RPS24

Question 1

First line treatment for Ringworm

Cetrizine 10mg tabs
clotrimazole 1% cream
Clotrimazole HC cream
Fluconazole 150mg capsule
Miconazole 2% powder

Answer 1

Clotrimazole 1%

Question 2

A 62 year old man has been prescribed doxorubicin for bladder cancer. He was informed his urine may become discoloured but that change is normal. Which colour is most likely
Blue
Brown
Green
Orange
Red

Answer 2

Urine may be pink or red for up to 48 hours after treatment. This is usually because of the colour of doxorubicin. It is not harmful.

Question 3

A 32-year-old woman has been prescribed isotretinoin 20 mg tablets, one tablet twice a day, for severeacne by her dermatologist. She is aware of the risks and is using the medication according to the conditionsof the Pregnancy Prevention Programme.Which of the following statements is true?
A) changes in mood or behaviour are usually self-limiting and will normally pass with chronic use
B) .she should take a pregnancy test one week before the new prescription is issued×
C).the prescriber can write a prescription for 56 tablets
D) The prescription will expire after 12 months
E) Wax epilation is safe once the patient has been drug free for at least 1 month

Answer 3

C
Isotretinoin prescriptions have a 7-day validity and can only be written for a 30 day supply. C is thereforecorrect as it is for 4 weeks

Question 4

56-year-old man recently underwent a health check through his company. They measured his BMI at 30.2kg/m2 and he has a QRISK3 score of 10.8%. He disclosed that he smokes 10-15 cigarettes a day and rarely has time to exercise or cook healthy food due to a demanding job and therefore often orders a takeaway.He does not drink alcohol however the clinician has advised he makes changes to his diet and lifestyle in-order to prevent cardiovascular disease in the future.
- advise the patient that his QRISK is score is too low for a statin
- Drink no more than 14 units per week
- Participate in 150mins of moderate intensity exercise per week
- Recommend nicotine patches alone to support smoking cessation
- Reduce salt intake to less than 8g a day

Answer 4

A – not the best answer as the QRISK score is high enough to qualify for a statin if lifestyle changes are
ineffective.
B – true, but not the best answer as the patient does not drink.
C – correct; 150 minutes of moderate-intensity or 75 minutes of high intensity per week is recommended.
D – not the best answer as patients should be offered two forms of NRT to maximise chances of quitting.
E – 6 g, not 8 g according to national recommendations.

Question 5

A 78-year-old man is prescribed MST Continus® 30 mg ONE tablet TWICE daily for pain but is struggling to
swallow. You have been asked to advise on alternative transdermal preparation.
https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/
See under opioid dose conversion, conversion from oral to transdermal administration, fentanyl
Which of the following strengths of fentanyl patch would provide the equivalent daily opioid dose?

a. fentanyl 12 patch
b. fentanyl 25 patch
c. fentanyl 37.5 patch
d. fentanyl 50 patch
e. fentanyl 75 patch

Answer 5

Fentanyl 25

Question 6

A 65-year-old woman comes into your pharmacy presenting with multiple mouth ulcers that have been
present for 5 days. The woman asks for your advice on what action she should take. She takes the following
medication:
* Paracetamol 1 gram four times a day when required
* Ibuprofen 5% gel to be applied three times a day when required
* GTN 400microgram sublingual spray – two sprays when required
* Ramipril 10 mg once daily
* Nicorandil 10 mg twice daily
Which one of the following would be the most appropriate action to take for the patient?
a. advise her the mouth ulcers will disappear on their own
b. gargle with dispersible aspirin 300 mg
c. refer her to A&E
d. refer her to the GP
e. sell her cetalkonium chloride (Bonjela®)

Answer 6

Refer- Nicorandil can cause serious skin, mucosal and eye ulceration including GI ulcers

Question 7

A 28-year-old man recently received a positive test for H. pylori therefore requires treatment with triple
therapy. He has a severe penicillin allergy.
Which of the following would be the most appropriate regimen?
a. amoxicillin 1 g bd, clarithromycin 500 mg bd, lansoprazole 30 mg bd for 7 days
b. amoxicillin 500 g bd, clarithromycin 500 mg bd, lansoprazole 30 mg bd for 7 days
c. metronidazole 400 mg bd, clarithromycin 500 mg bd, lansoprazole 15 mg bd for 7 days
d. metronidazole 400 mg bd, clarithromycin 500 mg bd, lansoprazole 30 mg bd for 7 days
e. metronidazole 400 mg bd, clarithromycin 500 mg bd, lansoprazole 30 mg od for 7 days

Answer 7

Metronidazole 400mg bd, claritrhomycin 500mg bd, lansoprazole 30mg bd

Question 8

You are a GP practice pharmacist running a respiratory clinic. You are conducting a review with a 33-year-
old woman with asthma. You find that she is struggling with her inhaled corticosteroid metered dose inhaler
and recommend using a spacer device with it.
Which of the following would be the most appropriate advice to give to the patient on how to clean their
new spacer device?
a. place on the top shelf of a dishwasher
b. wash in cold water with mild detergent and air dry at room temperature
c. wash in cold water with mild detergent and dry with a cloth or tea towel
d. wash in warm water with mild detergent and air dry at room temperature
e. wash in warm water with mild detergent and dry with a cloth or tea towel

Answer 8

D

Question 9

A 68-year-old man has recently been diagnosed with type 2 diabetes and has a past medical history of
heart failure. Upon review, the doctor identified that metformin does not adequately control his HbA1C and
therefore would like to intensify his treatment regimen.
Which of the following is the doctor most likely to avoid prescribing?
a. canagliflozin
b. gliclazide
c. glimepiride
d. pioglitazone
e. saxagliptin

Answer 9

Pioglitazone is CI in pts with a hx of HF

Question 10

A 17-year-old girl asks to speak to you in private. She tells you that she had unprotected sexual intercourse
2.5 days ago and would like to buy emergency contraception. Upon questioning, she weighs 75 kg, has
regular periods every 29 days and is on day 21 of her menstrual cycle.
Which of the following would be the most effective approach to pregnancy prevention?
a. refer her to her GP to get a prescription for a double dose of levonorgestrel 1.5 mg tablets
b. refer her to the sexual health clinic for the copper IUD
c. sell ulipristal acetate 30 mg tablets
d. supply a single dose of levonorgestrel 1.5 mg tablets
e. tell her she does not need emergency contraception as there is no risk of pregnancy given the stage
in her cycle

