rps22

Question 1

A 15-year-old boy asks to speak to you about his eye. You notice that his left eye
appears red and is watering. The boy informs you that his eye has been like this since
waking up this morning. His vision has not been affected but his eye is causing him
some pain and he is squinting due to the lights in the pharmacy.
A Advise him that his symptoms are self-limiting and will resolve in a few days
B Refer him to the GP
C Sell chloramphenicol 0.5% eye drops
D Sell hypromellose 0.3% eye drops
E Sell sodium cromoglycate 2% eye drops

Answer 1

Conjunctivitis is usually associated with a yellow sticky discharge and is described as feeling ‘gritty’ rather than being painful. Red watery eyes can be signs of dry eye or hay fever;however,eye pain and photophobia are red flag symptoms and require referral to either an optician or a GP for assessment.

Question 2

A 63-year-old man with a history of advanced throat cancer with bone metastases has
been referred to you for a review of his pain control. Due to his condition, he is now
struggling to swallow, and a decision has been made to switch him from tablets to
patches.
He currently takes the following medicines:
* Zomorph (morphine sulphate) 10mg capsules, TWO capsules TWICE daily
* Zomorph (morphine sulphate) 30mg capsules, ONE capsule TWICE daily
* Oramorph (morphine sulphate) 10mg/5mL, 2.5mL FOUR times a day
Information about fentanyl has been provided below.
A Durogesic DTrans (fentanyl) 50mcg/hr transdermal patch
B Fencino (fentanyl) 75mcg/hr transdermal patch
C Matrifen (fentanyl) 25mcg/hr transdermal patch
D Mezolar (fentanyl) 12mcg/hr transdermal patch
E Victanyl (fentanyl) 100mcg/hr transdermal patch

Answer 2

A
Total daily dose of morphine: 120mg2 x 10mg capsules BD = 40mg30mg capsules BD = 60mg2.5mL Oramorph = 5mg, 5mg QDS = 20mg120mg morphine salt is equivalent to fentanyl 50 patch

Question 3

A 35-year-old woman has presented to accident and emergency with signs of
haemolytic anaemia secondary to G6PD deficiency.
Which one of her medications is most likely to have caused her symptoms?
A Amlodipine 5mg tablets
B Bisoprolol 2.5mg once daily
C Cetirizine hydrochloride 10mg tablets
D Fentanyl 12mcg/hr patches
E Nitrofurantoin 100mg modified-release capsules

Answer 3

Nitrofurantoin

G6PD deficiency is a genetic disorder that some individuals may have, it is common in males and those originating from Asia, Africa, the Middle East and the Mediterranean region. G6PD is an enzyme that supports the functioning of red blood cells. Individuals with this deficiency are susceptible to haemolytic anaemia when they take a number of common drugs. From the options, nitrofurantoin is the only medication that is contra-indicated in G6PD deficiency.

Question 4

A patient is admitted into accident and emergency with Stevens-Johnson Syndrome
(SJS). You check the patient’s medication record to look for possible causes.
Which one of the following drugs is most likely to have caused Stevens-Johnson
Syndrome in this patient?
A Beclometasone 100 microgram inhaler
B Codeine 15 mg tablets
C Lamotrigine 100 mg tablets
D Paracetamol 500 mg tablet
E Salbutamol 100 microgram inhaler

Answer 4

Lamotrigine is the only medication in this section which has the potential to cause SJS

Question 5

A 60-year-old man with a history of hypertension, glaucoma and iron deficiency
anaemia is coming into your clinic for his annual hypertension review. He currently
takes the following medicine:
* Amlodipine 5mg once daily
* Atorvastatin 20mg once daily
* Ferrous sulphate 200mg twice a day
* Latanoprost 50microgram/ml eye drops 1 drop at night to both eyes
* Ramipril 5 mg once daily
Ahead of the review, he has had blood tests taken, the results of which are shown
below, his last results three months ago were all normal.
Urea 6.5 mmol/l (2.5-7.8 mmol/L)
Creatinine 80 micromol/L (59-104 micromol/L)
Alkaline phosphatase 40 U/L (30-130 U/L)
Alanine aminotransferase 240 U/L (<45 U/L)
Gamma glutamyl transferase 45 U/L (<70 U/L)

Which of the patient’s regular medication is most likely to have caused the change in
blood tests?
A Amlodipine
B Atorvastatin
C Ferrous sulphate
D Latanoprost
E Ramipril

Answer 5

Atorvastatin
BNF states: NICE suggests that liver enzymes should be measured before treatment andrepeated within 3 months and at 12 months of starting treatment. Those with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy

Question 6

A 28-year-old man presents in the pharmacy asking for information about the smoking
cessation service.
Which one of the following is most suitable to advise regarding smoking cessation?
A A quit date should be agreed to keep the patient motivated
B A single intervention is better than a combination
C Bupropion is first line for smoking cessation
D E-cigarettes are licensed for use in smoking cessation
E The patient should purchase varenicline for smoking cessation

Answer 6

A
The only correct and appropriate option is for a quit date to be agreed to keep the patient motivated.Combination intervention is better than single intervention when considering smoking cessation options. It should be noted that bupropion is not first line treatment for smoking cessation; various options should be explored included non-pharma logical interventions. E-cigarettes are not licensed for use in smoking cessation, and varenicline is a POM therefore cannot be supplied to the patient over the counter.Drug treatments for smoking cessation should be made on an individual basis, and consider:The individual’s previous experience of smoking cessation drugs.Their preference for treatment.*Contraindications, cautions, possible interactions andrisk of adverse effects of the treatments.

Question 7

The next two questions relate to a 63-year-old man, who comes into your
pharmacy to ask about a rash that has developed over the past 24 hours.
You take him into the consultation room, and he shows you the rash on the left side of
his abdomen. He says that he is recovering from a heavy cold and feels a bit run down.
He has no spots anywhere else on his body. He describes the area as itchy, painful
and burning. You check his medication records and find that he currently takes
amlodipine 5mg daily and indapamide M/R 1.5mg daily for hypertension.
What is the most likely cause of the patient’s rash?
A Allergy to his medication
B Scabies mites
C Streptococcus pyogenes
D Tinea corporis
E Varicella-zoster

Answer 7

The symptoms suggest shingles rash caused by varicella zoster. There is usually a prodromal phase with abnormal skin sensations and pain in the affected dermatome (area of skin served by an individual nerve). Within 2–3 days, a rash typically appears in a dermatomal distribution. It starts as maculopapular lesions then develops into clusters of vesicles, with new vesicles continuing to form over 3–5 days. The rash is usually painful, itchy, and/or tingly, and, unlike other rashes, does not cross the midline of the body.

Question 8

You refer the patient to his GP for treatment for shingles and after two weeks he returns to see you.
He says that the rash has faded, but he still has a lot of pain from the site.
What is the most appropriate treatment for the patient?
A Amitriptyline 10mg tablets 1-2 at night
B Buprenorphine 5mcg/hr patch applied directly to the site and changed every 7
days
C Hydrocortisone cream 1% applied to the area 3 times a day for 7 days
D Ibuprofen 400mg tablets 3 times a day
E Nefopam 30mg tablets 1-2 tablets 3 times a day

Answer 8

Patient is experiencing post-herpetic neuralgia. Amitriptyline would be the most appropriate treatment for this.

Question 9

A 58-year-old woman is admitted to hospital following persistent chest pains. After
routine investigations, she is diagnosed with angina and prescribed glyceryl trinitrate
400 microgram sublingual spray. You have been asked by the nurse to counsel the
patient on how to use the glyceryl trinitrate spray.
Which of the following instructions are you most likely to advise the patient?
A Use one spray under the tongue at the onset of symptoms. The dose may be
repeated after 5 minutes if required.
B Use one spray under the tongue at the onset of symptoms. The dose may be
repeated after 15 minutes if required
C Use one spray under the tongue at the onset of symptoms. The dose should not
be repeated.
D Use two sprays under the tongue at the onset of symptoms. The dose may be
repeated after 10 minutes if required.
E Use two spra

Answer 9

A

Question 10

A three-year-old girl is prescribed aspirin as an antiplatelet following cardiac surgery to
prevent thrombus formation. The junior doctor would like to know if there are any
precautions around its use in children.
Which of the following statements regarding aspirin in paediatric patients would be
most suitable to highlight to the doctor?
A Aspirin is licensed for use in under 16-year-olds
B Aspirin is safe to prescribe in those with a previous history of hypersensitivity to
NSAIDs
C Aspirin is safe to use in asthmatic patients
D The manufacturer states that aspirin should be avoided in under 16-year-olds due
to risk of Kawasaki disease
E The manufacturer states that aspirin should be avoided in under 16-year-olds due
to risk of Reyes syndrome

Answer 10

E
Aspirin should be used with caution in asthmatic patients. It can be used as an exception in Kawasaki disease; however, it is contraindicated ifthe patient hashad previous hypersensitivity. It is alsounlicensed in under 16-year-olds.

