is planning on quitting smoking. How would you expect quitting smoking to affect his theophylline levels? o Theophylline levels would increase, increased risk of toxicity o Theophylline levels would decrease, reduced risk of toxicity o Theophylline levels would increase, reduced risk of toxicity o Theophylline levels would decrease, increased risk of toxicity o There would be no clinically relevant effect on theophylline levels

Smoking increases the clearance of theophylline, so if smoking is stopped, theophyllineclearance will decrease, increasing the level of the theophylline and increasing the risk of toxicity.

A patient tells you that she has been invited to the surgery for a blood test to check her B12 levels due to one of the medications she is taking. Which medication is this monitoring most likely to be for? o Gliclazide o Metformin o Fluvastatin o Furosemide o Levothyroxine

B12 deficiency is a common side effect of metformin. This based off a June 2022 MHRA alert. Periodic monitoring should be considered in patients who have risk factors for B12 deficienc

A child with depression was assessed by a child and adolescent psychiatrist who deems it appropriate to start antidepressant therapy. Following assessment by a child and adolescent psychiatrist, which antidepressant is preferred if an antidepressant is indicated for depression in children? o Citalopram o Sertraline o Fluoxetine o Mirtazapine o Venlafaxine

Fluoxetine (which is an SSRI),is the first line antidepressant choice in children, if an antidepressant is prescribed.It should only be prescribed following assessment and diagnosis by a child and adolescent psychiatris

You are conducting an audit regarding anticoagulants in atrial fibrillation. As part of this audit, you are checking to see if the risk of bleeding has been considered and documented in patients’ records. Which score should be calculated to predict the risk of major bleeding for patients on anticoagulation for atrial fibrillation? CHA 2 DS 2 -VASc o HAS-BLED o ORBIT o QRISK2 o QRISK3

CHA 2 DS 2 –VASc is a tool used to predict the risk of stroke in patients with atrial fibrillation.ORBIT and HAS-BLED arebothtools used to predict the risk of major bleedingwith anticoagulation in AF,however ORBIT is the preferred tool recommended by NICE guidelines.QRISK scores calculate the risk of developing a heart attack or stroke over the next 10 years

You are completing your annual revalidation for your pharmacist registration. You need to complete one peer discussion record, and one reflective account record. In addition, you must also complete some CPD records. How many CPD records are you required to submit each year as part of your pharmacist revalidation? o 2 CPD records o 4 CPD records o 6 CPD records o 8 CPD records o 12 CPD records

4 CPD

You are clinically checking a drug chart on the surgical ward for a patient who has recently undergone surgery. You notice that the patient has been prescribed an antiemetic for a total of 10 days. You raise this with a prescriber to review because the duration of this antiemetic should not normally exceed 5 days of treatment, due to the risk of neurological adverse effects. Which antiemetic is being referred to? o Domperidone o Metoclopramide o Cyclizine o Dexamethasone o Ondansetron

As per the 2014 MHRA alert, metoclopramide should only be prescribed for short-term use (up to 5 days).This is due to the risk of neurological adverse effects such as tardive dyskinesia

A parent comes into the pharmacy with their 12-year-old child, who is complaining of a red, itchy and watery eye, which started yesterday. This is affecting the right eye only. On questioning and examination, there is no vision loss and no photophobia. There is no sticky or purulent discharge. There is no foreign body or injury to the eye. o Refer to A+E o Refer to GP o Refer to optician o Provide chloramphenicol eye drops o Provide self-care advice

The description suggestsviral conjunctivitis, so chloramphenicol eye drops would not be indicated(these are for bacterial conjunctivitis).Most cases can be managed with self-care measures.

You are working in a community pharmacy and providing the Pharmacy First service. An 18-year-old male patient presents having been bitten by a mosquito on his arm whilst camping in the UK. On questioning, the bite occurred around 6 hours ago. The patient reports that the bite is annoying and itchy but there are no other symptoms. The patient is systemically well. They have a known allergy to penicillin What is the most appropriate course of action? o Administer adrenaline o Refer to GP o Provide patient with flucloxacillin o Provide patient with clarithromycin o Provide self-care advice and offer patient an oral antihistamine or steroid cream, and provide safety netting advice

This is likely to be an inflammatory or allergic responserather than an infection -an antibiotic is not indicated.The presentation is not anaphylaxis–adrenaline is not indicated. Note that patient has a penicillin allergy so flucloxacillin also must not be used

During a medication review a patient tells you that she is experiencing milky nipple discharge. You have a look at her medication list to see if this could be related to any of her medications. Which medication below is most likely to cause this side effect? o Levothyroxine o Risperidone o Lithium o Bisoprolol o Gliclazide

Milky nipple discharge is a potential symptom of hyperprolactinaemia. Risperidone is an antipsychotic,which can cause hyperprolactinaemia.