Answer 10

IUD

Question 11

28-year-old woman comes into your pharmacy asking for something for her constipation. She has been
constipated for three days and is experiencing abdominal discomfort as a result. She has tried increasing
the fibre in her diet, and fluid intake and has been going for regular walks. She tells you that she is 28 weeks
pregnant and that the doctor told her she could get a laxative from the pharmacy.
Which of the following is the most appropriate to advise the woman?
a. continue to increase the fibre in her diet, fluid intake and physical activity
b. recommend ispaghula husk sachets
c. recommend lactulose solution
d. recommend senna tablets
e. refer her back to her GP

Answer 11

Bulk forming is firstline when diet and lifestyle advice fails

Question 12

A 56-year-old woman was diagnosed with and prescribed medication for stage two hypertension last
month. The following month, she returns to your pharmacy to collect her repeat prescription but mentions to
you that her ankles look swollen and is wondering whether this may be due to her new medication.
Which of the following drugs would have been most likely to cause this adverse effect?
a. bisoprolol
b. indapamide
c. lercanidipine
d. lisinopril
e. losartan

Answer 12

Lercanidipine
Peripheral oedema is a common side effect of calcium channel blockers. Calcium channel blockers are also
used first line in adults over the age of 55.

Question 13

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

Answer 13

Dantrolene sodium

acetylcysteine – for paracetamol overdose
activated charcoal – e.g. for aspirin poisoning
high flow oxygen – e.g. for CO poisoning
naloxone – for opioid overdose

Question 14

A 32-year-old man has recently been diagnosed with epilepsy. The doctor has advised that he must ensure
he stays on the same brand of anti-epileptic drug to avoid loss of seizure control.
Which of the following drugs should always be prescribed by brand?
a. clonazepam
b. lamotrigine
c. pregabalin
d. primidone
e. valproate

Answer 14

Primidone is in category 1 and for these drugs, doctors are advised to ensure that their patient is maintained
on a specific manufacturer’s brand. This is because they vary in their characteristics.

Question 15

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?
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

Answer 15

C

Question 16

A 33-year old patient has been prescribed mycophenolate mofetil oral suspension following a renal
transplant. She has read on the internet that the medication can cause skin cancer and would like to know
its likelihood.
The SmPC for mycophenolate mofetil oral suspension has been provided below.
Cellcept 500mg Film-Coated Tablets - Summary of Product Characteristics (SmPC) - (emc)
Which of the following best describes the likelihood of the patient experiencing skin cancer?
a. (≥1/10)
b. (≥1/100 to <1/10)
c. (≥1/1,000 to <1/100)
d. (≥1/10,000 to <1/1,000)
e. (<1/10,000)

Answer 16

B

Question 17

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

Answer 17

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.

Question 18

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?
a. amoxicillin
b. lithium carbonate
c. methotrexate
d. rivaroxaban
e. trastuzumab

Answer 18

Trastuzumab is a biosimilar. All biosimilars are black triangle drugs

Question 19

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

Answer 19

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

Question 20

A 20-year-old female asks to speak to you privately. She has been taking repeated courses of antibiotics for
recurrent urinary tract infections and would like some additional advice about preventing further episodes.
You establish that she is sexually active with a male partner and that she is not diabetic.
Which of the following is not appropriate advice for the patient?
a. do not consume sugary beverages
b. pass urine after sex
c. take prophylactic antibiotics to prevent UTIs from occurring in future
d. wear loose fitting, cotton underwear
e. wipe from front to back when you go to the toilet

Answer 20

A – this encourages bacterial growth.
B – urinating after sexual intercourse ensures introduced bacteria are washed away from the urinary tract.
C – inappropriate overprescribing of antibiotics.
D – wear loose, cotton underwear and clothing to keep the area dry and cool.
E – wipe from front to back to avoid introducing bacteria entering the urinary tract.

Question 21

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

Answer 21

A

Question 22

A 56-year-old man has been prescribed vincristine for his leukaemia.
Which of the following is the most appropriate route of administration?
a. intramuscular
b. intrathecal
c. intravenous
d. oral
e. subcutaneously

Answer 22

Administering medication via the correct route reduces the chance of treatment failure Vincristine injections
are for intravenous administration only. Inadvertent intrathecal administration can cause severe
neurotoxicity, which is usually fatal.

Question 23

A 14-year-old boy presents with moderate depression. He has been undergoing cognitive behavioural
therapy for 6 months however his doctor wishes to prescribe him an antidepressant in combination due to
little progress.
Which of the following antidepressant drugs would be the most appropriate?
a. amitriptyline
b. citalopram
c. fluoxetine
d. mirtazapine
e. sertraline

Answer 23

Fluoxetine is licensed and used first line in children who require antidepressants

Question 24

A 62-year-old man has been suffering from abdominal cramps and loose stools for nearly 4 weeks. Upon
further questioning he tells you that there is no blood in his stools but there is some mucus. He does not
recall a change in his diet but has been feeling stressed recently.
Which of the following is the most appropriate advice to give to the patient?
a. make an appointment with your GP for further investigation
b. monitor your symptoms for a further two weeks
c. reduce the amount of fibre in your diet
d. take loperamide capsules at the recommended dose
e. take rehydration salts to replenish any salts lost

Answer 24

Although there is no blood in his stool, there has been a change in bowel habits and, especially at his age,
this warrants further investigation to rule out anything more serious. His symptoms describe irritable bowel
syndrome e.g. abdominal cramps, loose stools, no blood but mucus with stress being the trigger, however
this cannot be confirmed until further tests have been done.

Question 25

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

Answer 25

Acarbose is contraindicated in those who have a hernia as it can worsen the condition. Due to its mechanisms of action, its also contraindicated in those with disorders of digestion or absorption

Question 26

A patient visits your community pharmacy and presents with a problem with their eye. They are surprised that they are otherwise feeling well; you confirm that they are not experiencing any pain, do not have any changes to their vision and that there has been no trauma to the eye or head. Their blood pressure has been well controlled, and they take ramipril 5 mg capsules TWICE daily and amlodipine 10 mg tablets ONCE daily and they are adherent. Which one of the following options best describes the advice you would give? a. offer sodium cromoglicate 2% eye drops b. offer sodium hyaluronate 0.2% eye drops c. refer the patient to an urgent GP centre d. suggest doing nothing; the blood shot appearance should resolve in one to two weeks e. suggest regularly washing the eye with lukewarm water

Answer 26

Blood shot eyes usually resolve by themselves (without treatment) in one to two weeks. napholazine hydrochloride eye drops are available as a GSL medication. Option A is incorrect as sodium cromoglicate is used for itchy eyes caused by hay fever or potential allergy. Option B is incorrect as it is for dry eyes. Option C is incorrect as the scenario doesn’t need urgent referral; their blood pressure is well controlled, therefore its unlikely to have caused a blood shot eye. Option E is incorrect as washing the eye with the lukewarm water is unlikely to benefit the patient. Thus, option D is correct.

