GPHc Exam Qs Flashcards by Jacqueline Gyamfi

(2017)

(B)

Background Information:
According to NICE guidance for acute flare up Colchicine is first line. This is because colchicine is effective controlling pain flare ups in gout. Colchicine is alkaloid derived from meadow saffron and inhibits pain by inhibiting the inflammatory response and immunological cells at the site where MSU crystals deposit. Colchicine disrupts the formation of microtubules polymerisation and mobilisation. Common S/E: Diarrhoea, nausea and vomiting. [https://www.mdpi.com/2673-9879/2/2/11]. For Long term gout control refer to picture attached.

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Pioglitazone is associated with liver toxicity developing the first 1-6 months of treatment. The symptoms include nausea, vomiting, abdominal pain, fatigue, dark urine (dark urine is associated with high bilirubin levels which can be attributed to inflammation].

Refer to link attached of case study show high Aminotransferase enzymes being high and jaundice [ https://www.ncbi.nlm.nih.gov/books/NBK548327/ ]

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(2017)

(E)

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(NON-GPHc related just learning).
What is the likely cause of this person’s eye symptoms?
A. Allergic conjunctivitis
B. Bacterial Conjunctivitis
C. Blepharitis
D. Subconjunctival haemorrhage
E. Acute angle closure glaucoma

(A)

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(B)

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(NON-GPHc related just learning). Patient presents with grit and general redness of the eye.
What is the likely cause of this person’s eye symptoms?
A. Allergic conjunctivitis
B. Bacterial Conjunctivitis
C. Blepharitis
D. Subconjunctival haemorrhage
E. Acute angle closure glaucoma
F. Viral Conjunctivitis

(F)

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(C)

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(E)

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(E)

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6. Which of the following drugs is it most important to withhold temporarily in view of his current blood pressure?
A aspirin
B enoxaparin
C ramipril
D Relvar Ellipta
E salbutamol
7. During his admission, he complains that for several weeks now he has had a sore mouth.

Which of the following drugs is the most likely cause of his sore mouth?
A aspirin
B isosorbide mononitrate
C ramipril
D Relvar Ellipta
E salbutamol

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C 9. B

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(2017)

He had an elective hip replacement two weeks ago and has a history of hypertension which is treated with amlodipine 5 mg daily and lisinopril 10 mg daily. There have been complications after surgery due to an infection.
10.
Which of the following drugs started in hospital is the most likely cause of his abnormal biochemistry results?
A co-codamol
B enoxaparin
C flucloxacillin
D fusidic acid
E naproxen
You receive a prescription for haloperidol depot injections for one of your patients. Your PMR system shows that the patient usually takes haloperidol tablets.
What is the most likely reason in this patient that the haloperidol has been changed from tablets to a depot injection?
A to improve adherence
B to improve efficacy
C to provide a more rapid response
D to reduce the risk of extrapyramidal side-effects
E to reduce the risk of neuroleptic malignant syndrome

E 11. A

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C 13. C

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D
20.D

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26.D
27.A

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It is a Saturday afternoon. A 54 year old male patients comes into your pharmacy and explains he has ran out of some of his medicines. You notice some of the medicines are controlled drugs.

Which one of the following medicines could you offer as an emergency supply at the request of a patient?

Select one of the following:

1 Zopiclone 3.75mg tablet

2 Morphine sulfate tablets

5 Gabapentin 100mg capsules

6 Tramadol 50mg capsules

28 Diazepam 5mg tablets

Zoplicone 3.75 mg tablets. You can supply max of 5 days for Schedule 4 and 5 CDs and all other options are illegal.

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A 25-year-old man is brought to the emergency department with altered mental status, respiratory depression, and bradycardia. He admits to taking 200 mg of loperamide (Imodium) in an attempt to self-treat his opioid withdrawal symptoms. His ECG shows a prolonged QT interval and ventricular arrhythmias. Which one of the following drugs would you administer as an antidote for loperamide overdose? Select one of the following: Flumazenil Naloxone N-acetylcysteine Pralidoxime Sodium bicarbonate

Naloxone

A 65-year-old woman with gastro-oesophageal reflux disease has been taking omeprazole 20 mg once daily for the past 6 months. She presents to her GP with fatigue, muscle weakness, and cramps. Her blood tests show a serum sodium level of 125 mmol/L, a serum potassium level of 2.8 mmol/L, and a serum magnesium level of 0.5 mmol/L. Which of the following is the most likely diagnosis for her condition? Select one of the following: Addison's disease Cushing's syndrome Hypomagnesaemia Hyponatraemia Renal tubular acidosis

Hypomagnesaemia

H Thick intense yellow green mucus: Sign of bacterial infection + thick mucus production indicates immune system reeved up.

John Smith presents to the emergency department with a chief complaint of fever, productive cough, and for the past four days. He reports feeling progressively more unwell and short of breath. He has been treated for pneumonia with oral clarithromycin 500 mg BD/5 days

Rust coloured sputum indicative of pneumonia. Reason: Vascular congestion is followed by red hepatization of the lung where alveoli are filled with blood-tinged fluid and bacteria to which neutrophils and fibrin are added. This results in the production of the rust-colored, purulent sputum classically seen in pneumococcal pneumonia.

An 83-year-old woman who presents in your pharmacy and is on the following medication: - ramipril 10mg once a day - nebivolol 10mg once a day - spironolactone 25mg in the morning - furosemide 20mg twice a day - ivabradine 5mg once a day You notice that her ankles are swollen in her sandals and she seems out of breath walking from the car to the counter.

E. Pink frothy sputum Acute pulmonary edema (PE) occurs when the pulmonary lymphatics fail to remove transupdated fluid [1]. The edema develops as fluid moves from the intravascular compartment into the interstitial space and from there, in severe cases, into the alveoli and eventually forms overt and copious pink frothy sputum.

A 64-year-old woman who is overweight and a smoker. She has had two weeks off work as she has sprained her ankle and her sister has come to stay with her to look after her. She is on the HRT Premarin® and ibuprofen 400mg three times a day for the sprain. Recently she has been experiencing shortness of breath and chest pain and her usual cough has changed.

F. Red Stained Sputum. PE has an acute onset. SOB/Chest pain followed with cough is common. Blood not mixed with sputum suggests pulmonary embolism. Reason: Pulmonary emboli often present with hemoptysis as a result of ischemic pulmonary parenchymal necrosis.