Question 11

You receive the below prescription for a three-year-old child. On the Pro-D3 (vitamin
D3) box, it states that there is a dropper built into the top of the bottle that dispenses
drops that are 50 microlitres in size.
How many drops of Pro-D3 is most appropriate to administer per dose?
A 4 drops
B 8 drops
C 10 drops
D 20 drops
E 40 drops

Answer 11

4 drops

Each drop is 50 microlitres. 1 mL = 1000 microlitres. 1000/50 = 20 drops per mL.2,000 iu / 20 drops = 100 iu per dropDose = 400 iu = 4 dropsExtract (if applicble)

Question 12

A patient has had a reaction after being given an overdose of ferric carboxymaltose
(Ferinject).
What would be the most appropriate action in which to investigate this?
A Complete a yellow card for the patient’s reaction
B Complete an audit of patients administered with Ferinject
C Report the practitioners involved to their appropriate governing bodies
D Complete the ‘near miss log’ in the pharmacy
E Use a root cause analysis tool to investigate why the error happened

Answer 12

The most appropriate action for this would be to complete an analysis tool, such as a Root Cause Analysis (RCA) tool

Question 13

You receive a private prescription for a controlled drug and note that the prescriber is
based in Portugal.
Which of the following controlled drugs can legally be supplied on this prescription?
A Codeine
B Ketamine
C Morphine
D Oxycodone
E Pethidine

Answer 13

The address of prescriber is required to be within the UK on prescriptions for controlled drugs, but not for Schedule 4 (part 1 and 2) or Schedule 5 controlled drugs. Codeine is Schedule 5 controlled drug, all other options are Schedule 2 controlled drugs

Question 14

A 58-year-old woman is currently taking digoxin 125micrograms daily for the past two
months. She has no known drug allergies. She has also been taking furosemide 40mg
tablets twice a day for the past two weeks. The patient tells you that she has not been
feeling very well and has been experiencing nausea, diarrhoea, palpitations and feeling
faint.
What is the most appropriate advice to give to this patient?
A She is experiencing a side-effect of digoxin, and whilst safe to continue taking it,
she may wish to see her GP for a review
B She should see her GP as the dose of furosemide may need to be decreased
C She should see her GP so that a digoxin plasma concentration level can be taken
D Stop taking digoxin straight away and see her GP as soon as possible
E Stop taking furosemide straight away and continue taking the digoxin

Answer 14

Advise the patient to stop taking digoxin and refer for medical review urgently. The BNF monograph recommends that if toxicity occurs, digoxin should be withdrawn as serious manifestations can occur requiring urgent specialist management. A digoxin plasma concentration within the therapeutic range does not exclude digoxin toxicity.

Question 15

You meet a patient on the oncology ward in your hospital who is about to undergo their
first round of chemotherapy. They are worried about being sick with chemotherapy.
Which of the following chemotherapeutic agents is most likely to cause vomiting?
A Bleomycin
B Cisplatin
C Etoposide
D Fludarabine
E Vincristine

Answer 15

Cisplatin

Question 16

One of your regular patients visits you complaining of acute gout. He has a history of
myocardial infarction 2 years ago and has no known drug allergies. He currently takes
the following medication:
- Aspirin 75mg once a day
- Bisoprolol 10mg once a day
- Ramipril 5mg once a day
- Simvastatin 20mg once a day
Which of the following medications is the most appropriate treatment?
A Allopurinol
B Colchicine
C Diclofenac
D Paracetamol
E Tramadol

Answer 16

Colchicine

Allopurinol is used to prevent gout, not to treat it. Diclofenac is contra-indicated due to the history of MI and paracetamol and tramadol are not anti-inflammatory so ineffective in gout.

Question 17

A patient calls the pharmacy at noon and asks for your advice on emergency contraception. She takes desogestrel regularly but forgot to take a tablet this morning. She took it yesterday morning at 8am as normal, and last night had unprotected intercourse. She is on day 13 of the pack of tablets

A- As long as the missed pill is no more than 12 hours late it can be taken straight away with no changes to dose timings. No further protection will beneeded.

B- As long as the missed pill is no more than 12 hours late it can be taken straight away with no changes to dose timings. The patient will need to use barrier methods for the next 7 days.
C- As long as the missed pill is no more than 24 hours late it can be taken straight away with no changes to dose timings. No further protection will be needed
D- As long as the missed pill is no more than 24 hours late it can be taken straight away with no changes to dose timings. The patient will need to use barrier methods for the next 7 days.
E- As long as the missed pill is no more than 72 hours late it can be taken straight away with no changes to dose timings. The patient will need to use barrier methods for the next 7 days

Answer 17

The SmPC section 4.2 states:Management of missed tabletsContraceptiveprotection may be reduced if more than 36 hours have elapsed between two tablets. If the user is less than 12 hours late in taking any tablet, the missed tablet should be taken as soon as it is remembered,and the next tablet should be taken at the usual time. If she is more than 12 hours late, she should use an additional method of contraception for the next 7 days. If tablets were missed in the first week after initiation of Cerazette and intercourse took place in the week before the tablets were missed,the possibility of a pregnancy should be considered

Question 18

patient visits the pharmacy and asks to purchase some chloramphenicol eye drops
for bacterial conjunctivitis.
How would you advise the patient to store the eye drops for the course they are on?
A Store in the refrigerator until opened and then can be left at room temperature and
used until the expiry date
B Store in a secure cupboard out of the light. Once opened can be used until the
expiry date.
C Store upright in a refrigerator between 2-8oC. Protect from light and discard four
weeks after opening.
D Store upright in a refrigerator between 2-8oC. Protect from light and discard four
weeks after the expiry date.
E Store upright in a refrigerator between 2-8oC. Once opened can be kept at room
temperature, protect from light and discard four weeks after opening

Answer 18

Chloramphenicalinformation leaflet states that the medicine needs to be stored upright between 2-8oC in a refrigeratorand protected from light and must be used within four weeks of opening.

Question 19

Responsible Pharmacist (RP) regulations mean that the owner of a retail pharmacy
business must appoint an RP to be in charge of the registered pharmacy.
You are discussing the regulations with your pre-registration trainee pharmacist to help
them with their revision.
Which one of the following statements is the most accurate in relation to the RP
regulations?
A The pharmacy record detailing the RP information must be kept for a period of
three years
B The RP can only be the RP for one pharmacy at any given time
C The RP may be absent for a maximum of four hours in the pharmacies business
hours
D The RP only needs to display the RP notice when they are absent
E The sale of GSL medicines does not require a RP to be in charge of the pharmac

Answer 19

B

Pharmacy record needs to be kept for 5 years. The RP can beabsent for maximum of2 hours.The sale of GSL medicines do need an RP to be in charge. The RP needs to display a notice whilst RP

Question 19

A 70-year-old man with advanced Parkinson’s disease is being started on apomorphine
therapy. He has recently been experiencing nausea and vomiting as a result of the
apomorphine.
Which of the following treatment options is the most appropriate for nausea and
vomiting?
A Domperidone
B Haloperidol
C Metoclopramide
D Ondansetron
E Prochlorperazine

Answer 19

Domperidone

Metoclopramide, haloperidol and prochlorperazine should not be used in Parkinson’s disease as they cross the blood brain barrier and cause dopamine blockade, resulting in worsening of symptoms. Ondansetron is contraindicated with apomorphine due to additive QTc prolongation and risk of serious arrhythmia. The manufacturers of apomorphine recommend the use of domperidone to control nausea and vomiting, however there is still a risk of QT prolongation with this combination, hence an assessment of cardiac riskfactors and ECG monitoring is recommended to ensure that the benefits outweigh the risks.