Question 27

A 32-year-old man is on his third cycle of chemotherapy and is due to receive doxorubicin by intravenous infusion. You note that he has anaemia, constipation, and nausea. He has previously received doxorubicin with no dose reductions or adverse effects. Which one of the following is most likely to require a doxorubicin dose reduction? a. alopecia b. constipation c. elevated bilirubin d. if the patient is also to receive intravenous tacrolimus e. respiratory depression

Answer 27

C Doxorubicin is metabolised and excreted primarily by the liver. If bilirubin is elevated, it suggests impaired liver function, which can reduce the clearance of doxorubicin, leading to increased toxicity. In such cases, dose adjustments are often necessary to prevent severe adverse effects, such as cardiotoxicity and myelosuppression

Question 28

A 14-year-old patient, weighing 42 kg, requires an iron infusion today. According to trust guidance you are to supply ferric carboxylase (ferinject). Their haemoglobin level returned as 11g/dL. They do not have renal or hepatic impairment. Information about ferinject 50 mg iron/mL has been provided below: https://www.medicines.org.uk/emc/product/5910 Which one of the following options is the correct dose for this patient? a. 84 mg b. 630 mg c. 640 mg d. 840 mg e. 1000 mg

Answer 28

840mg The best way to answer this question is by following the steps outlined in the product specification. Read the question carefully, as ferinject can be given via intravenous infusion and injection; both are given at different doses. The patient requires an INFSUION so dose of 20 mg/kg should be used. The SmPC specifies a maximum of a 1000 mg for injection and infusion. The question, however, says that the dose is to be given today. The worked-out dose does not exceed a 1000 mg, if it did then the dose would be capped at 1000 mg. Therefore, option E is incorrect. Question B is incorrect, 630 mg would be the final answer if the patient was to receive ferinject as an injection, dose of 15 mg/kg.

Question 29

A 6-year-old girl has been diagnosed with epilepsy. She has been prescribed carbamazepine liquid 100 mg/5 mL, at a dose of 30 mL per day to be taken in divided doses. The patient weighs 20 kg. The SmPC for carbamazepine has been provided below. https://www.medicines.org.uk/emc/product/1041 Which one of the following statements about carbamazepine is most accurate? a. dyskinesia is a very rare side effect of carbamazepine b. peak plasma concentrations of the unchanged substance are reached within two hours following a single oral liquid dose of carbamazepine c. studies have shown that children may require lower doses of carbamazepine (in mg/kg) than adults to maintain therapeutic concentrations d. the antidote for carbamazepine is readily available within hospitals e. the patient is on the maximum recommended dose of carbamazepine

Answer 29

The correct answer is: peak plasma concentrations of the unchanged substance are reached within two hours following a single oral liquid dose of carbamazepine

Question 30

A 40-year-old woman has Crohn’s disease and hypothyroidism and has been taking the following medications for the last three years: * Amlodipine 5 mg once daily * Omeprazole 40 mg gastro-resistant capsules once daily in the morning * Prednisolone 5 mg tablets once daily in the morning * Mesalazine modified release tablets (Asacol MR) 2.4 g daily in divided doses * Levothyroxine 75 micrograms once daily She has recently been complaining of feeling unusually tired, constipation, increased sensitivity to the cold and has gained weight. The GP requested blood tests, which returned as the following: thyroid stimulating hormone (TSH): 9.5 mU/L (0.38-5.33 mU/L) free T4: 5.2 pmol/L (7.9 – 14.4 pmol/L) potassium: 4.1 (3.5 – 5.2mmol/L) sodium: 138 mmol/litre (136-145mmol/litre) uric acid: 200 umol/L (140 – 360umol/L). Her blood pressure was 110/67 mmHg. Which one of the following options is the most appropriate action to take? a. increase amlodipine dose to 10 mg once daily and repeat blood pressure in a month’s time b. increase levothyroxine dose to 100 micrograms once daily c. increase prednisolone dose to 7.5 mg once daily and repeat blood test in three months’ time d. reassure her that these are common, non-serious symptoms and arrange to see her in a month’s time if she hasn’t improved e. stop prednisolone and suggest she has another blood test in six months’ time

Answer 30

This question is assessing the signs and symptoms of hypothyroidism and how to link the condition to characteristic blood test results. A high thyroid stimulation hormone result and a low T4 level usually indicates hypothyroidism. A common sign of the condition is feeling tired, gaining weight, increased sensitivity to cold, constipation, dry skin, and puffy face. Urea, electrolytes, and blood pressure readings are a distractor in this question; the results are all normal. Thus, option A is incorrect. Steroids can sometimes cause hypothyroidism and since this patient has been on prednisolone for three years (long term), it may be the case. Thus, option C, increasing prednisolone dose is incorrect. These are not trivial symptoms and readings so waiting a further month is not appropriate. Option E is incorrect as stopping steroids suddenly can cause a flare. Option B is correct; she needs her levothyroxine uptitrated

Question 31

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. Note she takes mesalazine Which one of the following options should the patient avoid? a. bisacodyl b. isphagula husk c. lactulose d. sodium docusate e. sodium picosulphate

Answer 31

Lactulose- Mesalazine interacts with lactulose. might prevent the release of mesalazine. This in turn, can worsen crohn’s disease symptoms or bring about a flare.

Question 32

A high street pharmacy is planning a public health promotion campaign focussing on mental health. Which of the following is best practice for pharmacy staff when carrying out interventions for this campaign? a. assign the same pharmacy colleague to deliver all the sessions of an intervention for a given patient b. make recommendations based on commercial targets c. train to become a mental health first-aider d. use the same general approach for every patient to deliver an intervention e. work independently of other services

Answer 32

To promote continuity of care, when possible, the same staff member should deliver all the sessions of an intervention if more than one session is needed. Interventions should never be carried out based on commercial targets or personal experience, but rather based on national or local guidelines and according to an individual' s needs. All staff involved in the campaign should be trained on the topic and skills needed for its successful delivery. Although training as a mental health aider would be advantageous to the pharmacy team and public, it is not necessary or ‘best practice’ to train as a mental health aider before carrying out interventions for the campaign. A tailored approach should be used when providing community pharmacy health and wellbeing interventions to maximise their impact and effect. Signposting is an integral part of any successful public health campaign and pharmacies should consider establishing a formal referral process with other services such as local GP surgeries.