H Metformin is renally excreted (lactic acidosis).

Failure to treat which of the above conditions may lead to heart failure?

A. Anaemia When anaemia becomes severe, the heart has to pump harder and faster to compensate for the decreased oxygen levels in the body.

H Spiriva respimat Rationale: respimat is pre-filled canister with cap and a press button for dose release.

Mrs JK is expressing thick, viscous sputum that is difficult to expectorate. Steam inhalation has proved to be ineffective. He has had COPD for 3 years, which is otherwise well-controlled. Which of the above treatments do you recommend?

A. Mucolytic

A 30-year-old lady comes to your pharmacy and asks to speak to you in private. She says that she has itching “down below” and says that there is a lot of discharge which is frothy-smelling and is yellow-green in colour. What is the most likely cause of her symptoms? A. Bacterial Vaginosis B. Trichomoniasis Vaginalis C. Candida albicans D. Cervical polyps E. Toxic shock syndrome

Rationale: A is usually characterised by thin, white, fishy-smelling discharge. C- usually white, cottage-cheese like d/c

Miss W wishes to purchase something to treat the abdominal cramping and pain on the first day of menstruation. She is otherwise fit and healthy. Which of the following would be the most appropriate recommendation? A. paracetamol B. naproxen C. codeine D. codeine-paracetamol combination product E. dihydrocodeine-paracetamol combination product

Rationale: b provides relief of the prostaglandin-mediated cramps

12-month old Master L has had a productive cough and nasal congestion for the last 3 days. His mother comes to your pharmacy requesting something to help his symptoms. Which one of the following is the most appropriate recommendation? A. pseudoephedrine nasal spray B. oxymetazoline nasal spray C. phenylephrine nasal spray D. saline nasal spray E. guaifenesin oral solution liquid

Rationale: a-c and e are not licensed for under 6’s-mhra guidance

What are the dose adjustment needed when simvastatin is prescribed with certain drugs

Which beta blcoker is watersoluble

B Lithium therapeutic range 0.4-1 mmol/L

D As with many other chemotherapeutic agents, MTX can induce intestinal mucositis, which can affect the entire gastrointestinal tract and cause malabsorption, diarrhea, and severe pain

Medication: amlodipine 10mg tabs x 65 simvastatin 10mg tab x56 aspiin 75 mg tab x56 allopurinol 200mg tabs x56 (new med)

7) Florence is a 5-year-old girl who is complaining of pain in her ear. She keeps tugging on the ear lobe, and has a temperature. There is no visible discharge that you can see, but her father did tell you that he saw a yellow sticky discharge this morning. What would be the most likely diagnosis? a) Excessive earwax b) Acute otitis media c) Acute otitis externa d) Glue Ear e) Prebyacusis

5) Katherine is a 24-year-old lady who presents to your pharmacy with episodes of throbbing headaches. She tells you that she has been suffering from these headaches for a few weeks now usually after going to the gym. She describes them as usually one sided, and lasting for a few hours. What could these symptoms describe? a) Cluster headache b) Migraine c) Tension headache d) Giant cell arteritis e) Sinusitis

9) Jake is a 26-year-old male who has just returned from a clubbing holiday in Ibiza. He had unprotected sex under the influence of alcohol on several occasions. He tells you that he has a mucopurulent discharge from his penis, which he has had for over a week now. There are no other symptoms. What of the following sexually transmitted infection do his symptoms suggest he has? a) Genital herpes b) Gonorrhoea c) Chlamydia d) HIV e) Thrush

10) Mrs Noor is a 58-year-old lady who suffers from type two diabetes. She presents to you in the pharmacy and tells you that she is suffering from tingling and pain on her tongue. She has had these symptoms for over two weeks now and it is gradually getting worse. When you examine the tongue, there is marked whitening built up on the surface of the tongue. Which of the following is Mrs Noor most likely to be suffering from? a) Neuropathic pain b) Oral thrush c) Mouth ulcers d) Malignant neoplasm e) Side effect of the antidiabetic drugs she is taking.

13) Kelly, a 23-year-old girl comes in to request the morning after pill (Urlipristal) after having unprotected sexual intercourse the night before. Before selling the medicine, you have to ask a few questions to ensure she is suitable to take the medication. Which of the following is a contraindication in taking this medication? a) She is normally taking regular contraception b) She has been unwell with the flu the week previous to this c) She has taken this tablet in a previous menstrual cycle d) She has already taken this tablet in this menstrual cycle e) She has vomited twice this morning.

15) You are working as a hospital pharmacist in a district general hospital. When taking a medication history from a patient you notice that a patient is allergic to penicillin. She tells you that when she has been prescribed it in the past, she suffers from a red itchy rash all over that doesn’t go away for a few weeks. Which of the following antibiotics would be acceptable to prescribe given that she suffers from this allergy? a) Flucloxacillin b) Piperacillin c) Cefotaxime d) Ceftriaxone e) Imipenum

16) A patient has been admitted into hospital with symptoms of muscle weakness and a fast pacing heart rate. It is found that they are suffering from slight hyperkalaemia. Which of the following medications are most likely to contribute to this? a) Furosemide b) Bendroflumethiazide c) Ramipril d) Theophylline e) Acetazolamide

17) Mrs Davy was admitted into hospital for a community-acquired pneumonia, she was prescribed antibiotics to help treat this as per protocol. Following the treatment of antibiotics, she started experiencing severe abdominal pain, a fever and odourous stools. The doctors have suggested these symptoms are due to the initial antibiotic treatment. Which of the following antibiotics could have caused these symptoms? a) Meropenum b) Metronidazole c) Erythromycin d) Trimethoprim e) Clindamycin

18) Mr Lawrence presents suffers from chronic kidney disease and has an estimated Creatinine clearance of 19ml/minute/1.73m. Which of the following options is most likely to be avoided for Mr Lawrence? a) Clarithromycin b) Gentamicin c) Co Amoxiclav d) Metronidazole e) Ciprofloxacin

19) Mr Carodine has just been discharged from hospital after being diagnosed with Angina after an episode of chest pain. He has been added onto a number of medications and has come to you for your advice. He tells you that he has been suffering from headaches since starting the new set of medications. They were at first a nuisance but are now getting more severe. Which of the following medication could be causing these symptoms? a) Aspirin b) Simvastatin c) Isosorbide Mononitrate d) Ramipril e) Bisoprolol