A patient asks to talk to you about their newly started medication, ramipril, as they are worried about potential side effects that they have read about, particularly a dry cough. According to the SPC, how many people would be expected to experience the side effect of dry cough with ramipril? o ≥ 1/10 o ≥ 1/100 to < 1/10 o ≥ 1/1,000 to < 1/100 o ≥ 1/10,000 to < 1/1,000 o < 1/10,000

A GP asks for your advice regarding a patient who experienced muscle aches and pains whilst she was taking atorvastatin 20mg OD for primary prevention. They want to a prescribe an alternative statin which is considered high intensity. Which of the following is considered a high intensity statin in terms of its reduction in LDL cholesterol? o Simvastatin 20mg OD o Pravastatin 20mg OD o Pravastatin 40mg OD o Fluvastatin 20mg OD o Rosuvastatin 20mg OD

Pravastatinisconsidered a lowintensity statin. Fluvastatin 20mg is a lowintensity statin. Simvastatin 20mg is medium intensity. Rosuvastatin 20mg is high intensity

You are preparing a presentation on the different classes of antidiabetic medications. Which of the following is associated with a risk of Fournier’s Gangrene? o Metformin o Gliclazide o Canaglifozin o Dulaglutide o Sitagliptin

Canagliflozin is a SGLT2 inhibitor, which is associated with a risk of Fournier’s Gangrene, aserious genital infection. Patients should be counselled to maintain good personal hygiene and urgently report any symptoms suggestive of infection. This is based off a 2019 MHRA alert

You are conducting a med review for a patient prescribed slidenafil Which of the following should be avoided with this drug - GTN Amlodipine Triemthoprim Co-codamol Rivaroxaban

Glyceryl trinitrate interacts with sildenafil and can increase the risk of hypotension–BNF states that manufacturer advises to avoid

You are sorting through stock in the pharmacy and checking expiry dates. You come across a box of nitrofurantoin which has an expiry date of June 2025. After what day should this medication not be taken? o It should not be taken after 30/06/25 o It should not be taken after 31/05/25 o It should not be taken after 01/06/25 o It should not be taken after 01/05/25 o It should not be taken after 01/07/25

Expiry date of June 2025 means that the medicine should not be used after the end of the month so in this case should not be taken after 30/06/25

You are performing a clinical and legal check on a methadone prescription for opioid dependence. Which statement is correct regarding methadone and methadone prescriptions? o Methadone consumption must always be supervised o Other items of medication can be included on the same form as methadone o Methadone is a schedule 3 controlled drug o Methadone is a schedule 2 controlled drug o Supply must only be given directly to the patient, under no circumstances can it be collected by a third party

Sch 2

A patient has been diagnosed with acute otitis media. The GP has prescribed amoxicillin. They are 11 years old and weigh 44kg. They do not have any renal impairment or other medical conditions. They are allergic to clarithromycin. They should be prescribed the adult dosage of amoxicillin o They should only be prescribed amoxicillin in paediatric suspension formulation o Amoxicillin is not appropriate for this indication o Amoxicillin should not be used due to the patient’s allergy to clarithromycin o Amoxicillin is not suitable for use in children

Section 4.2 on the SPC advises children over the weight of 40kg should be prescribed the adult dosage

You are clinically checking a prescription for a female patient. Their medication list is as follows: Mirtazapine 15mg ON for depression Apixaban 2.5mg OM for prophylaxis of stroke and systemic embolism in atrial fibrillation Lansoprazole 15mg OM for indigestion Weight: 54kg Creatinine: 123 micromol/litre Age: 84 years old CrCl = 26 mL/min Which statement below is correct? o The mirtazapine dosing is incorrect for this patient o The apixaban dosing is incorrect for this patient o The lansoprazole dosing is incorrect for this patient o There is a contraindication to using one of their medications o There is a clinically significant drug interaction between the patient’s medications

The apixiban dose is incorrect because the dose should be 2.5mg TWICE a day not once a day

A patient tells you that they have had an adverse reaction to amlodipine. How should adverse drug reactions be reported? o It should be reported to the GPhC o It should be reported to the GMC o It should be reported the Royal Pharmaceutical Society o It should be reported via the Yellow Card Scheme o It should be reported directly to the manufacturer

yellow card