Question 33

A 54-year-old man visits his GP with acute back pain. He has a family history of cardiovascular disease, has a BMI of 30 kg/m2, and smokes 20 cigarettes per day. His GP would like to prescribe a medicine to manage his pain and asks for your advice. Which one of the following medicines would be most appropriate for this patient? a. celecoxib b. diclofenac c. etoricoxib d. meloxicam e. naproxen

Answer 33

Naproxen (1 g daily) is associated with a lower thrombotic risk, and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction. COX-2 inhibitors, diclofenac and high dose ibuprofen are associated with increased CVD risk.

Question 34

A 72-year-old patient is admitted to the ward urgently with acute kidney injury at the request of their GP following a collapse at the supporting living accommodation where they live. The patient has a history of ischaemic heart disease and is prescribed the following regular medicines: * Isosorbide mononitrate MR 60 mg caps, 1OD * Furosemide 40 mg tabs, 2OM * Ramipril 5 mg caps, 1OD * Aspirin 75 mg tabs, 1OD * Atorvastatin 40 mg tabs, 1ON Three days prior to admission, the patient had been prescribed a new medicine which is suspected to be the reason for the acute kidney injury. Which one of the following medications is the most likely reason for the admission? a. bisoprolol 5 mg tabs b. co-codamol 15/500 tabs c. lansoprazole 30 mg caps d. sildenafil 50 mg tabs e. spironolactone 50 mg tabs

Answer 34

Nephrotoxic drug use within the last week (NSAIDs, ACEi, ARBs and diuretics) is a risk factor for acute kidney injury. Therefore, the most likely drugs to have caused the patients admission is spironolactone.

Question 35

A 25-year-old woman is commencing treatment with an antiepileptic drug. She asks you if there are any precautions she should take. Which of the following medicines requires additional monitoring in accordance with the pregnancy prevention programme? a. carbamazepine b. lamotrigine c. levetiracetam d. phenytoin e. sodium valproate

Answer 35

Sodium Valproate

Question 36

A 32-year-old man presents at your pharmacy with a fever, severe muscle and joint pain, headaches, and a skin rash on his arm. Upon questioning, you discover that the rash has been expanding gradually over the past few days. When his partner measured it a few days ago, it was 3 cm across; it now measures 8 cm. The patient explains that he is an avid hiker and one month ago he spent his holiday camping in the New Forest in the South of England. Which of the following conditions is the patient most likely to be suffering from? a. cellulitis b. lyme disease c. malaria d. psoriasis e. ringworm

Answer 36

The symptoms described are indicative of Lyme disease. * Lyme disease is a bacterial infection that can be spread to humans by infected ticks. Many people with early symptoms of Lyme disease develop a circular red skin rash around a tick bite. * The rash is often described as looking like a bull' s-eye on a dartboard. The rash can appear up to 3 months after being bitten by a tick and usually lasts for several weeks. Most rashes appear within the first 4 weeks.

Question 37

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? 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

Answer 37

Mebendazole is drug of choice to people over the aged of two. It is recommended that all family members should be treated, and a repeated dose should be given.

Question 38

A 38-year-old male presents to your community pharmacy and asks to speak to you privately. He is concerned about itching around his pubic area and tiny red blood spots in his underwear. He denies any discharge from his penis. There are no lesions, pain, or feelings of illness. He confirms that he was sexually active with a new partner 6 days ago and was symptom free before this. Which one of the following is the most likely explanation for his symptoms? a. chlamydia b. genital herpes c. gonorrhoea d. pubic lice e. syphilis

Answer 38

A is incorrect as chlamydia is often symptoms free but, when symptoms are present, they include pain and swollen testicles in males B is incorrect because genital herpes usually presents as blisters and tingling pain C is incorrect as there is no discharge from the penis E is incorrect as early signs include sores on the penis and general unwellness It is likely that the patient has a pubic lice infestation

Question 39

A mother presents to the pharmacy with her 3-year-old child. The sclera of the child’s left eye appears pink and there is an accumulation of yellow/green substance in the corner of their eye. It has been like this for the past day and the child’s eyelids were stuck together in the morning. Which of the following would be the most appropriate action to take in this scenario? a. refer the child to a walk-in centre b. refer the child to their GP c. sell the parent chloramphenicol eye drops d. sell the parent hypromellose eye drops e. sell the parent sodium cromoglicate eye drops

Answer 39

Chloramphenicol can be sold over the counter for children aged 2+ years for acute bacterial conjunctivitis. Referring the child to either the GP or the walk-in would be unnecessary. If it is bacterial then bathing of the eyes would help remove secretions but would not treat the bacteria causing the conjunctivitis. Sodium cromoglycate is a mast cell stabiliser which is used in allergic conjunctivitis so would not be appropriate.

Question 40

A patient presents to your community pharmacy having recently been prescribed ferrous sulphate 200 mg tablets once daily. They have experienced some constipation, which is affecting their adherence and would rather chew the tablet instead of swallowing it whole. They ask for your advice on both points. Which one of the following is the most appropriate advice to give to the patient? a. refer them to their GP b. take lactulose solution regularly; there aren’t any problems with letting the tablet dissolve in the mouth c. take lactulose solution regularly and trial taking the dose on alternate days. Tablets should be swallowed whole d. there is little information available whether tablets can be kept in the mouth, suggest they try swallowing tablets whole e. trial taking the tablets on twice a week; tablets should be swallowed whole

Answer 40

A - is incorrect as this scenario can be dealt with by a pharmacist. B - is incorrect, due to the risk of mouth ulcerations and tooth discolouration, tablets should not be sucked, chewed, or kept in the mouth, but swallowed whole with water. C - is correct, recent update to ferrous sulphate monograph, suggesting that if once daily dosing is not tolerated, to trial giving dose on alternate days. Suggesting a laxative whilst taking iron tablets is sensible. D - is incorrect as there is information available (see BNF or SmPC). E - is incorrect, due to dosing. Thus, option C is correct.

