EXAM QS: ONTRACK Flashcards by Jacqueline Gyamfi

For each of the following patients, select the most relevant safety concern associated with the patient’s medication. Each option may be used once, more than once or not at all.

A 64-year-old woman prescribed empagliflozin 10 mg once daily.
Atypical femoral fractures
Benign idiopathic osteonecrosis
Fatal diabetic ketoacidosis
Increased incidence of heart failure
Risk of severe harm and death
Subacute cutaneous lupus erythematosus
Suicidal ideation
Uterine perforation

FATAL DIABETIC KETOACIDOSIS:

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For each of the following products sold over the counter, select the minimum age that they can be used from. Each option may be used once, more than once, or not at all.

Nurofen® for Children 100 mg/5 mL.
2 months
3 months
6 months
12 years
16 years
18 years
45 years
65 years

3 months

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For each of the following products sold over the counter, select the minimum age that they can be used from. Each option may be used once, more than once, or not at all.

Alli® 60 mg hard capsules.

2 months
3 months
6 months
12 years
16 years
18 years
45 years
65 years

18 yrs

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For each of the following scenarios, choose the appropriate treatment for the patient. Each option may be used once, more than once, or not at all.

[You should refer to NICE guidance on COPD (NG 115): https://www.nice.org.uk/guidance/ng115/resources/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245]
A non-smoking patient who has spirometrically confirmed COPD and asthmatic features, but remains breathless despite optimised SABA treatment.

ICS
LABA
LABA + ICS
LABA + LAMA
LAMA
LAMA + LABA + ICS
SABA or SAMA
SAMA only

LABA + ICS

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For each of the following scenarios, choose the appropriate treatment for the patient. Each option may be used once, more than once, or not at all.

You should refer to NICE guidance on COPD (NG 115): https://www.nice.org.uk/guidance/ng115/resources/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245
A non-smoking patient with spirometrically confirmed COPD who does not have asthmatic features but remains breathless despite use of a SABA.

ICS
LABA
LABA + ICS
LABA + LAMA
LAMA
LAMA + LABA + ICS
SABA or SAMA
SAMA only

LABA + LAMA

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A patient newly diagnosed with COPD who needs treatment to relieve breathlessness and exercise limitation.

ICS
LABA
LABA + ICS
LABA + LAMA
LAMA
LAMA + LABA + ICS
SABA or SAMA
SAMA only

SABA or SAMA

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A patient with spirometrically confirmed COPD who has features suggesting steroid responsiveness and remains breathless despite taking LABA + ICS.

ICS
LABA
LABA + ICS
LABA + LAMA
LAMA
LAMA + LABA + ICS
SABA or SAMA
SAMA only

LAMA + LABA + ICS

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Which of the listed conditions are cautioned with the following products?

Pseudoephedrine tablets.

Asthma
Diabetes and hypertension
Epilepsy
Hay fever
Hypertension and asthma
Migraine
Ulcer
Ulcer and asthma

Diabetes and hypertension [ DIABETES: Due to activation of SNS it increases the blood glucose and in hypertension increases TPR/cardiac work=increasing BP]

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Paracetamol 500 mg and pseudoephedrine 30 mg.

Asthma
Diabetes and hypertension
Epilepsy
Hay fever
Hypertension and asthma
Migraine
Ulcer
Ulcer and asthma

Diabetes and hypertension

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A 38-year-old male who presents with excruciating pain in his right ankle at night. He described the ankle as being ‘red, inflamed and feels warm’.
Anaphylaxis
Asthma attack
Ectopic pregnancy
Gout
Hernia
Irritable bowel syndrome
Osteoporosis
Rheumatoid arthritis

GOUT [https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/gout]

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What are the signs and symptoms of gout.

Gout commonly affects the large toe but may also affect the ankles, heels, knees, wrists, fingers and elbows. It commonly occurs at night and may last 3-10 days.

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A 17-year-old female who experiences lower abdominal pain 8 weeks after having unprotected sex.
Anaphylaxis
Asthma attack
Ectopic pregnancy
Gout
Hernia
Irritable bowel syndrome
Osteoporosis
Rheumatoid arthritis

Ectopic pregnancy

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For each of the following patients described, select the most likely possible consequence of the drug interaction from the list above. Each option may be used once, more than once or not at all.

An 80-year-old man is on the following medication:

isosorbide mononitrate 50 mg m/r daily
aspirin 75 mg daily
amlodipine 10 mg daily

He has been newly prescribed lisinopril 10 mg daily.