16. Mr CT si collecting his new prescription for sublingual glyceryl trinitrate (GTN) 300mcg tablets, which has been prescribed for angina. Mr TC has never used them before and therefore requires further information on how to take them. Which of the folowing counselling points for Mr TC regarding his new tablets si INCORRECT? A. Sublingual glyceryl trinitrate tablets provide rapid symptomatic relief of angina, but its effects last only for 5 to 10 minutes. 2030mun B. GTN tablets should be discarded 8 weeks after opening. .C GTN tablets should preferably be taken sitting down. D. GTN tablets should not be transferred to another container. .E Facial flushing may occur as a side effect after taking GTN tablets

A. Sublingual glyceryl trinitrate tablets last for 20-30 minute

A. Candesartan cilexetil B. Indapamide C Methyldopa D. Modified-release nifedipine E Perindopril arginine F.Phentolamine mesilate G. Sodium nitroprusside H. Verapamil hydrochloride For each of the scenarios below, select from the list above the drug which is most likely being referred to. Each option may be used once, more than once, or not at all. 118. 117. A 45-year-old Egyptian man has been diagnosed with hypertension. After being initiated on the first- line treatment 2weeks ago, he si now complaining of side effects which he si not prepared ot put up with any longer. His GP agrees to try a different drug. What should this be? 118. A 31-year-old pregnant woman has developed hypertension during her second trimester. As hypertensive complications ni pregnancy can be hazardous for both the mother and the foetus, her GP decides to prescribe an appropriate antihypertensive. 119. A patient has brought in a new prescription for an antihypertensive, and you have spotted a potentially dangerous interaction with their digoxin tablets. You are concerned about the hypokalaemia which this new medication may cause. 120. Due to the risk of severe hypotension and heart failure, combining this with a beta blocker should only be contemplated under specialist supervision.

1. A 2. D (Second line after labetolol according to NICE guidance) 3. B 4. H

Which of the following is NOT a prescription requirement for a POM-V medicine? A. Name and address of the owner B. Identification and species of the animal C. Prescriptions are valid for six months and 28 days for schedule 2, 3 and 4 controlled drugs. D. Astatement highlighting that the medicine is prescribed under the veterinary cascade E . ) Standardised forms are required for Schedule 2 or 3 Controlled Drugs.

9. You are discussing with your colleague the various classes of veterinary medicines and their associated regulations. Which one of the following statements is INCORRECT? A. Aveterinary medicine that is classified as POM-VPS can be prescribed by apharmacist. B. A veterinary medicine that si classified as AVM-GSL can be supplied by a pharmacist. C. A veterinary medicine thatsi classified as POMV- can be prescribed yb apharmacist D. A veterinary medicine that si classified as NFA-VPS can be supplied by a pharmacist. A written prescription is not required .E An unauthorised veterinary medicine, which si an unlicensed medicine, can only be prescribed by a veterinary surgeon

Which of the following CANNOT be supplied under the terms of the cascade? A. Aveterinary medicinal product authorised ni the UK for another species or different condition B. A product prepared extemporaneously by a registered pharmacist ni accordance with a veterinary prescription C. Alicensed human medicine D. A licensed human medicine or a European Union unlicensed veterinary medicine .E Alicensed human medicine not authorised in the UK but authorised in another European Union country

1. Mrs W, one of your regular patients, presents ni the pharmacy on a Saturday afternoon having run out of one of her medicines. You confirm from your PMR the medicines which she si usualy prescribed, and agree to supply her with enough for the weekend. Regarding this particular situation, which one of the following does NOT have to be recorded in the POM register? A. The name and address of the prescriber. B. The date on which the POM was supplied. C. The name and address of the patient. D. Information on the nature of the emergency. E. The name and quantity of medicine supplied.

A 6-month-old child with no long-term medical conditions requires paracetamol for the treatment of pyrexia associated with flu-like symptoms. What is the most appropriate dose of paracetamol to be administered every six hours? A. 60 mg B.120 mg C. 180 mg D. 240 mg F. 360 mg

You are working on the neonatal unit and the nurse asks you to dispense a prescription for prophylactic sodium feredetate 1 mL daily for baby Tanya who was born 15 days ago, weighing 2.4 kg and is breastfed by her mother. When should you advise the baby's mother to start administering the sodium feredetate? The extract below is from the BNFC. A. Immediately B. In one weeks time C. In two to four weeks time D. In three weeks time E. In four to six weeks time

C. Supplementation is started in 4-6 weeks after birth. Baby Tanya is already 15 days old at the time that you are advising her mother. This needs to be factored in to the advice you give so the answer 2-4 weeks time.

You are instructing a trainee pharmacist in the schedules contained in the Misuse of Drugs Regulations. The Misuse of Drugs Regulations 2001 (as amended) classify controlled drugs into 5 schedules according to the different levels of control attributed to each. Which schedule includes clenbuterol? A. Schedule 1 B. Schedule 2 C. Schedule 3 D. Schedule 4 Part 1 E. Schedule 4 Part 2

95. D - Mouth Ulcers BNF73 p529 96. G – Reduced dental mobility (MHRA/CHM Advice: Osteonecrosis of the jaw). BNF 73 p667 97. A – Binge eating (Impulse Control Disorders) BNF73 p397

91. C 92. H 93. G 94. E

E blood glucose 11 mmol/L

2) When counselling her on how to use the cream, she asks how much she should use so you explain she should use fingertip measurements. ONE fingertip should cover what surface? A one adult finger B one flat adult handprint C torso of an adult D twice a flat adult handprint E whole body surface of adult

4) 8 month child, fever associated with viral infection, recommended to purchase paracetamol infant suspension (120mg/5mL) to control fever and reduce pain associated with infection, what is the correct dose for the child? A 2.5mL QDS max 4 doses in 24 hours B 5mL QDS, max 4 doses in 24 hours C 7.5mL QDS, max 4 doses in 24 hours D 10mL QDS, max 4 doses in 24 hours E 20mL QDS, max 4 doses in 24 hours

60 man, discharged from hospital after STEMI, no other conditions and no intolerances or allergies, which medicine would you NOT expect to see in long term management of his condition? A amlodipine 5mg tabs B atorvastatin 80mg tabs C aspirin 75mg tabs D bisoprolol 10mg tabs E ramipril 5mg capsules