Question 20

You are reviewing a patient as part of a ward round. You check their blood results
which were taken the day before.
The results are:
Haemoglobin 100g/L (115–165g/L)
Platelets 230 x 109/L (150–450 x 109/L)
Red blood count 4.3 x 1012/L (3.8–5.8 x 1012/L)
Mean corpuscular volume 110fL (80–100fL)
Hematocrit0.4L/L (0.37–0.47L/L)
Folate <2ng/mL (2–20ng/mL)
B12 500pg/mL (180–1000pg/mL)
Which of the following is most appropriate to recommend for this patient?
A Cyanocobalamin 50 micrograms daily
B Ferrous sulphate 200 mg daily for 3 months
C Folic acid 400 micrograms daily for 3 months
D Folic acid 5 mg daily for 4 months
E Hydroxocobalamin 1 mg once every three months

Answer 20

The blood results are suggestive of a folate deficiency. For folate deficiencies, NICE recommends supplementation with folic acid 5 mg daily for 4 months. Folic acid 400 micrograms is usually recommended to women of child-bearing age, to be taken before conception and until week 12 of pregnancy, for the prevention of neural tube defects.

Question 21

A 65-year-old man has been admitted into hospital after a referral from his GP. He is
suffering from symptoms that have been getting gradually worse. These include but are
not limited to: swollen ankles, which are worse in the evening; breathlessness, which is
worse after walking for 30 minutes; fatigue, which has not improved with multivitamins.
What would be the most appropriate diagnostic test to request for this patient?
A B12 levels
B CT pulmonary angiogram
C HbA1c
D Pro B-type natriuretic peptide
E Thyroid function test

Answer 21

This patients’symptoms indicate they have developed heart failure. A pro B-type natriuretic peptidewill measure cardiac function and will be raised in heart failure.HbA1cis adiagnostic for diabetes. Thyroid function test will indicatehyper or hypothyroidism. A CT pulmonary angiogramwill help diagnosea pulmonary embolism(PE). Patient does not have any chest pain which may indicate a PE. B12levels will help identify deficiencies –patient does not have any symptoms which may indicate B12deficiency

Question 22

A patient with diabetes and hypertension presents at her GP for a review. She takes
several medicines to manage her conditions. Her most recent blood test revealed that
her potassium level was 5.6 mmol/L (range 3.5 – 5.1 mmol/L).
Which of the following medicines is most likely to increase potassium levels?
A Amlodipine
B Bendroflumethiazide
C Gliclazide
D Losartan
E Metformin

Answer 22

Losartan
Angiotensin ii receptors such as Losartan cause hyperkalaemia. This is noted as a common adverse effect.

Question 23

You are the responsible pharmacist at a community pharmacy. A 24-year-old patient
visits your pharmacy and complains that they have been given the wrong medication.
Upon further investigation you find the prescription and notice that the incorrect
medicine was supplied the previous day when another pharmacist was on duty as the
responsible pharmacist.
Which of the following is the most appropriate initial actions to take?
A Apologise for the error made and make a correct supply of the medicine
B Ask the patient to come back when the regular pharmacist is in as they need to
know about the error
C Explain that the error is not very serious, so the patient does not complain further
D Find out who made the error and escalate the issue to senior colleagues
E Never apologise, as this is an admission of guilt

Answer 23

It would be most appropriate to apologise to the patient and rectify the error by supplying the correct medicine. It is important to investigate the error and share information with colleagues, escalating where appropriate, however these are not steps you should immediately take and could delay the patient getting the right treatment. Also,it is clear that an error has been made and it would be professional to acknowledge this and apologise (even if the error was not made by you)

Question 24

A 71-year-old man is having his routine biochemistry tested by his GP. His medical history includes hypertension and hypercholesterolaemia. His is currently taking the following medication: Amlodipine 5mg daily Bendroflumethiazide 2.5mg daily Colecalciferol 400iu daily Paracetamol 500–1000mg 6-hourly as needed Simvastatin 40mg at night. Blood test results showed his potassium levels to be below the normal range. Which one of the following is the most likely cause of his abnormal biochemistry results? A Amlodipine B Bendroflumethiazide C Colecalciferol D Paracetamol E Simvastatin

Answer 24

Bendroflumethiazide is a thiazide diuretic that causes hypokalaemia by increasing potassium excretion by the kidney

Question 25

You have received a prescription for morphine 10mg tablets, a schedule 2 Controlled Drug (CD), and have supplied it to a patient. You record the supply in the appropriate CD register. Which of the following is a professional and legal requirement with regards to CD register records? A- A running balance is mandatory to be recorded in the CD register B CD stock balance checks must be completed once a week on the same day each week C Electronic CD registers may allow entries to be amended at a later date D Electronic CD registers should be kept for two years from the date of the last entry E Written CD registers must be maintained alongside electronic registers at the premises

Answer 25

It is a legal requirement to keep CD registers (paper and electronic) for two years from the date of the last entry.The other options are not legal requirements. It is not necessary to have both written and electronic CD registers. Registersin general shouldn’t be amendable at a later date, however there may be some instances where an error has been made with an entry therefore an amendment will be required. For most organisations stock checks should be at least once a week but may be more or less frequent based on risk. Keeping a running balance in a CD register is good practice requirement not yet mandatory

Question 26

An 83-year-old man and has presented to A&E with an ongoing fever for three days, with loss of appetite and dehydration. From the patient’s medication record (PMR) you note that he was dispensed amoxicillin 500mg capsules one to be taken three times a day for a total of seven days. You suspect symptoms of sepsis. Which one of the following investigations is the most appropriate to undertake to diagnose sepsis? A Chest x-ray B C-reactive protein levels C Haemoglobin levels D Liver function tests E Urine dipstick

Answer 26

C-reactive protein is marker for inflammation which is often associated with sepsis. Full blood counts will usually be undertaken, which will include haemoglobin, however, haemoglobin levels are not usually measured in isolation without other blood markers. Anaemia is often present during sepsis which affected haemoglobin levels.A chest x-ray and urine dipstick may help diagnose specific infections, for example, pneumonia or a urinary tract infection, respectively. Sepsis can lead to liver injury, which will require liver function tests

Question 27

A 47-year-old man visits his GP for a regular diabetes review. The GP asks for your advice on intensification of treatment for the patient’s uncontrolled type 2 diabetes. The patient has an elevated HbA1c. The patient is taking metformin as monotherapy. The patient has a medical history of current active bladder cancer for which he is undergoing chemotherapy. His last cycle ended three weeks ago. Which of the following medicines is most likely to be contraindicated in this patient? A Acarbose B Canagliflozin C Gliclazide D Pioglitazone E Semaglutide

Answer 27

Pioglitazone is contraindicated in active, or previous bladder cancer. The European Medicines Agency (EMA)safety report (July 2011) small increased risk of bladder cancer associated with pioglitazone use. It should not be used in patients with active bladder cancer or past history of bladder cancer or in those who have uninvestigated macroscopic haematuria

Question 28

A 32-year-old-man has recently changed his diet to incorporate more fibre. His stools are not as loose, but he has been experiencing more wind, which he finds embarrassing. He therefore asks you to recommend a product to combat the increased wind. Which one of the following products would be most appropriate to recommend to alleviate his symptoms? A Dulcolax tablets (bisacodyl) B Fybogel sachets (ispaghula) C Gaviscon advance liquid (sodium alginate, sodium bicarbonate, calcium carbonate) D Milk of magnesia liquid (magnesium hydroxide) E Rennie deflatine tablets (simethicone, calcium carbonate, magnesium carbonate

Answer 28

E Simeticone is an anit-foaming agent and is most appropriate for these symptoms.

Question 29

A 26-year-old man asks for your advice regarding a rash on his knee. The rash appeared two weeks ago and is itchy, burns and sore. He has no other medical conditions but has recently been feeling quite stressed due to work priorities A Contact dermatitis B Discoid eczema C Pityriasis versicolor D Psoriasis E Tinea corporis

Answer 29

Psoriasis oftenoccurs on extensor surfaces (elbows and knees),trunk,flexures,sacral and natal cleft,scalp and behind the ears, and umbilicus. This is an image of plaque psoriasis, which generally presents as large plaques. There is usuallya clear delineation between normal and affectedskin. May be pink or red, but in people with pigmented skin this may not be obvious. Scale is typically silvery in colour.Psoriasis may be caused by infection, drugs (including corticosteroid withdrawal), ultraviolet light exposure, trauma, hormonal changes, stress, smoking, and alcohol.