Bleeding risk increased
Bradycardia
Constipation
First dose hypotension
Hypertensive crisis
QT interval prolongation
Reduced eGFR
Serotonin syndrome

First dose hypotension

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A 77-year-old woman is on the following medication:

atorvastatin 10 mg daily
aspirin 75 mg daily
digoxin 62.5 mcg daily.

She has been newly prescribed atenolol 10 mg daily.
Bleeding risk increased
Bradycardia
Constipation
First dose hypotension
Hypertensive crisis
QT interval prolongation
Reduced eGFR
Serotonin syndrome

Bradycardia

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A patient who takes warfarin for atrial fibrillation and has an INR of >8 is admitted onto your ward. What should be given by slow intravenous injection?
Ascorbic acid
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc

Vitamin K

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This requires hydroxylation by the kidneys to its active form, therefore, in patients with a severe reduction in renal function, alfacalcidol should be prescribed instead of this.
Ascorbic acid
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc

Vitamin D, colecalciferol, is the non-activated form of vitamin D. It is activated in the kidneys, so if a patient has reduced renal function then the activated form (alfacalcidol) should be given instead.

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This helps the absorption of calcium in the gut.
Ascorbic acid
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc

Vitamin D

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Used in the prevention of a methotrexate side effect.
Ascorbic acid
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc

Folic acid

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Which of the following has a side effect that can cause stools to be darkened?
Ascorbic acid
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc

Iron

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You should advise pregnant patients to avoid liver and oil products due to the fact they contain this.
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc

Retinol (Vitamin A)

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When a patient has an overload of this substance, deferasirox should be administered to the patient.
Calcium
Folic acid
Iron
Retinol
Vitamin D
Vitamin K
Zinc

Iron Indicated for the treatment of chronic iron overload when desferrioxamine is contraindicated or inadequate (with non-transfusion-dependent thalassaemia syndromes).

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A drug has an indication for deep vein thrombosis and is described as a direct thrombin inhibitor with a rapid onset of action.
Apixaban
Aspirin
Clopidogrel
Dabigatran etexilate
Dalteparin sodium
Danaparoid sodium
Dipyridamole
Unfractionated heparin

Dabigatran etexilate is direct thrombin inhibitor with a rapid onset of action.

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A patient is being treated for deep vein thrombosis and is only aware of the dose of the medication they are taking. They inform you they were told to take ‘10 mg twice daily for 7 days, then a maintenance dose of 5 mg twice daily’. Which medication is this likely to be?

Apixaban
Aspirin
Clopidogrel
Dabigatran etexilate
Dalteparin sodium
Danaparoid sodium
Dipyridamole
Unfractionated heparin

Apixaban is licensed for use in the treatment of DVT at a dosage regime of ‘10 mg twice daily for 7 days, then a maintenance of 5 mg twice daily’.

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A patient aged 7 years has contracted Kawasaki disease and a doctor asks which drug is most useful to help treat the condition.

Apixaban
Aspirin
Clopidogrel
Dabigatran etexilate
Dalteparin sodium
Danaparoid sodium
Dipyridamole
Unfractionated heparin

Aspirin; Kawasaki is thrombotic disease involving the arterial making aspirin the most appropriate agent to deal with the disease pathogenesis.

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Which of the drugs below requires the following counselling points according to the BNF? Each option may be used once, more than once, or not at all. Brush teeth for one minute before spitting out. Avoid drinking or rinsing mouth for 30 minutes after use. A. Alendronic acid B. Amiodarone C. Chlorhexidine D. Colgate Duraphat® E. Felodipine F. Olsalazine sodium G. Pancreatin H. Rotigotine

Which of the drugs below requires the following counselling points according to the BNF? Each option may be used once, more than once, or not at all. It is important to ensure adequate hydration at all times in patients receiving higher-strength preparations of this drug. A. Alendronic acid B. Amiodarone C. Chlorhexidine D. Colgate Duraphat® E. Felodipine F. Olsalazine sodium G. Pancreatin H. Rotigotine

Patients should be advised to report any unexplained bleeding, bruising and sore throat. A. Alendronic acid B. Amiodarone C. Chlorhexidine D. Colgate Duraphat® E. Felodipine F. Olsalazine sodium G. Pancreatin H. Rotigotine

f. olsalazine: interference in the metabolism of arachidonic acid to prostaglandins and leukotrienes, scavenging,of reactive oxygen species, effects on leucocyte function and production of cytokines. Analogue of 5-ASA