13) 60 man, diagnosed with stable angina, prescribed GTN 500mcg SL tabs for anginal attacks, which is appropriate advice to give to this patient? A ensure container always contains cotton wool wadding to protect from moisture B tablets should be discarded after 8 weeks in use C tablets should be stored in containers with a maximum of 50 tabs D tablets should be stored in plastic amber bottles E tablets should be swallowed whole with a glass of water

14) Which of the following is a high intensity statin? A atorvastatin 20mg B fluvastatin 80mg C pravastatin 20mg D rosuvastatin 5mg E simvastatin 40mg

17) 21 year old woman, diagnosed with UC, commenced on mesalazine 2g OD, which of the following is NOT appropriate advice to give her regarding this drug? A if there is a suspicion of blood dyscrasia then stop immediately B liver function should be monitored at 1 month, 3 months and annually thereafter C renal function should be monitored before starting mesalazine, at 3 months and then annually after D she should report any unexplained bleeding or bruising E she should report sore throat, fever, malaise

B; Ten cases of mesalazine-induced renal injury were identified using a systematic literature review. Mesalazine has nephrotoxicity and can cause adverse events (AEs), such as interstitial nephritis (0–1%), proteinuria (0.3%), and renal failure (0–0.2%) (1). At least 10% of patients with mesalazine-induced interstitial nephritis progress to end-stage renal disease (ESRD); . It is generally considered to be a hypersensitivity reaction and independent of the dose and duration of treatment (2, 6). A genome-wide association study demonstrated a potential association between 5-ASA induced nephrotoxicity and HLA regions and showed that it is more common in male patients case study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9125087/

19) Mr B has attended his monthly INR blood tests and result is slightly higher than expected, which of the following is most likely action that will be taken? A decrease warfarin dose B increase warfarin dose C keep warfarin dose same D send him to A+E E stop warfarin as target INR has been reached

20) Mr B asks what Is likely to happen when he needs to go to hospital for elective surgery that has been planned for 6 months. What is the most appropriate action to take in regards to warfarin and elective surgery? A stop warfarin 1 day before surgery B stop warfarin 3 days before surgery C stop warfarin 5 days before surgery D stop warfarin 7 days before surgery E stop warfarin 10 days before surgery

21) 1 year later, Mr B decided to stop warfarin and change to rivaroxaban as he could not fit in regular INR checks with busy lifestyle, what is the most appropriate dose for Mr B? A 2.5mg BD B 10mg OD C 10mg BD D 20mg OD E 20mg BD

D. 20MG OD

28) 7 child, severe allergy to peanuts which can result in anaphylaxis, what would be the correct volume of adrenaline 1 in 1000 (1mg/mL) for a HCP to administer to the child in a case of anaphylaxis? A 0.1mL B 0.15mL C 0.3mL D 0.5mL E 1mL

29) 16 male, suffers from seasonal rhinitis and is concerned that his watering eyes and blocked nose will affect his performance in upcoming exams. He would like an antihistamine that he only needs to remember to take in the morning and will not cause drowsiness. What is the most appropriate antihistamine to recommend? A alimemazine B chlorphenamine C cyclizine D loratadine E promethazine

32) 50 female, presents to the pharmacy looking for something to help her go to the toilet, she says she is finding it difficult to pass stools as they are too hard, she has not tried anything and is on no other meds. Most appropriate medication? A docusate sodium B ispaghula husk C lactulose D senna E sodium picosulfate

39) Woman prescribed loperamide 2mg capsules for treatment of acute diarrhoea, when picking up her script she asks you how many she can take in one day, which of the following is the max daily dose of loperamide? A 2mg B 4mg C 8mg D 16mg E 32mg

53) Mr D has been referred to a specialist who has confirmed the diagnosis of PD, he is started on pramipexole at titrating dose, which of the following is the least appropriate advice to give regarding pramipexole? A BP should be monitored due to risk of postural hypotension B if a rash occurs the dose should be reduced until rash resolved C never stop treatment immediately as it carries small risk of neuroleptic malignant syndrome D sudden onset of sleep is a possible side effect on this med E treatment is associated with impulse control disorder

54) Mr D has been told that he will need to see his specialist regularly for reviews, after PD diagnosis how often should diagnosis be reviewed? A 1-2 weeks B 1-2 months C 3-6 months D 6-12 months E 1-2 years

55) 2 years later, Mr D’s PD has advanced and he now takes co-beneldopa 50mg/200mg caps 1 TDS, which is not a common side effect of co-beneldopa? A abnormal dreams B depression C dementia D hypertension E taste disturbances

57) 45 female, diagnosed with TB, she has been told she will undergo 2 phases of treatment, an initial and a continuous phase, which of the following meds are most appropriate to use in the continuation phase of treatment? A amoxicillin and metronidazole B clarithromycin and ethambutol C isoniazid and rifampicin D pyrazinamide and ethambutol E rifampicin and phenoxymethylpenicillin

58) Rifampicin can cause a change in coloration of urine, which of the following is the most likely coloration that will be experienced? A black-grey B brown-black C blue-green D orange-red E white-yellow

60) 30 female, prescribed disulfiram for the treatment of alcohol dependence. She would like to know what she will experience if she drinks alcohol whilst taking disulfiram. A flushing of the face B full body rash C palpitation D throbbing headache E vomiting

62) 50 male, prescribed oxybutynin HCL tabs to treat urinary incontinence. How often should the need for continuing therapy be reviewed? A every 1-2 weeks until symptoms stabilise then annually B every 4 weeks until symptom stabilise then no need to review further C every 4-6 weeks until symptoms stabilise then every 6-12 months D every 6 weeks for the duration of therapy E every 6 months for duration of treatment

patient is on prolonged course of clindamycin and treatment has exceeded 10 days. Which of the following should be monitored? A liver and renal function B liver and thyroid function C renal and thyroid function D WBC and renal function E WBC and liver function

25 female, going to go on an 8 hour journey and she would like to purchase something to help prevent motion sickness, she is going on the journey in 3 hours and would prefer something that will not make her too drowsy, what is the most appropriate medication to recommend? A cinnarizine B hyoscine hydrombromide C promethazine D metoclopramide E domperidone