Question 41

You are completing your weekly controlled drug balance check and there is a discrepancy for fentanyl 12 patches and fentanyl 25 patches. Upon investigation, it appears that the fentanyl 25 patches have been supplied to the patient instead of fentanyl 12 patches. Which of the following is the most appropriate initial action to take? a. inform the patient promptly b. inform the persons who supplied the incorrect strength c. offer a formal apology d. supply the correct drug e. tell the accountable officer

Answer 41

Inform patient immediately - avoid overdose

Question 42

A 43-year-old woman presents to your community pharmacy to buy travel sickness tablets. The counter assistant tells you that the patient has hypertension, type 2 diabetes and chronic back pain which are all adequately managed by her regular medication. Which one of the following options is the most appropriate course of action for the patient? a. advise to drink plenty of fluids half an hour before her planned journey b. refer the patient to her GP for advice c. sell a pack of 12 hyoscine hydrobromide 300 microgram tablets d. sell a pack of 20 hyoscine butylbromide 10 mg tablets e. use your independent prescribing qualifications to prescribe domperidone 10 mg tablets to be taken three times daily

Answer 42

The patient’s medical conditions do not interfere or relate to travel sickness and thus can be supported without referral. Domperidone is ineffective in managing travel sickness and thus is not a suitable option. Encouraging fluid consumption is unlikely to prevent travel sickness. Hyoscine butylbromide is licensed to treat abdominal cramps/spasms and IBS like symptoms. Hyoscine HYDRObromide is used for travel sickness and available to purchase without a prescription. Thus option C is correct.

Question 43

A 70-year-old male with atrial fibrillation is prescribed digoxin 125 micrograms ONCE daily and has been stable on this dose for the past 4 months. The patient is severely allergic to penicillin; the GP calls asking for advice for an antibiotic choice for a chest infection. Which antibiotic would most be most appropriate for the GP to prescribe? a. cefalexin b. co-amoxiclav c. clarithromycin d. doxycycline e. piperacillin with tazobactam

Answer 43

A - incorrect because potential cross reactivity with penicillin allergy and as allergy is severe, not worth the risk B - incorrect because penicillin allergy C - incorrect because risk of digoxin toxicity due to interaction D – most appropriate E - incorrect because this is an IV drug and this is a GP asking for advice, who will not easily be able to treat the patient with IV therapy

Question 44

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? 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

Answer 44

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.

Question 45

You are a GP practice pharmacist conducting an asthma review for a 38-year-old man. He is still symptomatic despite treatment with salbutamol 100 microgram inhaler one to two puffs when required and a beclometasone 100 microgram inhaler two puffs twice a day. You have confirmed they have the appropriate inhaler technique and have been using their beclometasone regularly, so you decide to step up treatment to the next step. Which of the following medicines would be the most appropriate to add on to this patient’s treatment? a. inhaled fluticasone b. inhaled salmeterol c. oral montelukast d. oral prednisolone e. oral theophylline

Answer 45

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

Question 46

A father brings his 8-month-old daughter into the pharmacy and would like some advice. She has been experiencing a dry cough that tends to be worse at night. He says she has a barking cough, takes a gasp for breath between coughs, and seems to have noisy breathing. Her father confirms she is up-to-date with the recommended vaccinations. Which one of the following conditions is most likely to be associated with the presenting symptoms? a. asthma b. bacterial upper respiratory tract infection c. bronchitis d. croup e. pertussis

Answer 46

croup Upper Respiratory Tract Infection associated with cold-like symptoms and fever; Asthma unlikely in an 8- month-old and pertussis associated with congestion and vomiting.

Question 47

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? a. 28 days b. 30 days c. 3 months d. 6 months e. 12 months

Answer 47

6 months - sch5

Question 48

A hospital inpatient experiences swallowing difficulties post-operatively and is fitted with a nasogastric tube to facilitate enteral feeding and medication administration. They normally take phenytoin capsules, however this has now been supplied as an oral suspension. 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 48

Interrupt feeding for two hours before and after dose 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 49

A 29-year-old woman is in her first trimester of pregnancy and has been reading about vitamins. She visits your community pharmacy and wants to know if there any vitamins / supplements that she should avoid. Which one of the following options is a vitamin or supplement that this woman should avoid? a. cyanocobalamin b. ferrous sulphate c. vitamin A d. vitamin D e. vitamin E

Answer 49

In view of evidence suggesting that high levels of vitamin A may cause birth defects, women who are (or may become) pregnant are advised not to take vitamin A supplements (including tablets and fish liver oil drops), except on the advice of a doctor or an antenatal clinic; nor should they eat liver or products such as liver paté or liver sausage.

Question 50

A 32-year-old woman has been taking desogestrel 75 microgram tablets once daily for the last three months. She has missed today’s dose by eleven hours and is worried that she may no longer be protected from pregnancy; she last had unprotected intercourse yesterday evening. She is feeling nauseous and has a headache. Which one of the following are you most likely to advise the woman? a. feeling nauseous could be an early sign of pregnancy, suggest that she takes a pregnancy test b. she is no longer protected against pregnancy and must speak with a GP as soon as possible c. take the delayed dose as soon as possible and take the next dose at the usual time d. take the delayed dose as soon as possible and take the next dose two hours earlier than the usual time e. take the delayed dose as soon as possible and to use extra protection for the next 48 hours

Answer 50

C- take the delayed dose as soon as possible and take the next dose at the usual time A is incorrect as nausea can be a side effect of desogestrel tablets; since the patient has been on the contraceptive pill for three months it’s unlikely for her to be pregnant. The scenario also doesn’t tell us that she has missed pills in the past. B is incorrect as, by missing the pill by eleven hours, protection against pregnancy is not lost. D and E are incorrect and not suitable for the scenario described

Question 51

A patient was discharged from hospital following treatment for neutropenia and acute pancreatitis. You are reviewing their discharge medication list and notice that a regular medication of theirs has now been stopped. Which one of the following options is the most likely medication to have been stopped? a. aspirin b. bumetanide c. carbimazole d. levothyroxine e. risedronate

Answer 51

Carbimazole can cause neutropenia. It should not be used in patients with a history of acute pancreatitis associated with previous treatment. Re-exposure may result in life threatening acute pancreatitis with a decreased time to onset. The other drugs listed, do not cause neutropenia and/or pancreatitis.