For the patients described, select the most likely contraindication or caution from the list below. Each option may be used once, more than once, or not at all. Ganciclovir. A. 18-year-old male B. 21-year-old male with type 1 diabetes mellitus C. 29-year-old male with an abnormally low neutrophil count D. 35-year-old male with unstable myasthenia gravis E. 38-year-old female with a haematoma on her upper arm F. 45-year-old female with blood pressure of 187/112 mmHg G. 58-year-old female who regularly drinks ginger tea H. 72-year-old male with erectile dysfunction

You are training a summer student on the use of medicines. Which of the following non-prescription topical preparations should be used once at night? A. Canesten® soft gel pessary B. Clotrimazole 2% cream C. Daktarin® oral gel D. HC45® hydrocortisone 1% cream E, Zovirax® 5% cream

The local community nurse phones you to say her patient has run out of medicines. The nurse would like to know which of the patient's medicines she can prescribe for the patient. She is not an independent or supplementary prescriber. Which of the patient's medicines could the nurse prescribe? Atenolol Bendroflumethiazide E45 cream Morphine sulphate 20 mg tablets Timodine cream®

E45 cream

Which symptom is LEAST likely experienced with thrush? A thin, white discharge Discharge associated with a strong odour Dysuria Superficial dyspareunia Vaginal itching and soreness

Discharge associated with a strong odour

Which of the following is NOT a recommended check point for avoiding prescribing errors? A. Right dose B. Right medicine C. Right patient D. Right quantity Right route

It is mid-March and a patient presents to you in the pharmacy displaying cold-like symptoms. On questioning she says she remembers having a really bad cold last year at the same time. On questioning the patient, you suspect she might have an allergy rather than a cold. What is the likely cause of her allergy? A. Dust mites B. Grass pollen C. Mould D. Pet allergy E. Tree pollen

You are working a Sunday morning shift in a high street pharmacy in England. A mother approaches you and asks for a spacer for her five year old son because his has broken. What would be the most appropriate course of action? Advise the mother to ask her GP for a prescription on the Monday Demonstrate how to use an inhaler without a spacer Make an emergency supply Sell the mother a spacer Send the mother to an out of hours service for a prescription

Sell mother a spacer

For each of the following questions or statements, select the illness which is correct. Each option may be used once, more than once or not at all. Vaccination against this disease is usually given within the first year of life in a combination vaccine with diphtheria, tetanus, haemophilus influenza type b and polio. Atopic eczema Chicken pox (varicella) German measles (rubella) Impetigo Measles (morbilli) Mumps (epidemic parotitis) Slap cheek syndrome (parvovirus) Whooping cough (pertussis)

Whooping cough (pertussis)

Pregnant women have to be extra cautious to ensure that they will not come into contact with this disease as there is an increased risk of congenital abnormalities. A. Atopic eczema B. Chicken pox (varicella) C. German measles (rubella) D. Impetigo E. Measles (morbilli) F. Mumps (epidemic parotitis) G. Slap cheek syndrome (parvovirus) H. Whooping cough (pertussis)

Multi-part question: part 2 of 2 For each of the following patients, select the vitamin deficiency that is the most likely cause of the signs and symptoms described in the scenario. Each option may be used once, more than once, or not at all. Mr D comes into your pharmacy. He tells you that he has recently been to visit his 93 year old father. He expresses his concern regarding his father's health over the past 3 months. He says that he has swollen and bleeding gums and that he has developed red spots on his shins. He has also noticed a few bruises on his body. Vitamin A Vitamin B1 Vitamin B3 Vitamin B12 Vitamin C Vitamin D Vitamin E Vitamin K

The correct answer was Vitamin C His fathers symptoms are indicative of scurvy (vitamin C deficiency). Although rare, it could occur in very elderly patients who may find it harder to cook or maintain a healthy diet.

all. Mr D started to feel generally unwell a week ago and had a tingling feeling on the left side of his trunk associated with back pain. A band-like rash appeared in that same area a few days later . He described the rash as red and blotchy, developing into fluid filled blisters, which then dried out and formed scabs. Allergic reaction Chickenpox Eczema Impetigo Psoriasis Scabies Shingles Urticaria

Shingles

You regularly dispense mycophenolate for this patient. What would be appropriate counselling for the patient? Each option may be used once, more than once or not at all. He calls the pharmacy to state he is stopping his mycophenolate mofetil treatment to try for a baby. He would like to know how long he needs to continue to use contraception for. 1 week 4 weeks 30 days 6 weeks 2 months 90 days 26 weeks One year

90 days

You regularly dispense mycophenolate for this patient. What would be appropriate counselling for the patient? Each option may be used once, more than once or not at all. She calls the pharmacy to state she is stopping her mycophenolate mofetil treatment to try for a baby. She would like to know how long she needs to continue to use contraception for. Incorrect answer 1 week 4 weeks 30 days 6 weeks 2 months 90 days 26 weeks One year

6 weeks

Multi-part question: part 1 of 5 How many times in total (i.e. first dispensing plus repeats) can you dispense the following prescriptions? Each option may be used once, more than once or not at all. A private prescription for fluconazole 200 mg capsules with the word "repeat" stated. 0 1 2 3 4 5 6 7

The correct answer was 2 Private prescriptions without the number of repeats stated can be repeated once - so dispensed twice in total.