70) You are training pharmacy staff on safe supply of Viagra connect (sildenafil 50mg tabs) OTC, in which of the following circumstances would it be most appropriate to supply without a prescription? Assume no PGDs are in place. A 50 year old man wants medication for premature ejaculation, no other meds and no other conditions B 62 year old man who currently takes sildenafil 25mg on prescription but is running out before his repeat prescription is due so would like to purchase more OTC C 45 year old man who would like a medication for erectile dysfunction, he had a stroke 1 month ago and now takes aspirin 75mg tabs, ramipril 5mg caps and simva 40mg tabs D 25 year old man, taking fluoxetine 20mg caps for 3 months for depression, he has been experiencing erectile dysfunction since starting fluoxetine and feels that is affecting his relationship with his partner E 16 year old who has erectile dysfunction, he takes no other meds and has no other conditions

What should the pre-dose ‘trough’ concentration be of vancomycin for Mrs D? A 5-10 mg/L B 10-15 mg/L C 15-20 mg/L D 20-25 mg/L E 25-30 mg/L

vancomycin Which of the following should be monitored during Mrs D’s treatment? A liver function, ECG and blood counts B renal function, liver function and blood counts C renal function, urinalysis and blood counts D thyroid function, liver function and renal function E urinalysis, blood counts and ECG

C Vancomycin can induce thrombocytopenia and neutropenia therefore monitoring FBC is required. It can also in nephrotoxicty.

76) For which of the following antiepileptics is it most appropriate to maintain the patient on a specific manufacturer’s brand? A clobazam B gabapentin C levetiracetam D phenytoin E sodium valproate

78) 30 female, takes fluconazole 150mg once weekly for recurrent vulvovaginal candidiasis. A month into treatment she discovers she is pregnant so asks your advice on what she should do, what is the most appropriate advice to go? A it is safe to continue taking fluconazole during pregnancy, no action required B she should go to A+E immediately C she should inform GP asap as congenital abnormalities are reported with long term use D she should purchase fluconazole 50mg OTC to take as lower dose safer in pregnancy E she should take 5mg folic acid to prevent any side effects from fluconazole during pregnancy

79) 30 male asks advice on antimalarials as he is travelling around Africa for 1 year, he remembers being told in the past that there is an antimalarial he can’t take due to history of psychiatric disorders, what is the most likely medication that this patient was told not to take? A chloroquine B doxycycline C mefloquine D proguanil E quinine

C. Mefloquine is MOST likely to cause it due to long half life whereas chloroquine is likely to happen in indivudals with NO history of psychaitric ailment.

95. C 96. G 97. F 98. H 99. D

100. f 101. e 102. e 103. g 104. b

105. h 106. g (give LAMA) 107. E (LABA+ICS)

108. b 109. f 110. g (due to phosphate binding to calcium to try and remove it out of the blood)

114. H 115. A 116. E

A 66-year-old woman is scheduled for surgery under general anaesthetic. During her pre-operation consultation she was informed of the rare risk of malignant hyperthermia as a result of general anaesthesia, which is characterised by high temperature and tachycardia. Which of the following is the most appropriate treatment for malignant hyperthermia? a. acetylcysteine b. activated charcoal c. dantrolene sodium d. high flow oxygen e. naloxone

All registered pharmacists and pharmacy technicians must undergo revalidation on an annual basis to remain registered. Which of the following must registered professionals complete according to the revalidation framework? Question 15Answer a. 2 CPD entries (1 planned and 1 unplanned), 1 peer review and 1 reflective account b. 4 CPD entries (at least 2 planned) only c. 4 CPD entries (at least 2 planned), 1 peer review and 1 reflective account d. 4 CPD entries (at least 2 unplanned), 1 peer review and 1 reflective account e. 4 CPD entries (2 planned and 2 unplanned), 2 peer review and 2 reflective accounts

Post COVID – 4 CPD entries (at least 2 planned), 1 peer review and 1 reflective account is the expectation Assessment topic: Law and Ethics Reference: https://www.pharmacyregulation.org/revalidation - revalidation framework The correct answer is: 4 CPD entries (at least 2 planned), 1 peer review and 1 reflective account

A 57-year-old woman of African-Caribbean family origin has just been diagnosed with stage 1 hypertension. She has type 2 diabetes, and a QRISK3 score of 13%. She has no known allergies and renal function tests are within the normal range. Which of the following drugs is the most appropriate first-line therapy according to national guidance? a.amlodipine b.bisoprolol c.candesartan d.doxazosin e.indapamide

C Your answer is incorrect. ACE or ARB are recommended as step 1 therapy for diabetics of any age or family origin. NICE also recommends an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor, in adults of black African or African-Caribbean family origin. Assessment topic: Cardiovascular Reference: NICE clinical guidelines for hypertension in adults - https://www.nice.org.uk/guidance/ng136 The correct answer is: candesartan

You are counselling a patient who is starting treatment with a drug that has Black Triangle designation and explain the Yellow Card scheme for the reporting of adverse drug events. For which of the following drugs should all adverse events be reported via the yellow card scheme? Question 18Answer a. amoxicillin b. lithium carbonate c. methotrexate d. rivaroxaban e. trastuzumab

Trastuzumab is a biosimilar. All biosimilars are black triangle drugs. Assessment topic: Pharmacy Practice Reference: https://bnf.nice.org.uk/medicines-guidance/adverse-reactions-to-drugs/ The correct answer is: trastuzumab

A 69-year-old male undergoes yearly blood tests and observations at the GP surgery as part of routine monitoring due to hypertension. He is normally prescribed: * Lisinopril 20 mg ONCE daily * Furosemide 40 mg TWICE daily * Spironolactone 50 mg ONCE daily Today his results were as follows: Sodium 138 mmol/L Potassium 5.7 mmol/L Creatinine clearance 73 ml/min (no change from baseline) Blood pressure 135/85 Which of the following would be the most appropriate management option for this patient? a. add in amlodipine 5 mg ONCE daily b. double the dose of furosemide to encourage renal potassium depletion c. encourage him to increase his intake of tomatoes to help balance his potassium levels d. hold lisinopril e. reduce Spironolactone to 25 mg ONCE daily and recheck potassium and BP in one week

A - distractor because calcium channel blockers are appropriate for HTN in this age group but will not impact potassium in any way. B– Inappropriate given patient’s BP. C – Tomatoes are high in potassium. D - Disproportionate for the level of hyperkalaemia and he has good BP control. E – Proportionate approach. Assessment topic: Blood and Nutrition Reference: https://bnf.nice.org.uk/treatment-summaries/hypertension https://kidneycareuk.org/get-support/healthy-diet-support/lowering-your-potassium-levels/ The correct answer is: reduce Spironolactone to 25 mg ONCE daily and recheck potassium and BP in one week

A 72-year-old woman has been prescribed alendronic acid 70 mg tablets to reduce the risk of hip fractures. Which of the following is the most appropriate advice? a. take at least 30 minutes before first food, beverage, or other medicinal product of the day b. take at the same time as a calcium supplement c. take one tablet daily before bedtime d. take upon arising for the day with at least 300 mL of water e. you may lie down as soon as you have taken alendronic acid

B – should not be taken at the same time as a calcium supplement. C – this is incorrect because alendronic acid is taken as a weekly dose rather than a daily dose. D & E – the patient must take with at least 200 mL of water and must sit up for at least 30 minutes after the dose to reduce oesophageal irritation.