Question 52

A double-blind, randomised, placebo-controlled trial is conducted to assess the efficacy of a new drug for the treatment of juvenile idiopathic arthritis. Of the 165 patients included, 39% showed an adequate response in the treatment group compared to 20% in the placebo group (P = 0.006). Which of the following conclusions is the most appropriate? a. the number-needed-to-treat to achieve an adequate response is 8 b. the result of this trial is inconclusive as the sample population is too small c. the use of the new drug in juvenile idiopathic arthritis may be supported as there is a significant difference between the placebo group and treatment group d. the use of the new drug in juvenile idiopathic arthritis may not be supported as the results are subject to selection bias e. the use of the new drug in juvenile idiopathic arthritis may not be supported as there is no significant difference between the placebo group and treatment group

Answer 52

The p value of 0.006 is statistically significant so it can be concluded that the results of this trial may support the use of the new drug in juvenile idiopathic arthritis. As this trial has a randomised double-blind design, the chance of selection bias is eliminated. Although the sample population may not be large enough to be reflective of the total population, the results of the trial are still significant, and a conclusion can still be made. A, is not correct: NNT = 1/(0.01*(39-20) = 5.2 (quoted as 6 as NNT is rounded up to a whole person)

Question 53

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 biologic medicine that is similar to an already licensed biologic medicine in terms of quality, safety and efficacy  b. a biologic medicine that is similar to an unlicensed biologic medicine in terms of quality c. a biologic medicine that is similar to an unlicensed biologic medicine in terms of safety d. a biologic medicine that is similar to an unlicensed biologic medicine in terms of safety and efficacy e. a biosimilar is a medicine developed to treat a similar disease category as the original product

Answer 53

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 any period of marketing exclusivity have expired

Question 54

A parent visits your pharmacy to purchase analgesia for their 4-year-old child, who has chicken pox. Which of the following is the most appropriate course of action? a. refer the parent to the GP in order to obtain a free prescription b. sell calamine lotion c. sell ibuprofen 10 mg/5 mL suspension d. sell paracetamol 125 mg/5 mL suspension e. sell Phenergan 5 mg/5 mL oral solution

Answer 54

A is incorrect: The parent is requesting a purchase, there is no need to delay by referring them to the GP and this would not be a good use of the GP’s time. B is incorrect as, even though calamine lotion is used topically for chicken pox, it relieves itching, not pain. C is not correct because ibuprofen should ideally not be used during chicken pox if there is an alternative. D is correct, this is the right strength of paracetamol for the age and paracetamol is an analgesic. E is incorrect as Phenergan® is a sedating antihistamine. It may help with itch but not pain

Question 55

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 20 mL/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 is most appropriate to recommend to the doctor? a. 400 mg every 8 hours continued for 2 days after crusting of lesions b. 800 mg every 12 hours for 7 days c. 800 mg every 8 hours for 7 days d. 800 mg 5 times a day for 7 days e. 800 mg 5 times a day continued for 2 days after crusting of lesions

Answer 55

This patient has renal impairment; therefore, a dose adjustment is required. The BNF states: For herpes zoster, use normal oral dose every 8 hours if eGFR 10–25 mL/minute/1.73 m2 = 800 mg every 8 hours for 7 days

Question 56

A patient with a new diagnosis of atrial fibrillation is being discharged home. They have been commenced on amiodarone. By the time they leave hospital, they will have completed their first week of treatment. Information about amiodarone hydrochloride has been provided below: https://www.medicines.org.uk/emc/product/13964/smpc#gref How many 200 mg tablets will the patient need to be discharged with to ensure they have a month’s supply (28 days) of medication on discharge? a. 35 b. 42 c. 55 d. 72 e. 88

Answer 56

Week 1 = 200 mg x 2 tablets = 2 tablets daily x 7 days = 14 Week 2-4 = 200 mg x 1 tablet = 1 tablet daily = 21 days = 21 14 + 21 = 35 tablets

Question 57

A 62-year-old man informs you he has been prescribed a new medicine for his overactive bladder that requires close blood pressure monitoring. Which of the following medicines has most likely been prescribed for the patient? a. finasteride b. mirabegron c. oxybutynin d. propiverine e. solifenacin

Answer 57

Blood pressure should be monitored before starting treatment and regularly during treatment, especially in patients with pre-existing hypertension with mirabegron. All licensed for overactive bladder apart from A, but no specific requirement regarding BP.

Question 58

Which of the following would most likely lead to suspected diagnosis of type 2 diabetes? a. HbA1c of 44 mmol/mol and fasting plasma glucose of 5.0 mmol/L b. HbA1c of 44 mmol/mol and random plasma glucose of 7.0 mmol/L c. HbA1c of 46 mmol/mol and random plasma glucose of 10.0 mmol/L d. HbA1c of 48 mmol/mol and fasting plasma glucose of 5.0 mmol/L e. HbA1c of 48 mmol/mol and random plasma glucose of 12.0 mmol/L

Answer 58

HbA1c of 48 mmol/mol and random plasma glucose of 12.0 mmol/L

Question 59

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? 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

Answer 59

metformin is only effective in the presence of insulin Metformin exerts its effect mainly by decreasing gluconeogenesis and by increasing peripheral utilisation of glucose; since it acts only in the presence of endogenous insulin it is effective only if there are some residual functioning pancreatic islet cells.

Question 60

A 38-year-old man has undergone a renal transplant and has been taking mycophenolate mofetil. He is now planning on conceiving a child and would like to know what he needs to consider in view of his history and current treatment. Information about mycophenolate mofetil has been provided below: https://www.medicines.org.uk/emc/product/9294 Which one of the following options is the most appropriate advice to give to this man? a. mycophenolate use in males affects fertility b. only a small amount of mycophenolate is passed into sperm; advice to ensure that his partner attends all medical appointments once pregnant, this will help identify any problems early c. suggest stopping the mycophenolate and speak to a family planning clinic for advice d. there is little evidence to suggest that there is an increased risk of malformations following paternal exposure to mycophenolate. Advise to continue with planning for a baby e. use reliable contraception during treatment and for at least 90 days after cessation of mycophenolate mofetil in consultation with his doctor

Answer 60

use reliable contraception during treatment and for at least 90 days after cessation of mycophenolate mofetil in consultation with his doctor

Question 61

A 14-year-old girl recently fell off her rollerblades and wounded her knee. Her mum is a nurse and tells you that the wound has low exudate and there could be a sign of some infection in the area. Information about wound management has been provided below: https://bnf.nice.org.uk/wound-management Which of the following dressings is the most appropriate to use on the patient? a. alginate dressing with silver b. foam dressings c. hydrocolloid dressings d. hydrogel dressings e. iodine dressings

Answer 61

Iodine dressings

Question 62

A 55-year-old man has been taking metformin 500 mg three times a day for the last six months. The consultant reviews his recent blood test results and wants to add on empagliflozin 25 mg once daily to his prescription. What of the following is the most likely consequence of the drug interaction? a. decreased absorption of new medicine b. hypercalcaemia c. hypertension d. hypocalcaemia e. hypoglycaemia

Answer 62

Both metformin and empagliflozin are antidiabetics that can increase the risk of hypoglycaemia.