Question 30

You are checking the accuracy of some dispensed medication within your pharmacy to ensure it contains all the necessary legal requirements. Which of the following is a legal requirement required on dispensed medication labels? A The brand and generic name of the product B The date the item was dispensed C The expiry date of the product D The formulation of the product E The warning ‘Keep out of the reach and sight of children’

Answer 30

It is a legal requirement for the following to appear on dispensed medicinal products:* Name of the patient* Name and address of the supplying pharmacy* Date of dispensing* Name of the medicine* Directions for use* Precautions relating to the use of the medicine.The Royal Pharmaceutical Society also recommends the following also appears on the dispensing label:* ‘Keep out of the reach and sight of children’* ‘Use this medicine only on your skin’ where applicable

Question 31

A 31-year-old woman has been seizure free for the past two years and would like to stop treatment with anti-epileptic medication. Her GP calls you to ask for your advice on how to stop treatment effectively. Which of the following statements with regards to withdrawing anti-epileptic therapy is most appropriate to advise the patient’s GP? A The decision to withdraw should be based on long term risks associated with the medicine B The patient must be seizure-free for at least six years C Withdraw antiepileptic drugs gradually over a period of 3–4 weeks D Withdraw benzodiazepines over a period of 1 month E Withdraw one drug at a time if on multiple regime

Answer 31

Withdrawal ofanti-epileptics should be undertaken one at a time if the patient is on a multiple regime. Avoid abrupt withdrawal, particularly of barbiturates and benzodiazepines, because this can precipitate severe rebound seizures. Reduction in dosage should be gradual and, in the case of barbiturates, withdrawal of the drug may take months.The minimum time frame for withdrawing treatment is 2 years. The decision to withdraw medication should be taken by the patient, their family, and the specialist after a full discussion of the risks and benefits of withdrawal

Question 32

A patient comes into the pharmacy with a private controlled drug prescription for 28 tablets of temazepam. The prescription is dated 31st May 2022, today’s date is 3rd June 2022. What details of the supply DO NOT need to be recorded in the prescription only medicines (POM) register? Answer options A Brand of temazepam prescribed B Date of supply C Formulation of the temazepam D Prescription date E Prescriber details

Answer 32

Brand Date of supply, prescription date, medicine details (name, quantity, formulation and strength), prescribed details and patient details should all be recorded in the POM register.

Question 33

A 52-year-old man has recently started a new job role that requires extensive use of the computer, which has resulted in his eyes feeling dry, irritated and sometimes watery. He reports that he also suffers from occasional hay fever, which mainly causes a runny nose Which of the following options would be the best for the patient? A Advise him to avoid the outdoors on days where pollen counts are high B Refer him to an optician C Sell hypromellose 0.3% eye drops D Sell loratadine 10 mg tablets E Sell Xailin (white soft paraffin, white mineral oil, lanolin alcohols) eye ointment

Answer 33

Hypromellose Dry eyes with a known cause such as excessive use of computer screens does not necessarily warrant a referral to another healthcare professional, thus option Bis incorrect. Xailin eye ointment is not the best choice as ointment use can cause temporary blurred vision following administration and is generally recommended at night. Thus, this may not be ideal for the patient who is likely to be working during the day.Loratadine and avoiding the outdoors would support hay fever symptoms, however these are not the patient’s principal problem and reason for visiting the pharmacy. The question also outlines that he only has a runny nose from hayfever. Note that his eyes sometimes feel watery which can be a symptom of hayfever, however dry eyes can over stimulate the lacrimal eye glands and cause watery eyes

Question 34

A 35-year-old woman has been prescribed a medication for the management of an autoimmune condition. She has been advised to use effective contraception during treatment and for at least 6 months after the treatment ends. Which of the following medication is likely to have been prescribed? A Azathioprine B Methotrexate C Mycophenolate D Sulfasalazine E Tacrolimus

Answer 34

When taking methotrexate,the manufacturer advises effective contraception during and for at least 6 months after treatment in men and women.Contraceptive precautions should be advised whilst either partner is receiving azathioprine. Male patients or their female partner should use effective contraception during treatment with mycophenolate and for 90 days after discontinuation.Patients should be advised to use contraception during treatmentwith sulfasalazine.Patients should be advised to use a reliable means of contraception during and for at least three months after treatmentwith tacrolimus.

Question 35

You have been asked to conduct an audit about the prescribing and administration of antibiotics on your hospital ward so that you can identify areas for improvement. You have set yourself an aim of identifying whether local prescribing protocols are being met. Which of the follow processes is most appropriate to complete as part of an audit cycle? A Collecting data on the prescribing of antibiotics B Gaining ethics approval for the audit C Investigating errors associated with the prescribing of antibiotics D Re-auditing the prescribing of antibiotics after a one-month period E Updating your local prescribing protocols before you conduct the audit

Answer 35

Data collection is a key step in an audit cycle. Collecting and analysing data on the administration of medicines will provide evidence of whether standards are being met and enable you to achieve your aim.Ethics approval is not usually required for audits, however if your evaluation includes patients, you may require approval. If in doubt check with the National Institute for Health and Care Research (NIHR) Also looking for errors is not usually part of audit/improvement process. It is good practice to re-audit after a certain period, however doing this after one month would be too soon and is unlikely to provide new or useful results. It is unusual to update guidelines and protocols before an audit takes place. This may be a recommendation you action after the audit.

Question 36

A 28-year-old woman suffering from abdominal pain and dyspepsia has been diagnosed with a gastric ulcer. Which one of the following medicines is contraindicated in women of childbearing age unless effective contraception is used? A Cimetidine B Lansoprazole C Misoprostol D Pantoprazole E Ranitidine

Answer 36

Misoprostol should not be used in women of childbearing potential unless pregnancy has been excluded. It can be used to terminate pregnancies

Question 37

A patient has recently been diagnosed with polycystic ovary syndrome (PCOS) and has been prescribed metformin 500mg once daily for one week initially by her specialist. She has read the patient information leaflet, which states that metformin is licensed for the treatment of diabetes. She is concerned by this as she has not been diagnosed as diabetic. Which one of the following would be the most appropriate response? A Advise her not to take the metformin B Advise her that an error has been made C Advise her that metformin is licensed for the treatment of diabetes, but can also be used for the treatment of PCOS D Advise her that a lot of women with PCOS get diabetes so metformin is used to prevent this E Advise her to continue taking the metformin but to see her GP as soon as possible to check if the prescription was correct

Answer 37

C Metformin is used for the treatment of PCOS, but is not licensed for this indication, as oftenwomen with PCOS also have insulin resistance

Question 38

A patient was admitted into hospital for coronary bypass surgery. A parenteral nutrition bag was mistaken for a cardioplegic solution for the coronary bypass surgery resulting in a significant medication error. Following this medication error, the hospital pharmacy conducted a root cause analysis. Which of the following is the most appropriate action regarding a root cause analysis in this case? A A root cause analysis is inappropriate to be used in this case B A root cause analysis should be used to confirm that a medication error has taken place C A root cause analysis should be used to identify all factors that could have contributed to this error for analysis D A root cause analysis should be used to identify the pharmacist who made the error E A root cause analysis should be used for indemnity insurance purposes

Answer 38

C A root cause analysis is not intended to focus on blame but on all factors that could have been related to this error and therefore prevented by better systems. Factors might include training of pharmacist and technicians, the label,etc

Question 39

A 56-year-old man presents himself at the pharmacy you are working in. He would like some painkillers after hurting his ankle playing football. He is weight bearing although limping slightly. He has tried nothing so far for the pain in his ankle. You ask the patient if he is on any regular medication, he tells you he takes: * Multivitamins * Omeprazole 20mg once daily * Folic acid 5mg daily (four-month course) * Symbicort turbohaler two puffs twice a day and when required A Refer him to the GP for assessment B Refer him to the walk-in centre for urgent assessment C Sell him a diclofenac 2.32% gel and advise him to rest the joint. D Sell him ibuprofen 400 mg tablets and advise him to rest the joint E sell him paracetamol 500mg tablets and advise him to rest the joint

Answer 39

E This patientdoes not need referring to the GP or the walk in centre as he is able to weight bear, which indicates that an over the counter medicine will be able to help him manage his symptoms. The patientis usinga symbicort inhaler, on aSMART/MART regime which indicates he has respiratory disease such as asthma or COPD,therefore an NSAIDsuch as ibuprofen or diclofenacwould not be the most appropriate. Also, he is taking omeprazole which indicates that NSAIDs, in particular, ibuprofen,would not be suitable.