A 42-year-old patient was diagnosed with diabetes six months ago. They have tried to control their condition by changing their diet and increasing exercise, however, this has not been successful. They have a past medical history of hernia and epilepsy which is well controlled by medication. Which one of the following options should the patient avoid? a. acarbose b. alogliptin c. dapagliflozin d. gliclazide e. glimepiride

Acarbose is contra-indicated in those who have hernia as it can worsen the condition. Due to its mechanism of action, its use is also contra-indicated in those with disorders of digestion or absorption.

Two months later the same patient returns. She is now biochemically euthyroid and most of her symptoms have improved but she is still suffering from constipation. Which one of the following options should the patient avoid? patient is on mesalazine a. bisacodyl b. isphagula husk c. lactulose d. sodium docusate e. sodium picosulphate Feedback

c The manufacturers of some mesalazine gastro-resistant and modified-release medicines (Asacol MR tablets, Ipocol, Salofalk granules) suggest that preparations that lower stool pH (e.g. lactulose) might prevent the release of mesalazine. This in turn, can worsen crohn’s disease symptoms or bring about a flare.

A father brings his 3-year-old child into the pharmacy. The child’s symptom of perianal night-time itching leads you to conclude that he has threadworm. Which one of the following is the most appropriate course of action? Question 37Answer a. do not supply mebendazole as he is too young and provide hygiene advice instead b. supply mebendazole as a single dose to the child only c. supply mebendazole as two doses, at a 14-day interval to the child only d. supply mebendazole to all family members as a one-off dose e. supply mebendazole to the whole family, followed by a repeat dose after 14 days

Whilst conducting a medication review for one of your patients who suffers from Sjogren’s syndrome, she informs you that she does not always take her omeprazole 20 mg capsules once daily as she finds them difficult to swallow. Which one of the following would be the most suitable alternative for the patient? Question 44Answer a. esomeprazole 10 mg g/r granules sachets - once daily b. esomeprazole 10 mg g/r tablets – two tablets once daily c. lansoprazole 15 mg orodispersible tablets – once daily d. omeprazole 10 mg / 5 mL oral suspension – 10 mL once daily e. omeprazole 10 mg g/r tablets – two tablets once daily

Individuals with Sjogren’s syndrome have reduced secretions so find it difficult to swallow tablets and capsules. Therefore, only A and D are viable options. Option D is correct as it is closest to her current dose. Assessment topic: Immune system and malignant disease Reference: https://www.nhs.uk/conditions/sjogrens-syndrome/symptoms/ The correct answer is: omeprazole 10 mg / 5 mL oral suspension – 10 mL once daily

A 39-year-old man hands you a prescription for a single issue of morphine sulfate 10 mg/5 mL oral solution. How long is this prescription valid for from the stated appropriate date on the prescription? Question 47Answer a. 28 days b. 30 days c. 3 months d. 6 months e. 12 months

The patient is provided with dietary and lifestyle advice and initiated on a new medicine. He brings in a prescription to the pharmacy for metformin 500 mg once a day. Which one of the following statements about metformin is correct? Question 59Answer a. gliclazide is associated with a lower risk of hypoglycaemia compared to metformin b. hypoglycaemia commonly occurs with metformin use c. metformin can cause weight gain and is usually prescribed if symptoms persist despite adequate attempts at dieting and weight loss d. metformin exerts its effect mainly by increasing gluconeogenesis in the liver e. metformin is only effective in the presence of insulin

The correct answer is: metformin is only effective in the presence of insulin

An 81-year-old woman visits your clinic with urinary incontinence. She has tried bladder training with no success, so you decide to prescribe medication. The patient has a history of mild dementia and is frail. You are concerned about her risk of falls and therefore decide to prescribe her a drug with the lowest anticholinergic burden. Which of the following drugs for urinary incontinence would most likely be prescribed? Question 64Answer a. fesoterodine b. mirabegron c. oxybutynin d. solifenacin e. tolterodine

Mirabegron acts on beta-3-adrenocetors. Therefore, it has a minimal anticholinergic burden unlike the other options which are all antimuscarinics and have a high anticholinergic burden.

A patient comes into the pharmacy as they have run out of bisoprolol 5 mg tablets. You check their record and determine that it is appropriate for you to provide an emergency supply of the medicine. Which of the following is the most appropriate action to take with regards to the supply? Question 67Answer a. you can give a full two months’ supply of medication b. you can lend the medicine to the patient and deduct the quantity from their next prescription c. you must give 28-day supply of medication d. you must give five days’ supply of medication e. you should make a record of the supply in the pharmacy prescription book

e Your answer is incorrect. Lending medication would be very difficult to justify if an emergency supply could have been used. See requirements of recording and general requirements of emergency supply at request of patient. You cannot supply more than 30 days treatment.

A woman has come into your pharmacy wanting to buy something to treat her toenail infection. She was reading about Curanail® (amorolfine 5% nail lacquer) on the internet and was wondering whether this would be suitable. You are satisfied it is a fungal nail infection and proceed to make a supply. Which one of the following statements is true regarding the supply of Curanail® (amorolfine 5% nail lacquer)? Question 68Answer a. can be sold for mild cases of distal lateral subungual onychomycosis b. can only be sold if up to 3 nails are affected c. should be used daily for a maximum of 6 months d. suitable for patients 16 years or over e. suitable for use in diabetic patients

Which of the of the following would be the most appropriate advice for this patient on how to apply the patch? Question 75Answer a. apply a new patch after showering/bathing, ensuring that the previous patch is removed beforehand. Choose a different area of skin every time the patch is replaced. b. apply the patch every morning to any part of the chest, upper arm, abdomen, or shoulders, avoiding areas that are hairy. Remove the patch before going to bed. c. apply the patch immediately with the onset of angina and remove once symptoms have resolved. Do not apply more than one patch per day. d. apply the patch to the side of the chest for 12-14 hours and then remove. The patch may also be applied to the upper arm, abdomen, or shoulder. e. apply the patch to the side of the shoulder and replace it every 12-14 hours with a new patch. Apply the patch to the other shoulder every time it is replaced.