Question 63

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. you refuse the supply and advise the patient to contact the vet for a further supply of hypromellose eye drops d. you supply hypromellose eye drops as an emergency supply and make a record of this on your patient medication record (PMR) e. you supply hypromellose eye dr

Answer 63

You can’t provide an emergency supply. Dose in animals is not equivalent to in humans. Licensing of OTC products is for humans. 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 64

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? a. fesoterodine b. mirabegron c. oxybutynin d. solifenacin e. tolterodine

Answer 64

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.

Question 65

A 6-year-old boy requires treatment with antibiotics for a chest infection. He has a history of asthma and an allergy to penicillin. His drug history includes salbutamol 100 mcg inhaler two puffs as required, and beclometasone (Qvar) 50 mcg one puff twice daily. Which one of the following antibiotics would be most appropriate to treat the patient’s chest infection? a. amoxicillin b. azithromycin c. ciprofloxacin d. co-amoxiclav e. doxycycline

Answer 65

Amoxicillin and co-amoxiclav are not appropriate due to allergy. Doxycycline – deposits in bones/teeth so not ideal for children. Ciprofloxacin should be used with caution in children, so azithromycin is most appropriate

Question 66

A 62-year-old woman was admitted to your cardiac ward one day ago with a potential chest infection and irregular heartbeat. She is on the following medication at home: * Trimethoprim 50 mg once daily at night * Amlodipine 5 mg once daily * Simvastatin 20 mg once daily * Paracetamol 1 gram four times daily * Ibuprofen gel 5% used when required. Her most recent blood results are: Sodium 138 (135 - 145 mmol/L) Potassium 5.5 (3.6 - 5.2 mmol/L) Calcium 2.4 (2.2 - 2.6 mmol/L) Phosphate 1.2 (0.8 - 1.5 mmol/L) Haemoglobin 128 (120 - 160 g/L) Which one of the following medications is most likely to contribute to the abnormality in the most recent blood results? a. amlodipine b. ibuprofen gel c. paracetamol d. simvastatin e. trimethoprim

Answer 66

From the blood results provided, the patient’s potassium levels are raised. Trimethoprim is the most likely medication that may have caused this - candidates may select amlodipine in error as they may not read correctly or assume that the trimethoprim is a short course rather than it being an on-going prescription for prophylaxis.

Question 67

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? 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

Answer 67

you should make a record of the supply in the pharmacy prescription book 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.

Question 68

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)? 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

Answer 68

Curanail 5% w/v medicated nail lacquer SPC. The product only covers the treatment of up to two toenails are affected and should be used between 6-9 months for optimum effect. It is only licensed for 18 years and over and cannot be used in diabetic or patients with peripheral arterial disease. It is licensed for treatment where fungal infection has originated from the distal or lateral areas of the toenail.

Question 69

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 5 mg tablets b. bisoprolol 2.5 mg once daily c. cetirizine hydrochloride 10 mg tablets d. fentanyl 12 mcg/hr patches e. nitrofurantoin 100 mg modified-release capsule

Answer 69

G6PD deficiency is a genetic disorder that 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 70

A 70-year-old man with advanced Parkinson’s disease is being started on apomorphine therapy. Which of the following treatment options is the most appropriate for the pre-treatment of this patient, to prevent nausea and vomiting as a result of the initiation of apomorphine? a. domperidone b. haloperidol c. metoclopramide d. ondansetron e. prochlorperazine

Answer 70

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 risk factors and ECG monitoring is recommended to ensure that the benefits outweigh the risks

Question 71

You are working in a GP practice reviewing patients at significantly high risk of gastric bleed to identify who may need appropriate effective gastroprotection to reduce the risk. Which one of the following patients would be at high risk of gastric bleed and may need appropriate effective gastroprotection? a. a 65-year-old patient prescribed amlodipine, indapamide and ramipril b. a 69-year-old patient prescribed amitriptyline, Clenil Modulite inhaler and Ventolin inhaler c. a 72-year-old patient prescribed atorvastatin, citalopram and clopidogrel d. a 76-year-old patient prescribed aspirin, topical diclofenac and GTN spray e. a 78-year-old patient prescribed allopurinol and metformin

Answer 71

People are at high risk of GI adverse effects with antiplatelet treatment if concomitant medicines that are known to increase the risk of GI bleeds are also given. An example of these medicines is SSRIs such as citalopram. Whilst NSAIDs do come with a high risk of GI bleeding or ulceration, when used topically they do not carry this risk.

Question 72

A 68-year-old woman has been recently diagnosed with hypothyroidism and initiated on levothyroxine 50 microgram once daily each morning. The patient asks you how to take the medicine. What is the most appropriate advice to provide the patient about levothyroxine? a. dose to be taken 30–60 minutes before breakfast, caffeine-containing liquids, or other medication b. dose to be taken 60 minutes after breakfast, caffeine-containing liquids, or other medication c. swallow whole with a full glass of milk 30-60 minutes before breakfast and other medication d. swallow whole with a full glass of water in the morning e. swallow whole with or after breakfast

Answer 72

dose to be taken preferably 30–60 minutes before breakfast, caffeine-containing liquids (e.g., coffee, tea), or other medication

Question 73

You are a GP practice pharmacist and have been asked to review an 11-year-old boy with his mother. For the past month, he has been complaining of lethargy, excessive thirst and waking up to go to the toilet at night. Before this he was fit and well and played in the school football team, which he cannot do at the moment. His random blood glucose is 32 mmol/L, and he has ketones and glucose in his urine dipstick. What would be the most appropriate next step to take for this child? a. refer the patient to the NHS 111 service b. refer the patient to the local out of hours service c. repeat the tests daily for the next three days d. repeat the tests in three days’ time e. urgent referral to the accident and emergency department

Answer 73

The signs and symptoms are likely to be a diagnosis of type 1 diabetes. The child needs to go urgently to the local hospital for assessment and treatment as is at risk of diabetic ketoacidosis given the blood glucose and urine dipstick.