Question 40

A 40-year-old woman visits your community pharmacy and asks to purchase travel sickness tablets, as she is going on a long-haul flight next week. The counter assistant tells you that she has hypertension, type 2 diabetes and occasional back pain, which are all adequately managed by her regular medication. Which of the following options are you most likely to take next? Answer options A Advise to drink plenty of fluids half an hour before her planned journey B Refer the patient to her GP to have a medicine prescribed C Sell a pack of 12 hyoscine hydrobromide 300 microgram tablets D Sell a pack of 20 hyoscine butylbromide 10 mg tablets E Sell a pack of 100 cinnarizine 15 mg tablets

Answer 40

C The patient’s medical conditions do not interfere or relate to travel sickness and thus can be supported without referral. Hyoscine HYDRObromide is used for travel sickness and available to purchase without a prescription and is the most appropriate option.Cinnarizine 15 mg tablets are also suitable and indicated for travel sickness, however this pack size is not reality available as a P medicine(usually sold as Stugeron 15, pack size 15), and selling a pack of 100 is excessive. You may have also chosen to sell hyoscine butylbromide 10 mg tablets, however hyoscine butylbromide is licensed to treat abdominal cramps/spasms and IBS like symptoms. Encouraging fluid consumption is unlikely to prevent travel sickness, thus is not a suitable cause of action for the patient

Question 41

A 28-year-old woman has recently undergone surgery to insert a metallic heart valve. She needs to be prescribed an anticoagulant to manage the risk of thrombosis on the valve and possible embolism. Which of the following medicines is the most appropriate option for this patient? A Apixaban 2.5 mg twice daily B Aspirin 75 mg daily C Clopidogrel 75 mg daily D Rivaroxaban 20 mg daily E Warfarin 5 mg daily

Answer 41

Warfarin is commonly prescribed as prophylaxis in patients with prosthetic valve replacements and is the only medicine from the list of options indicated for this use. It should be taken initiallyat a dose of5–10 mgon day 1, andsubsequent doses should be adjusted dependent the patient’s INRreading. The recommended target INR depends on the type and location of the valve, and patient-related risk factors.

Question 42

A 33-year-old woman visits your pharmacy and asks to speak to you privately about a sensitive issue. She explains that she is experiencing a sharp pain when going to the toilet. She is finding it difficult to pass stools and on occasions has noticed blood in the toilet. She has been experiencing these symptoms for two weeks. She is otherwise well and does not take any other medication. Which of the following conditions is the patient most likely to be suffering from? A Anal fissure B Constipation C Haemorrhoids D Rectal cancer E Urinary tract infection

Answer 42

The symptoms are suggestive of an anal fissure.Typical symptoms are anal pain which always occurs with passing a stool; the pain is severe and sharp, sometimes described as a tearing sensation,and often followed by deep burning pain that can persists for some hours. Bleeding may also occur with defecation, which is usually seen as a small quantity of bright red blood on the stool or toilet paper.

Question 43

A woman brings a bag of unused medication to your community pharmacy for disposal and informs you that her husband has recently died. You notice fentanyl 25microgram patches amongst the medication. Which one of the following actions regarding the destruction of patient-returned controlled drugs would you take? A Contact an Accountable Officer to witness the destruction B Place on the dispensary shelves while awaiting destruction C Record the destruction in the controlled drug register D The pharmacist can destroy with a pharmacy technician present E Update the controlled drug register balance with the quantity received

Answer 43

D An Accountable Officer is only required to witness the destruction of out-of-date controlled drugs. Patient-returned controlled drugs should be stored in the controlled drug cabinet whilst awaiting destruction, clearly segregated from other stock. The patient-returned controlled drugs received and destroyed should be recorded in a separate register kept for this purpose

Question 44

A 34-year-old woman visits the pharmacy and asks for advice regarding a cold sore that appeared two days ago. She experienced similar symptoms about 3 months ago but did not use anything. She would like to purchase a medicine that may help speed up the recovery for her current symptoms. Which of the following products would be most appropriate to supply to manage the patient’s symptoms? A Bonjela gel (choline salicylate) B Freederm treatment 4% gel (nicotinamide) C Iglu gel (lidocaine hydrochloride monohydrate) D Vaseline (petroleum jelly) E Zovirax 5% cream (aciclovir)

Answer 44

From the list above, Zovirax 5% cream would be the most appropriate product to suggest. Zovirax 5% cream contains aciclovir which can treat herpes simplex virus serotype 1 (HSV-1) of the mouth, lips,and eye. Zovirax 5% is only licensed for the treatment of herpes simplex virus present on the lips and face

Question 45

A 36-year-old man visits the pharmacy for advice on his symptoms. He has just eaten at a new restaurant and now feels wheezy and lightheaded with clammy skin and a fast heartbeat. Upon questioning him about his medical conditions, you find out he has a nut allergy. Question Which of the following actions is the most appropriate to take? A Administer adrenaline to the patient immediately B Advise the patient that you need a prescription to supply adrenaline C Advise the patient to attend accident and emergency immediately D Call 999 for an ambulance immediately E Call NHS 111 for advice on what action to take

Answer 45

Regulation 238 of the Human Medicines Regulations 2012 allows adrenaline to be administered by anyone for the purpose of saving life in an emergency.Therefore,pharmacists using their professional and clinical judgement can administer adrenaline in an emergency to persons presenting with symptoms of anaphylaxis. If a pharmacist administers adrenaline,they must also ensure that an ambulance is called by dialling 999 and reporting that there is a caseof suspected anaphylaxis. Adrenaline should be given as soon as possible so you would administeradrenaline before phoning 999.

Question 46

A 72-year-old woman has been taking methotrexate at a dose of 15mg once weekly for the past two years. She has presented at your community pharmacy today complaining of dark urine. Which one of the following would be the most appropriate course of action? A Advise her that this a normal side effect of methotrexate B Advise her to drink more water as this a sign of dehydration C Ask when she last had a blood test D Refer her to her GP as she is displaying signs of a blood disorder E Refer her to her GP as she is displaying signs of liver toxicity

Answer 46

Dark urine with mix is a sign of liver toxicity, and she should be referred to her GP for urgent assessment

Question 47

A patient is admitted into medical admissions following urgent referral by their GP, as they have symptoms that suggest abnormal potassium levels. The patient’s blood potassium level is taken and are found to be 6.2mmol/L (3.5–5.3mmol/L). Which of the following medicines would be the most appropriate to administer to the patient? A Calcium acetate B Magnesium aspartate C Patiromer calcium D Potassium chloride E Sevelamer

Answer 47

Patiromer calcium is used to manage hyperkalaemia. It is a non-absorbed cation-exchange polymer that acts as a potassium binder in the gastro-intestinal tract.The dose is initially 8.4 g once daily; adjusted in steps of 8.4 g as required. Dose adjustments should be made at intervals of at least one week; maximum 25.2 g per day.Magnesium aspartate isused for hypomagnesaemia.Potassium chloride used for hypokalaemia. Sevelamer and calcium acetate are used for hypophosphatemia.

Question 48

A patient comes into the pharmacy complaining of trouble sleeping since coming off nightshift. They have tried good sleep hygiene techniques, which do not seem to be working. Which of the following is the most appropriate product to recommend? A Cetirizine B Chlorphenamine C Diphenhydramine D Promethazine, paracetamol and dextromethorphan E Valerian extract

Answer 48

Diphenhydramine(Nytol)is the only medication which is licensed for insomnia. The other options are licensed for other conditions and the management of other symptoms.Valerian extract (Nytol Herbal) could also be considered, however there is lack of evidence for its effectiveness compared to medicinal products, therefore is not the most appropriate option in this scenario

Question 49

A patient was started on oral digoxin after not tolerating oral amiodarone. He has been stable on a dose of 125 micrograms once daily for the past four months. His atrial fibrillation is well controlled. The general practitioner calls asking for advice on the most appropriate antibiotic choice. Which antibiotic would most likely precipitate digoxin toxicity in this patient and should be avoided? A Amoxicillin B Flucloxacillin C Clarithromycin D Neomycin E Tetracycline

Answer 49

Macrolides arepotent enzyme inhibitors, causing increased serum levels of digoxin and therefore increasing the likelihood of digoxin toxicity

Question 50

A 54-year-old man with type 2 diabetes requires an add on medication to his metformin, as his HbA1c is not at his agreed target. He has a past medical history of bladder cancer. He is currently overweight and needs to lose around 20 kg. He has no history of cardiovascular disease. Which of the following medicines is most appropriate to prescribe as add on therapy? A Canagliflozin B Gliclazide C Pioglitazone D Repaglinide E Sitagliptin