A mother brings her 3-year-old son into your pharmacy and tells you she thinks he has an ear infection. He has been complaining of pain around the ear and scratching his ear. He has also recently had a temperature and has been congested following a cold, preventing him from sleeping properly. Which of the following would be the most appropriate advice to give the mother? Question 81Answer a. give cetirizine solution to reduce itching and help sleep b. give chlorphenamine to help him to settle at night-time c. most ear infections clear up on their own within 48 hours d. refer them to the GP for antibiotics e. supply olive oil ear drops to remove any ear wax

A – do not give cetirizine B – this is not a licensed use of chlorphenamine C – most infection clear up on their own within 72 hours D – there is no need to refer to the GP immediately – maybe after 72 hours or, if not, treatable via Pharmacy First E – this will not treat an ear infection or relieve the symptoms. Assessment topic: Ear, nose, and oropharynx Reference: https://www.nhs.uk/conditions/ear-infections/ The correct answer is: most ear infections clear up on their own within 48 hours

A 27-year-old man is on high dose intravenous methotrexate for osteosarcoma. You are reviewing their medication list for any potential drug interactions. Which of the following medications would most likely cause a negative interaction? Question 85Answer a. ibuprofen 5% gel applied once daily only when required b. lansoprazole 30 mg gastro-resistant capsules once daily c. metformin hydrochloride 1000 mg tablets twice a day d. nitrofurantoin 50 mg tablets once daily e. ramipril 5 mg capsules once daily

A patient has had a hip replacement and has had a difficult time with pain management; they have trialled multiple opioids and are now taking morphine sulphate slow-release tablets regularly. Which one of the following options is the most appropriate licensed option for this scenario? Question 108Answer a. bisacodyl b. co-danthramer c. docusate sodium d. glycerol suppository e. isphagula husk f. lactulose g. macrogol h. naloxegol

h Opioids are commonly known to cause constipation, naloxegol is licensed to treat opioid induced constipation. Assessment topic: Gastro-intestinal system Reference: https://bnf.nice.org.uk/drugs/naloxegol/ The correct answer is: naloxegol

A 55-year-old male attends your clinic for a medication review and you note that he has been recently started on tamsulosin hydrochloride 400 mcg modified release capsules. He is currently taking citalopram 10 mg tablets and simvastatin 40 mg tablets. Which one of the following options best describes the adverse effect the patient is likely to experience? Question 110Answer a. constipation b. depression c. epistaxis d. hypertension e. nausea f. sexual dysfunction g. skin reaction h. vision disorders

f Sexual dysfunction is a common side effect of tamsulosin hydrochloride. Assessment topic: Genito-urinary tract Reference: https://bnf.nice.org.uk/drugs/tamsulosin-hydrochloride/#side-effects The correct answer is: sexual dysfunction

An 11-year-old girl visits your pharmacy with her mother. The mother tells you her daughter is suffering from a dry cough. She mentions it is unproductive and very irritating. She has had it for 3 days and no other symptoms present. She takes no other medication and has not yet tried anything. Which of the following medicines is most suitable for this patient? Question 114Answer a. beclometasone nasal spray (Beconase hayfever®) b. cetirizine 5 mg/5mL liquid c. dextromethorphan 7.5 mg/5 mL liquid (Robitussin dry cough sugar free®) d. glycerol liquid (Covonia, Dry and Tickly Cough Linctus®) e. guaifenesin 100 mg/5 mL liquid (Robitussin chesty cough sugar free®) f. pholcodine 5 mg/5 mL linctus g. prochlorperazine 3 mg buccal tablets (Buccastem M®) h. pseudoephedrine 60 mg tablets (Sudafed®)

Cough suppressants such as pholcodine 5 mg/5 mL and dextromethorphan should not be used for under the age of 12. Covonia ® is a soothing preparation for relief of the symptoms of coughs and sore throats and is suitable for children over the age of 1. Pholcodine can be used from 6 years of age at concentration of 2 mg/5 mL - Galenphol Paediatric Linctus, (CHM/MHRA advises that pholcodine should not be given to children under the age of 6). Assessment topic: Respiratory Reference: BNF 72 page 271 The correct answer is: glycerol liquid (Covonia, Dry and Tickly Cough Linctus®)

Gout is a type of inflammatory arthritis which can cause intense pain and joint swelling. Flares often begin in the big toe, but can affect other joints in the body, and usually last for one to two weeks. Which of the following drugs is least appropriate to initiate during an episode of acute gout? Question 14Answer A. Colchicine B. Febuxostat C. Naproxen D. Paracetamol E. Prednisolone

b Not a treatment for acute gout but continue if attack develops when already receiving febuxostat, and treat attack separately.

opical corticosteroids can be used to treat many skin conditions, however topical steroid withdrawal reactions may infrequently result from long-term use or overuse. This is particularly common after use on sensitive skin, such as the facial and genital areas. Which of the following can be a sign of topical corticosteroid withdrawal? Question 16Answer A. Cushing's syndrome B. Extensive damage to mucous membranes C. Flare of original symptoms D. Redness of the skin E. Skin thinning

A pharmacist in a community pharmacy is discussing multivitamins with a new mother. Children’s multivitamin drops are available over the counter containing both water soluble and fat soluble vitamins. Which of the following vitamins is recommended as a daily supplement for all children in the UK from age 6-months to 5-years-old? Question 23Answer A. Vitamin A (retinol) B. Vitamin B1 (thiamine) C. Vitamin B2 (riboflavin) D. Vitamin E (alpha tocopheryl acetate) E. Vitamin K (phytomenadione)

A The WHO recommends treating xerophthalmia with VAS of 50,000 IU for children less than 6 months of age, 100,000 IU for children 6-12 months of age, and 200,000 IU for children greater than 12 months of age daily for 2 days followed by an additional dose after 2 weeks. It reduces child mortality and morbidity