How many times in total (i.e. first dispensing plus repeats) can you dispense the following prescriptions? Each option may be used once, more than once or not at all. A private prescription for a combined hormonal contraceptive with the word "repeat" stated on the prescription. 0 1 2 3 4 5 6 7

The correct answer was 6 Private prescriptions for combined hormonal contraceptives that state "repeat" can be dispensed a total of 6 times.

A private prescription for a schedule 4 drug where the word "repeat" is NOT stated on the prescription. 0 1 2 3 4 5 6 7

5 How many times in total (i.e. first dispensing plus repeats) can you dispense the following prescriptions? Each option may be used once, more than once or not at all. A private prescription for a Schedule 2 CD stating repeat x 3. 0 1 2 3 4 5 6 7

39. Mr B, a 28-year-old man, was stopped this morning on his way to work by police for speeding and careless driving. Mr B informs the police he takes regular medication prescribed by his doctor that sometimes make him drowsy. The police use a roadside drug-screening device to test his saliva and Mr B tests positive for the presence of a drug. Which of the following drugs can be detected using a roadside screening device? (give other examples too) A- zopiclone B-Flunitrazepam C- Alprazolam D- Fluvoxamine E – Aripiprazole

B Ampfetamine, Clonazepam, Diazepam, Flunitrazepam, Lorazepam, Methasone, Morphine based, Oxazepam, Temezapam

68. A junior doctor states that his patient has told him that she has researched the nausea/vomiting associated with certain chemotherapy treatments and is very anxious about this. Which of the following options has the greatest risk of chemotherapy-induced nausea and vomiting? A- Vinorelbine B - Cisplatin C- Bleomycin D- Vincristine E – Ariprepant

82. Mrs. Y, a 49-year-old woman has been diagnosed with a malignant tumor. She is to commence chemotherapy following surgical removal of the tumor. Mrs. Y has read about chemotherapy related side effects and is worried about the associated blood-related side effects. Which chemotherapy agent is not associated with bone marrow suppression? A- Carboplatin B - Epirubicin C- Mitoxantrone D- Vincristine E – Cyclophosphamide

D and bleomycin.

The SPC for Utrogestan capsules states “In women receiving estrogen replacement therapy there is an increased risk of endometrial cancer which can be countered by progesterone administration.”. In this scenario, Utrogestan is a type of progesterone. See: https://www.medicines.org.uk/emc/product/352/smpc#about-medicine Exam framework: GU system The correct answer is: It reduces her risk of endometrial cancer while using the Evorel 50 patch

Your answer is incorrect. SGLT-2 inhibitors (dapagliflozin and empagliflozin) are licensed for use in chronic heart failure – NICE TAs are included in BNF monographs of the drugs. SGLT-2 inhibitors are showed to reduce heart failure hospitalisation, cardiovascular and all-cause mortality in patients with or without diabetes, with a low incidence of adverse events. As the patient has HFpEF (LVEF of 50%), four pillar treatments are not required. Loop diuretic e.g. furosemide is used rather than thiazide diuretics in the symptomatic management of HF. Ivabradine is not appropriate as only used in patients with EF of 35% or less, as adjunct to standard treatment (provided that pulse is >75bpm) Exam framework: CVS, endocrine, antidiabetic drugs, insulins, antihypertensives The correct answer is: Dapagliflozin

Your answer is incorrect. It is good practice for a maximum of 30 days for Schedule 2 and 3 CDs to be prescribed, so 1 BD x 30 days = 60 tablets See: latest MEP guide Exam framework: Statutory regulations and professional requirements for the supply of human and veterinary medicines The correct answer is: 60 tablets