Answer 50

Based on NICE guidelines, the next step add on therapy (with no history of cardiovascular disease) is a dipeptidyl peptidase-4inhibitor (DDP4), pioglitazone, flozin or sulphonylurea. The patient’s history of bladder cancer rules out pioglitazone; sulphonylureas cause weight gain; and DDP4 are neutral. Therefore, a flozin, such as canagliflozin is the most appropriate as this promotes weight loss, and this patient needsto lose weight. Repaglinide can cause mild weight gain and can be associated with hypo’s so is reserved as a third or fourth line agent for most patients

Question 51

An 84-year-old man has presented to your community pharmacy after feeling increasingly unwell for three days. On further questioning he says that he developed a urine infection a few days ago. Your trainee pharmacist thinks that he may be developing sepsis. Which one of the following options is NOT a symptom of sepsis? A Confusion B Dry non-productive cough C Fast respiration rate D Pale or blotchy skin E Skin rash that does not fade when pressed with a glass

Answer 51

Patients with sepsis will not usually have a dry non-productive cough. However, a productive cough is a symptom of an infection. All of the other symptoms are seen in a patient with sepsis

Question 52

A mother visits the pharmacy and asks to buy ibuprofen for her 5-year-old child who has been suffering from aching limbs and pyrexia since this morning. The child does not take any other medicines and has no other pre-existing medical conditions. What is the most appropriate dose of ibuprofen to be administered three times a day? A 50 mg B 100 mg C 150 mg D 200 mg E 300 mg

Answer 52

C The recommend dose of ibuprofen for a 4-6 year old child is 150mg to be taken three times a day

Question 53

A 66-year-old man started on dapagliflozin 10 mg once a day for two weeks. He has also been taking metformin 500 mg three times a day and gliclazide 40 mg twice a day for the past four years. When collecting his repeat prescription, he complains of having stomach pain, feeling sick and frequent urination in the last few days. His blood sugar level is normal. He believes that the new tablet may be the reason for his symptoms. Which of the following is the most appropriate advice to give to this patient? A He is experiencing a side-effect of dapagliflozin, and whilst safe to continue taking it, he may wish to see his GP for an alternative B He should see his GP as the dose of dapagliflozin may need to be increased C He should see his GP as the dose of dapagliflozin may need to be reduced D He should stop taking dapagliflozin straight away and attend A&E to seek medical treatment

Answer 53

Euglycemic diabetic ketoacidosis (EDKA) is a clinical triad comprising increased anion gap metabolic acidosis, ketonemia or ketonuria and normal blood glucose levels <200 mg/dL.It is considered as a serious adverse effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors. Patient should stop the associated medication and receive urgent medical treatment in hospita

Question 54

A 67-year-old woman with a past medical history of Crohn’s disease would like to purchase a product over-the-counter for a sore throat. She tested positive for coronavirus 6 months ago but has fully recovered. The patient feels well in herself and takes the following medication: * Amlodipine 10mg once daily * Lansoprazole 15mg once daily * Sulfasalazine 1g four times a day * Perindopril erbumine 4mg once daily A Do not treat; see GP if unresolved within 7 days B Refer to accident & emergency (A&E) C Refer to GP urgently D Sell Chloralieve lozenges (lidocaine/amylmetacresol); see GP if unresolved within seven days E Sell Strefen lozenges (flurbiprofen) and advise having regular warm drinks

Answer 54

Refer to GP urgently Sulfasalazine can cause blood disorders -patients receiving aminosalicylates, and their carers, should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever, or malaise that occurs during treatment.

Question 55

A 67-year-old man has chronic obstructive pulmonary disease (COPD). He was admitted with SpO2 87%, purulent sputum, cough, and shortness of breath. He has been diagnosed with an infective exacerbation of COPD. The patient is treated with 2 L oxygen, and prescribed prednisolone 30 mg for 5 days. He also needs to be initiated on an antibiotic. He has no known allergies. Which of the following would be the most suitable first-line antibiotic for this patient? A Co-amoxiclav B Co-trimoxazole C Doxycycline D Levofloxacin E Piperacillin with tazobactam

Answer 55

For adults aged 18 years and over, the first-choice antibiotic for the management ofaninfective exacerbation of COPDareamoxicillin, doxycyclineor clarithromycin. Doxycycline is prescribed at a dose of 200 mg on first day, then 100 mg once a day for 5‑day course in total.

Question 56

A 5-year-old boy is an inpatient on the cardiology intensive care ward. He is on several medications. His recently blood results reveal high potassium levels. Which of the following medications is most likely to have cause his potassium levels to be elevated? A Bisoprolol B Clonidine C Glyceryl trinitrate D Paracetamol E Spironolactone

Answer 56

Spironolactone is the only medicine listed which can cause hyperkalaemia. Spironolactone, as a competitive aldosterone antagonist, increases sodium excretion whilst reducing potassium loss at the distal renal tubule. It has a gradual and prolonged action.

Question 57

A patient has come into the pharmacy with a four-week prescription for ciprofloxacin 500mg tablets for prostatitis. Upon checking the patient’s medical record, you note an interaction between a pre-existing medication and their ciprofloxacin. Which of the following medicines is most likely to interact with ciprofloxacin? A Bisoprolol B Ibuprofen C Omeprazole D Paracetamol E Ramipri

Answer 57

Ibuprofen interacts with ciprofloxacin to reduce seizure threshold. This is listed as a severe interaction and the manufacturer advises caution

Question 58

Your pharmacy dispensing technician is confused about record keeping requirements for the supply of medicines and asks you about situations where records are required and not required. Which of the following scenarios does not require an entry to be made in the prescription only medication (POM) register? A You make an emergency supply of metformin tablets at the request of a doctor B You make an emergency supply of a salbutamol inhaler at the request of a patient C You make a supply of amlodipine tablets prescribed on a veterinary prescription D You make a supply of morphine tablets prescribed on an NHS prescription E You make a supply of salbutamol inhalers requested on a written order signed by the principal or head teacher

Answer 58

Medicines prescribed on NHS prescriptions do not need to be recorded in a POM register, however in this case, a controlled drug register entry is legally required because morphine tablets are a Schedule 2 controlled drug. Lower strengths of morphine, such as morphine oral solution 10 mg/5 mL (Oramorph), are Schedule 5 controlled drugs, which does not need to be recorded in the controlled drugs register.Although the supply of salbutamol inhalers on a written order does not require POM register it is good practice for audit purposes

Question 59

A 77-year-old woman with type 1 diabetes is getting forgetful. She has a carer who visits once a day to help her with her medication. Which of the following insulins is suitable for once daily administration? A Humalog (insulin lispro) B Humalog mix 50 C Levemir (insulin determir) D Novomix 30 E Novorapid (aspart insulin)

Answer 59

Levemir (Insulin detemir)

Question 60

You are working in a community pharmacy clinically screening prescriptions when you come across a prescription for: Trimethoprim 200mg tabs x 14 Take one twice a day You note from the patients PMR that they are also prescribed the following medications: Methotrexate 15mg once weekly Folic acid 5mg once weekly on a different day to methotrexate You identify an interaction between the patient’s medicines and decide to contact the patients GP surgery. What is the most likely consequence of the interaction?

Answer 60

Trimethoprim is another anti-folate drug and concomitant use can result in bone marrow suppression resulting in life threatening infections, anaemia or spontaneous severe bleeding.

Question 61

A 79-year-old woman comes into your pharmacy. She has osteoporosis and has been in hospital for 8 weeks due to a hip fracture and has been discharged on co-codamol 8/500mg tablets. She would like to take a medication to help strengthen her bones to reduce the risk of another fracture. Which would be the most appropriate medication to recommend to this patient? A Ascorbic acid 500mg tablets B Calcium carbonate and colecalciferol (Adcal-D3) tablets C Folic acid 400 micrograms tablets D Glucosamine 500mg tablets E Multivitamin capsules BPC

Answer 61

Calcium and colecacliferol (vit D) are recommend for people at high risk of osteoporotic fracture.