A woman has gone to the GP complaining of pain on urination and spots of blood in her urine. The GP has diagnosed her with an uncomplicated lower urinary tract infection. Her eGFR is 30mL/min and she is penicillin allergic. The GP gives you a call to speak about what to prescribe. Which of the following is the most appropriate antibiotic choice for this patient? A. Metronidazole B. Cefalexin C. Nitrofurantoin D. Trimethoprim E. Amoxicillin

For UTIs the best options are nitrofurantoin or trimethoprim or amoxicillin. As she is penicillin allergic, she cannot have amoxicillin or cefalexin because there is likely to be cross-sensitivity. Nitrofurantoin should be avoided is the eGFR is less than 45mL/min/1.73m2. For trimethoprim, you use half normal dose after 3 days if eGFR 15-30ml/min/1.73m2

Mrs M Bid, brings in a prescription for Nitrofurantoin 100mcg M/R capsules – One to be taken TWICE daily for a total of 3 days. She has never taken these antibiotics before, so you take the liberty to fully counsel her on the medication. Which of the following statements below is most appropriate for the administration of Nitrofurantoin? A. Take with or just after food, or a meal B. Take 60 minutes before any food C. Do not drink alcohol D. Take 2 hours before or after food

Miss P is in your pharmacy and hands over a prescription for Phenoxymethylpenicillin. Upon checking the PMR you can see she has not had it before and confirm this with her. When handing out the medication, you give her some counselling pointers, especially surrounding the administration of the medication. Which of the statements below is most accurate with regards to the administration of Phenoxymethylpenicillin? A. Take 30 to 60 minutes before food B. Take with or just after food, or a meal C. Do not take milk, indigestion remedies, or medicines containing iron or zinc, 2 hours before or after you take this medicine D. Take this medication when you stomach is empty. This means an hour before food or 2 hours after food.

A pharmacist is dispensing a prescription for desmopressin oral lyophilisates for a 7-year-old boy with nocturnal enuresis. The parent asks for some advice as there is an upcoming school residential trip in a few weeks. Which of the following counselling points is least appropriate, regarding the use of desmopressin for managing nocturnal enuresis for this child? Question 39Answer A. Concurrent use of drugs that cause low sodium should be avoided B. Desmopressin should be withheld during periods of acute illness C. Doses should be taken once daily in the morning for effective treatment D. Fluid intake should be restricted to 1 hour before and 8 hours after dose is taken E. Swimming activities for prolonged periods should be avoided

Lithium salts have a narrow therapeutic/toxic ratio and should therefore not be prescribed unless facilities for monitoring serum-lithium concentrations are available. Samples should be taken 12 hours after the dose to achieve a serum-lithium concentration of 0.4–1 mmol/litre (lower end of the range for maintenance therapy and elderly patients). A target serum-lithium concentration of 0.8–1 mmol/litre is recommended for acute episodes of mania, and for patients who have previously relapsed or have sub-syndromal symptoms. It is important to determine the optimum range for each individual patient. See: https://bnf.nice.org.uk/drugs/lithium-carbonate/#monitoring-requirements Option D relates to carbamazepine: Plasma concentration for optimum response 4–12 mg/litre (20–50 micromol/litre) measured after 1–2 weeks. Option E relates to phenytoin: The usual total plasma-phenytoin concentration for optimum response is 10–20 mg/litre (or 40–80 micromol/ litre). Exam framework: CNS, narrow therapeutic index The correct answer is: 0.4 - 1 mmol/L, at the lower end of the range for maintenance

A 25-year-old pregnant woman has come to the pharmacy requesting treatment for constipation. Upon further questioning, the woman describes that when passing stools, they have been smaller than usual and a lot harder to pass. She is currently 13 weeks pregnant. She has tried to increase the amount of fibre in her diet and is also drinking more water than usual to try and help, but with no success. There are no red flags that you can identify, she is not on any medication and has no known drug allergies. Which of the following is the most appropriate first line treatment for her constipation? Question 49Answer A.Docusate B.Ispaghula husk C.Lactulose D.Macrogol E.Senna

B In the pregnancy section, it states that lifestyle changes such as increasing dietary fibre and fluid intake should be the first intervention. In this scenario, the patient has already tried lifestyle changes, but seen no benefit. The next step is drug treatment, and in this case, ispaghula husk is the first thing to try. Ispaghula husk is known as the brand Fybogel and is a bulk-forming laxative, which can be bought over the counter. The other options are all treatments for constipation, but these treatments are not first line. The next step in treatment would be to try an osmotic laxative such as lactulose or macrogol. A short course of a stimulant laxative could then be trialled if no benefit is seen after that, such as senna or docusate.

1. Ms. O a 36-year-old woman with no known medical conditions visits her GP complaining of shoulder pain. She explains to the GP that the pain started two nights ago following a strength training session using dumb bells. She has tried taking paracetamol to help with the pain, which has helped but only slightly. Following examination, the GP informs Ms. O that she would benefit from taking an NSAID. As Ms. O. has experienced severe GI side effects with previous NSAID treatment, she wants to use an NSAID with the least risks of GI side effects. Which of the following NSAIDs is the GP most likely to prescribe? A- Naproxen 500 mg BD B- Ibuprofen 400mg QDS C- Piroxicam 20mg OD D- Indomethacin 50mg OD E- Diclofenac 25mg TDS

4. Question 4 – 5 relate to Mr. R, a 68-year-old man admitted to the hospital with a clostridium difficile infection. While taking a medication history, Mr. R hands you a bag of the following medication which he is currently taking: Metformin 500mg THREE times DAILY Metronidazole 400mg THREE times daily for 7 days Amlodipine 5mg ONCE DAILY Omeprazole 20mg ONCE DAILY Bendroflumethiazide 2.5mg ONCE DAILY Which of the medications that Mr. R is taking is most likely to have contributed to him developing a clostridium difficile infection? A- Metformin B- Metronidazole C- Amlodipine D- Omeprazole E- Bendroflumethiazide

D e potential mechanism to explain this association may be that elevated gastric pH levels facilitate the growth of potentially pathogenic upper and lower gastrointestinal tract flora. Although Clostridium difficile spores are acid resistant, vegetative forms are susceptible to acidity. Higher gastric PH therefore increases vegetative bacteria counts in the small and large intestine. Other potential mechanisms include impairment of leukocytes and other immune responses and antimicrobial properties of PPIs. In recent years, much research has been contributed to prove the relationship between PPIs and CDI as causal.