A 77-year-old man with a background of COPD is taking Nuelin SA (theophylline) 250mg every 12 hours. He has recently decided to stop smoking and undergo a smoking cessation programme with nicotine patches. What ADR would be expected? Question 104Answer A. confusion B. diarrhoea C. dryness of lips D. mouth ulcers E. palpitations F. QTc prolongation G. tremor H. vertigo

b Your answer is correct. Smoking cigarettes (not the nicotine) increases the metabolism of theophylline by stimulating the hepatic enzyme CYP1A2. The dose of theophylline may need to be reduced by about one-quarter to one-third one week after withdrawal but it may take several weeks for enzyme induction to dissipate. Theophylline concentration needs to be monitored periodically on smoking cessation and patient should be advised to seek help if they develop signs of theophylline toxicity such as palpitations or nausea. Exam framework: respiratory The correct answer is: palpitations

Patient of Afro-Caribbean descent and <55 years old with new diagnosis of hypertension so first line treatment is CCB. Lercanidipine is most appropriate given patient would like to remain on current medications and maximum dose of simvastatin is 20mg with concurrent use of amlodipine. As per Stockley’s (accessed Feb 24) - Lercanidipine does not have a clinically relevant effect on simvastatin exposure. Simvastatin does not affect the exposure to lercanidipine. The concurrent use of simvastatin and a calcium-channel blocker does not appear to increase the incidence of myopathy. Exam framework: CVS, antihypertensives The correct answer is: Lercanidipine tablet 10mg once a day

Her HBPM reading shows hypertension is not optimally controlled by current treatment. Patient is already on maximal dose of CCB and ACEi. Third line antihypertensive as per NICE is thiazide diuretic, however, this is not suitable given patient’s history of gout. From BNF: gout can be precipitated by a thiazide diuretic. Fourth line treatment includes a mineralocorticoid receptor antagonist (spironolactone) or alpha/beta-blocker. Beta-blocker is not suitable given patient’s history of asthma and not for spironolactone given recent potassium level >4.5mmol/L. Exam framework: CVS, antihypertensives, resource The correct answer is: Doxazosin MR tablet 4mg once a day

Which one of the following is least likely to be a presenting symptom of Type 1 diabetes? A. Abdominal pain B. Enuresis C. Hypoglycaemia D. Fatigue E. Weight loss

. Mrs P, a 35-year-old Type 1 diabetic, who has been admitted to hospital whilst visiting the UK from the USA. She uses Humulin R-500 insulin (500 units per 1 mL) from a 20mL vial: 70 units in the morning, 95 units at lunchtime and 35 units at teatime. Mrs P had been self- administering her insulin using her own vial but this ran out 2 days and Mrs P has been unwell. The drug chart indicates that the nursing staff continued to administer the same 0.4mL daily dosing using their ward stock of 10mL vial of Humulin I (100 units per 1 mL). What is the most likely cause of Mrs P’s symptoms? A. Hypoglycaemia B. Hyperglycaemia C. Erratic blood glucose levels due to stress D. Changes in the effectiveness of Humulin E. The ward supply of Humulin I is out of date

B Mrs P has 200 units of Humulin R-500 which is 0.4mL, however she has been having 0.4mL of Humulin I which is 100 units per mL, which equates to 40 units daily. 40 units is much lower than her usual 200 units and therefore is most likely unwell due to hyperglycaemia.

At Mrs D’s 6 monthly diabetes review it is found that her HbA1c is much lower than usual. You are asked if this could be caused by changes in her medication. Which one of the following drugs that Mrs D has been started on in the last 3 months, is the most likely to have caused the change in her result? A. Aspirin B. Co-amilozide C. Clopidogrel D. Metformin E. Ramipril

What statin is most suitable to consider for someone who is type 2 diabetic and has established CVD? A. Atorvastatin 20mg B. Atorvastatin 80mg C. Simvastatin 40mg D. Simvastatin 80mg

Mr S Ukarto is a new patient at your practice. You are conducting a new patient meds reconciliation and review with the patient. From his previous practice records you note that he is a Type 2 diabetic, who is stable is on Metformin, Gliclazide and Dapagliflozin. You have a look at his previous Hb1Acs and can see that it is stable, around 52 mmol/mol. How often should Mr G Phage get his HbA1c checked? A. Every month B. Every 3 months C. Every 6 months D. Every 12 months

You are conducting an annual medication review with Mr L Sugar, who has Type 1 diabetes. As well as discussing his medicines, you also touch upon management of his diabetes and ensure that he is following guidelines in relation to blood testing, as you notice that he has not been ordering his blood glucose testing strips frequently. How often should routine self-monitoring of blood glucose be carried out daily? A. At least ONCE daily B. At least TWICE daily C. At least THRICE daily D. At least FOUR times a day

113. F 114. A 115. G

C 30 day max supply; 28 day until prescription expires