Question 62

A woman calls your community pharmacy as she is concerned about her husband. He underwent his first cycle of chemotherapy for lung cancer last week and has begun to feel unwell. His symptoms include: lethargy; a temperature of 39°C; complaining of feeling hot and cold. Which of the following would be the best advice to give his wife? A Call 999 for an ambulance as this is a medical emergency B Recommend that if his symptoms do not improve within five days, he should contact his GP C Refer him to his GP for urgent assessment D Refer him to his oncologist for urgent assessment E Sell paracetamol and advise him to drink plenty of fluids

Answer 62

This patient could be exhibiting signs of neutropenic sepsis possibly caused by chemotherapy. Symptoms includedysuria, diarrhoea, aproductive cough,chills, shivers, rigors, a temperature greater than 38°C.Neutropenic sepsis is a medical emergency and he needs to seek medical attention immediately. In this case the fastest option would be to ring 999for an ambulance

Question 63

A 10-year-old girl on the cardiothoracic intensive care unit has been newly prescribed digoxin to be taken in divided doses. She has been taking it for ten days now and her therapeutic drug monitoring level is 2.4 nanograms/mL (normal range: 0.8 - 2.0 nanograms/mL). Which of the following would be the most appropriate advice to provide the medical team in regard to this patient’s digoxin level? A The level is within range and the dose does not need adjusting B The level is too high and the dose needs decreasing C The level is too high and the time between doses needs increasing D The level is too low and the dose needs increasing E The level is too low and the time between doses needs decreasing

Answer 63

B- Digoxin level is out of range too high and therefore the dose will need decreasing

Question 64

A 52-year-old man has been admitted into hospital with non-severe cellulitis of the lower limb. He is a type 2 diabetic. The junior doctor would like to prescribe a course of oral antibiotics. The patient is allergic to penicillin (widespread rash).Which of the following antibiotics would be most suitable for this patient? A Cefuroxime BCephalexin C CoAmoxiclav D Doxycycline E Flucloxacillin

Answer 64

Doxycycline is most suitable for this patient due to their allergies.Both flucloxacillin and co-amoxiclav are penicillin antibiotics, therefore are not appropriate for this patient.Cefuroxime is only available as intravenous preparation and the pharmacology is similar to penicillin, which may not be suitable in a true allergy. Cephalexin is available as an oral formulation but is a cephalosporin, which may result in a cross-sensitivity reaction, and should be used with caution

Question 65

A regular patient comes in and asks for advice regarding their pet. They explain that they have run out of repeat medication for their cat and would like some more. They show you an empty bottle of hypromellose eye drops that they administer to their cat. Which of the following actions is most appropriate to take in response to the request? A Sell the hypromellose eye drops and advise the patient to continue the treatment until the symptoms have eased in their cat B Sell the hypromellose eye drops and advise the patient to phone the vet to confirm how long to use the medicine for C Refuse the supply and advise the patient to contact the vet for a further supply of hypromellose eye drops D Supply hypromellose eye drops as an emergency supply and make a record of this on your patient medication record (PMR) E Supply hypromellose eye drops as an emergency supply and make a record in the prescription only medicines (POM) register

Answer 65

You should refuse the request and refer the individual to the vet.It is not legal to make an emergency supply in this situation, also the licensing of P and GLS products is for human use not animals and pets. It should be noted thatthedose in humansis not equivalent to in doses of medicines used in animals; and a vet would be the most appropriate person to advise on clinical appropriateness. Furthermore, there are specific labelling requirements for veterinary products when the prepared medicine is for animal use, which has been prescribed by a veterinary practitioner under the cascade.

Question 66

A 58-year-old man has been admitted to hospital and diagnosed with herpes zoster (shingles). He is recommended to start oral aciclovir treatment by the microbiologist. His current eGFR result is 20mL/min. The patient’s doctor asks you about the most suitable dose of oral aciclovir for this patient. Information from the BNF about aciclovir has been provided here: https://bnf.nice.org.uk/drug/aciclovir.html Which of the following doses are you most likely to recommend to the doctor? A 400mg every 8 hours continued for 2 days after crusting of lesions B 800mg every 12 hours for 7 days C 800mg every 8 hours for 7 days D 800mg 5 times a day for 7 days E 800mg 5 times a day continued for 2 days after crusting of lesions

Answer 66

C

Question 67

A 33-year-old woman is due to undergo cholecystectomy, a major surgery in 2 months’ time. She is currently taking a regular contraceptive that should be stopped at least 4 weeks before the procedure. Which of the following contraceptives is the patient likely to be taking? A Desogestrel 75 microgram tablets B Intrauterine copper device C Levonorgestrel 150 microgram/ethinylestradiol 30 microgram tablets D Levonorgestrel 1500 microgram tablet E Ulipristal 30mg tablet

Answer 67

Levonorgestrel/ethinylestradiol is a combined hormonal contraceptive which increases the risk of thrombosis in patients undergoing major surgery and should be discontinued at least 4 weeks prior to major surgery.Progestogen-only pills, injections, implants, and intra-uterine systems are suitable for use as contraceptives in females undergoing surgery. Combined hormone contraceptive may be recommenced 2 weeks afterfull remobilisation

Question 68

You are looking after a patient who is recovering from a total hip replacement. He has lost a considerable amount of weight because of the surgery and is on enteral feeds. His nurse asks you for advice on how to administer his next phenytoin dose. Which of the following would be the most appropriate advice to give the nurse? A Administer the feed immediately after the phenytoin dose B Consider using an alternative anti-epileptic that does not require administration changes C Consult the dietician for advice D Interrupt feeding for four hours before and after dose E Interrupt feeding for two hours before and after dose

Answer 68

Patients who receive enteral feeding preparations have lower than expected phenytoin levels, reducing seizure control.Therefore, the feed must be interrupted for two hours before and after phenytoin doses.Closer monitoring of levels is required

Question 69

patient suffers from depression and has recently been started on amitriptyline tablets. He received some blood reports from his GP and would like to discuss them with you as this is the third time that he has had experienced a fall since initiating amitriptyline. You note that his results summary specifies that he does not have postural hypotension. Which of the following readings will you review closely - Blood glucose - Blood Pressure - Phosphate levels - Respiratory rate - Sodium Levels

Answer 69

Antidepressants are known to cause hyponatreamia which can caused falls

Question 70

A 38-year-old woman presents to your community pharmacy with increased frequency of urination particularly at night, a burning sensation when urinating and foul-smelling urine. Which one of the following is the most likely causative organism of her infection? A Escherichia coli B Haemophilus influenzae C Pseudomonas aeruginosa D Staphylococcus aureus E Streptococcus pneumoniae

Answer 70

E coli

Question 71

39-year-old man with uncomplicated dyspepsia has undertaken a Urea (13C) breath test for H.pylori and the result is positive. He does not have any allergies and has not previously used any antibiotics. It is his 40th birthday in 2 days’ time and he is having a party to celebrate and would like to be able to have an alcoholic drink at this. Which of the following is the most appropriate treatment regime for this patient? A Proton pump inhibitor plus amoxicillin plus clarithromycin B Proton pump inhibitor plus amoxicillin plus metronidazole C Proton pump inhibitor plus bismuth subsalicylate plus metronidazole plus tetracycline D Proton pump inhibitor plus clarithromycin plus metronidazole E Proton pump inhibitor plus clarithromycin plus tetracycline

Answer 71

The patient does not have a penicillin allergy and has no previous history of antibiotic use therefore oral first line no penicillin allergy treatment would be appropriate (PPI plus amoxicillin and either clarithromycin or metronidazole). As he would like to be able to drink at his birthday party, it would be more appropriate to use clarithromycin than metronidazole.Tetracycline is only recommended as second line treatment where previous antibiotic therapy has been used

Question 72

A mother has brought her 4-year-old daughter to A&E with a suspected case of meningitis. The child has a rash with tiny purple spots that are firm when pressure has been applied. She is lethargic and has a temperature of 39 °C. It is noted the child has previously had an immediate anaphylactic reaction to penicillin and cephalosporins. You are the on-call hospital pharmacist and have been asked to recommend an appropriate antibiotic for this patient. Which of the following antibiotics would be the most appropriate to recommend for this patient? A Benzylpenicillin IV B Cefotaxime IV C Chloramphenicol IV D Teicoplanin oral E Tigecycline IV

Answer 72

C For the treatment of meningococcal diseases benzylpenicillin is recommended, cefotaxime (if allergic to penicillin). If there is history of immediate hypersensitivity reaction (including anaphylaxis, angioedema, urticaria, or rash immediately after administration) to penicillin or to cephalosporins, chloramphenicol can be used.Tigecycline (tetracycline antibiotic) is contraindicated in children under the age of 8 years old due to the risk of deposition in growing bones and teeth.Teicoplanin should not be given by mouth for systemic infections because it is not absorbed significantly. It is also not indicated to treat meningitis.

Question 73

Which of the following conditions would lead to you refusing the sale and supply of sildenafil? A Asthma B Diabetes C Hypercholesterolemia D Mild renal impairment E Unstable angina

Answer 73

E There are several precautions for the sale and supply of sildenafil. Contraindications for use of sildenafil includesevere cardiovascular disorder such as recent (6 months) acute myocardial infarction (AMI) or stroke, unstable angina, or severe cardiac failure, sexual activity may be inadvisable.These patients should be referred this their GP, even if they have been prescribed his previously to ensure that they can resume sexual activity. Consider referring the patient if they are already using a different dose of sildenafil, or a different treatment for erectile dysfunction.

Question 74

The patient mentions that he also takes other medication. He is also suffering from an ear infection and has been taking some antibiotics. He wants to ensure that he can take sildenafil at the same time as the antibiotics. Which of the following is most likely to result in a serious drug interaction? A Amoxicillin B Ciprofloxacin C Co-amoxiclav D Erythromycin E Metronidazole

Answer 74

Sildenafil metabolism is principally mediated by the cytochrome P450 (CYP) isoforms 3A4 (major route) and 2C9 (minor route). Therefore, inhibitors of these isoenzymes may reduce sildenafil clearance and inducers of these isoenzymes may increase sildenafil clearance.Both sildenafil and erythromycin prolong the QT interval. This noted as a severe interaction and most manufacturers advise avoiding the use of two or more drugs that are associated with QT prolongation.

Question 75

A 34-year-old man is taking moclobemide 150 mg twice a day for depression and has recently been prescribed amitriptyline 25 mg for neuropathic pain. In the next few days, the patient presents with tremor and mental confusion and is rapidly deteriorating. His partner asks if the tremor is a sign that his epilepsy is no longer under control and whether this could be linked with his binge drinking. Which one of the following is the most likely cause of the patient’s symptoms? A Absence seizure B Encephalopathy C Hypomania D Liver cirrhosis E Serotonin syndrome

Answer 75

presenting symptoms suggest a drug interaction. Simultaneous administration of amitriptyline and moclobemide may cause serotonin syndrome (a combination of symptoms, possibly including agitation, confusion, tremor, myoclonus, and hyperthermia). The interaction is listed as severe and the manufacturer advised to avoid concomitant use.

Question 76

You have started work in the medicine information department at your local hospital. You have received a query about biosimilar medicines. Which of the following statements is the most accurate description of a biosimilar medicine? A A biosimilar is a medicine developed to treat a similar disease category as the original product B A biologic medicine that is similar to an already licensed biologic medicine in terms of quality, safety and efficacy C A biologic medicine that is similar to an unlicensed biologic medicine in terms of quality D A biologic medicine that is similar to an unlicensed biologic medicine in terms of safety E A biologic medicine that is similar to an unlicensed biologic medicine in terms of safety and efficacy

Answer 76

B A biosimilar is a biologic medicine that is similar to an already licensed biologic medicine in terms of quality, safety and efficacy. A biosimilar is specifically developed and licensed to treat the same disease(s) as the original innovator product. A biosimilar can only be marketed after the patent protecting the originator product and anyperiod of marketing exclusivity have expired.

Question 77

A 38-year-old man with type 2 diabetes visits your community pharmacy to collect his repeat medication. You overhear him conversing with the counter assistant about ulceration on his left foot. Which one of the following options would be the most appropriate action to take? A Offer the patient a foot care leaflet and sell Flexitol (urea 25%) foot cream B Refer the patient to the foot protection service C Refer the patient to his GP for a review of his diabetes medication D Review the patient’s lifestyle and encourage him to buy more comfortable footwear

Answer 77

B Poor diabetes control can increase the likelihood of foot infections due to neuropathy–a long-term complication of type 2 diabetes. The patient should be referred to the foot protection servicefor review of the patient’s foot symptoms and appropriate management.It is also important to refer the patient to their GP for a review of their medicines and to request blood glucose levels to ensure adequate glycaemic control, however this is a secondary intervention; foot ulceration should be the prime concern here.The other listed options are not appropriate as they will not adequately manage the symptoms or could make them worse.

Question 78

You are a GP practice pharmacist conducting an asthma review. The adult patient you are currently reviewing is still symptomatic despite being on salbutamol 100microgram inhaler one to two puffs when required and a Qvar 100microgram inhaler two puffs twice a day. You have confirmed they have the appropriate inhaler technique, so it is decided to step up treatment. Which of the following medicines would be the most appropriate to add on to this patient’s treatment? A Inhaled fluticasone B Oral montelukast C Oral prednisolone D Oral theophylline E Replace Qvar inhaler with Fostair (beclomethasone/formoterol)

Answer 78

E According to the BTS/SIGN guidelines you would add an inhaled LABA (salmeterol) to low or medium dose ICS as initial add on therapy for asthma managemen

Question 79

What is the MOA of trimethoprim A Trimethoprim attacks fungal microbes to begin with by facilitating the killing of bacterial micro-organisms B Trimethoprim binds to the 50s ribosomal subunit of bacteria which disrupts protein synthesis, this causes changes in the cell wall surface, this in turn aids intracellular killing or organisms C Trimethoprim inhibits bacterial cell wall synthesis resulting in bactericidal activity D Trimethoprim is a broad-spectrum antibiotic and is used when the causative organism is unknown E Trimethoprim kills bacteria by stopping them converting folic acid, which they need to survive

Answer 79

E Trimethoprim is a dihydrofolate reductase inhibitor which affects the nucleoprotein metabolism of micro-organisms by interference in the folic-folinicacid systems, inhibiting the conversion of bacterial dihydrofolic acid to tetrahydrofolic acid, required for the synthesis of some amino acids.

Question 80

You are a prescribing pharmacist operating a minor ailments clinic. A 26-year-old woman presents with urinary urgency and a burning sensation upon passing urine. A urine dipstick test is positive for nitrites and reveals moderate amounts of leukocytes in the urine. Based on your clinical assessment, you diagnose the patient with a lower urinary tract infection. She is currently 10 weeks pregnant and has a mild penicillin allergy (rash); she takes no regular medication. Her eGFR has been recorded at >90 mL/min. Which of the following would be the most appropriate antibiotic for this patient? A Amoxicillin 500 mg 3 times a day for 7 days B Cefalexin 500 mg twice a day for 7 days C Nitrofurantoin MR 100 mg twice a day for 7 days D Pivmecillinam 400 mg for 1 dose, then 200 mg 8 hourly to a total of 10 tablets E Trimethoprim 200 mg twice a day for 3 days

Answer 80

C Nitrofurantoin is usually first choice andshould be prescribed for 7 days in pregnancy (additional info: Nitrofurantoin should be avoided at term (36-42 weeks)). Amoxicillin &pivmecillinamwould be inappropriate due to penicillin allergy.Manufacturers advise to avoid trimethoprim during pregnancy, particularly in the first trimester due risk of teratogenicity. Cefalexin is safe to use in pregnancy and duration of 7 days is appropriate for pregnant womenbut there is around a 10% a risk of allergy in cephalosporins with penicillin-allergic patients. Although the previous reaction was mild, cefalexin is best avoided in this patient

Question 81

An 86-year-old man has been admitted into hospital with repeated falls. You take a medication history and begin to review his medication. His sitting and standing blood pressure is taken and is within normal range. Which of the following is the most likely medication to have caused the patient’s repeated falls? A Allopurinol 100 mg tablets B Bisoprolol 1.25 mg tablets C Calcichew D3 forte tablets D Hyoscine butyl bromide 20 mg tablets E Temazepam 20 mg tablets

Answer 81

Tempazepamis a benzodiazepine which causes sedation and drowsiness and is the most likely cause of this man’s falls. Calcichew and allopurinol are unlikely to cause falls in this patient. Hyoscine butyl bromide is mildly anticholinergic which may increase his anticholinergic burden leading to falls. Bisoprolol is an antihypertensive but at a low dose and this patient’s blood pressureis normal so unlikely to be the cause of falls.

Question 82

A 38-year-old woman is diagnosed with ulcerative colitis following a raised faecal calprotectin result and thus a referral to the gastroenterology team. Following the referral, the secondary care team conducted a colonoscopy as the next investigation. Which of the following would they most likely see on the imaging for this diagnosis? A Continuous full thickness from the mouth to the anus B Full thickness from the mouth to the anus but not continuous C Full thickness inflammation in the oesophagus D Inflammation and continuous partial thickness in the rectum that extends through the colon E Partial thickness and inflammation in the oesophagus with fistulae and/or abscesses

Answer 82

D- Adiagnosisofulcerative colitiscan be confirmed by examining the level and extent of bowel inflammation