Question 74

A 4-year-old girl is prescribed aspirin as an antiplatelet following cardiac surgery to prevent thrombus formation. You check the BNF and confirm the dose is correct and it is listed as appropriate to prescribe. Which of the following statements regarding aspirin in paediatric patients is most accurate? a. aspirin is licensed for use in under 16-year olds b. aspirin is safe to prescribe in previous history of hypersensitivity to NSAID c. aspirin is safe to use in asthmatic patients d. manufacturer states avoid aspirin in under 16-year olds due to risk of Kawasaki disease e. manufacturer states avoid aspirin in under 16-year olds due to risk of Reyes syndrome

Answer 74

manufacturer states avoid aspirin in under 16 year olds due to risk of Reyes syndrome

Question 75

You are dispensing a new prescription for glyceryl trinitrate patch Deponit® to be applied once a day, for a 65-year-old man for the management of his angina. Which of the of the following would be the most appropriate advice for this patient on how to apply the patch? 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.

Answer 75

The GTN patch remains on the skin for only 12-14 hours and then removed. It is not replaced every 12-14 hours. The patient needs a nitrate free period to prevent tolerance occurring.

Question 76

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 5 mg daily * bendroflumethiazide 2.5 mg daily * colecalciferol 400 iu daily * paracetamol 500–1000 mg 6-hourly as needed * simvastatin 40 mg at night The biochemistry test results are as follows: Value Normal range Sodium 133 mmol/L 35 – 145 mmol/L Potassium 2.7 mmol/L 3.5 – 5.0 mmol/L Urea 4.2 mmol/L 3 – 7 mmol/L Creatinine 75 μmol/L 59 - 104 μmol/L 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 76

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

Question 77

She has started on empirical therapy. She weighs 60 kg, has an allergy to penicillin causing a rash, and is not taking any regular medication. A midstream specimen of urine (MSU) sample has been sent to microbiology. Which bacterial organism is the most likely cause of the UTI? a. chlamydia trachomatis b. escherichia coli c. haemophilus influenza d. staphylococcus aureus e. streptococcus pneumonia

Answer 77

UTIs are predominantly caused by bacteria from the gastrointestinal tract entering the urinary tract, with escherichia coli being the most common cause.

Question 78

The GP would like to prescribe the patient with some antibiotics for initial empirical treatment of the UTI. Which of the following antibiotics is the most appropriate treatment choice for this patient? a. amoxicillin 500 mg three times a day for five days b. co-amoxiclav 625 mg three times a day for five days c. gentamicin 300 mg once a day for three days d. metronidazole 400 mg three times for three days e. nitrofurantoin 50 mg four times a day for three days

Answer 78

Nitro

Question 79

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 2.2 nanograms/mL taken 4 hours post dose (normal range: 0.8 - 2.0 nanograms/mL). Her heart rate is within normal parameters. Which of the following would be the most appropriate advice to provide the medical team in regard to this patient’s digoxin level? a. a further level should be taken before making a decision 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 within range and the dose does not need adjusting

Answer 79

The level has been taken too early and so doesn’t indicate her true digoxin level. She is not showing signs of digoxin toxicity which is encouraging but it would not be appropriate to act on this level. There may be time to take another level before the next dose of digoxin is due. The correct answer is: a further level should be taken before making a decision

Question 80

A 19-year-old woman has recently been prescribed Microgynon® 30 tablets (ethinylestradiol / levonorgestrel). She suffers from several medical conditions and wants to know whether these tablets are safe for her to take. Which one of the following conditions is most likely to be a contra-indication for combined oral contraceptives? a. asthma b. diabetes c. eczema d. hypertension e. hyperthyroidism

Answer 80

Combined oral contraceptives (COC) are contra-indicated in hypertension (blood pressure systolic 160 mmHg or diastolic 100 mmHg or higher), The risk of arterial thromboembolic complications or of a cerebrovascular accident in COC users increases in women with risk factors, such as hypertension. The SPC for Microgynon 30 states: Although small increases in blood pressure have been reported in many women taking COCs, clinically relevant increases are rare. However, if sustained hypertension develops during the use of a COC, antihypertensive treatment should normally be instigated at a level of 160/100 mm Hg in uncomplicated patients or at 140/90 mm Hg in those with target organ damage, established cardiovascular disease, diabetes or with increased cardiovascular risk factors. Decisions about the continued use of the COC should be made at lower BP levels, and alternative contraception may be advised

Question 81

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? 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

Answer 81

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 Firs

Question 82

A 27-year-old man has been suffering from severe depression. He has been taking amitriptyline hydrochloride 25 mg tablets once daily for the past three months and does not feel any better. He has not reported any side effects to you or the GP. Which one of the following options describes the most appropriate reason for treatment failure? a. inadequate dosing b. inappropriate choice of formulation c. inappropriate frequency d. period of use is not sufficient e. period of use is too extensive

Answer 82

inadequate dosing 10% - 20% of patients fail to respond to tricyclic and related antidepressant drugs and inadequate dosage may account for some of these failures. Amitriptyline hydrochloride 50 mg once daily or divided into two doses, may have been more appropriate for the man. Although not an option, the choice of anti-depressant may also be contributing towards treatment failure. Fluoxetine is usually the best choice in young people presenting with depression.

Question 83

Your trainee dispenser wants to know exactly how much pholcodine linctus she will need for the below regimen. Prescription: Pholcodine linctus 10 mg/ 5mL Initially 10 mg QDS for 2/7 then 10 mg TDS for 3/7 then 5 mg QDS 2/7 What is the total volume required? a. 90 mL b. 95 mL c. 105 mL d. 115 mL e. 125 mL

Answer 83

105ml

Question 84

A 63-year-old woman returns a bag with her husband’s old medication to your pharmacy. As you sort through the bag, you notice an unopened box of Zomorph® 60 mg capsules and 25 tramadol 50 mg capsules. A Foundation pharmacist in your dispensary asks how in-date patient-returned controlled drugs are handled. You take the opportunity to also advise how expired controlled drugs in your controlled drug cabinet are handled. Which of the following is the most important thing for you to explain to the Foundation pharmacist regarding controlled drugs? a. a record should be made in the controlled drugs register during the destruction of schedule 2 patient returns. b. an authorised witness must be present during the destruction of expired schedule 2 controlled drugs c. an authorised witness must be present during the destruction of expired schedule 3 controlled drugs d. an authorised witness must be present during the destruction of patient returned schedule 2 controlled drugs e. only schedule 2 and 3 controlled drugs require denaturing

Answer 84

an authorised witness must be present during the destruction of expired schedule 2 controlled drugs a record should be made in a separate register

Question 85

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? 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

Answer 85

The use of oral NSAIDs and methotrexate may increase the likelihood of nephrotoxicity, however with topical preparations, ibuprofen absorption via skin is low. This coupled with it being used PRN, makes it appropriate to use whilst on methotrexate. Patients should be counselled to speak with a healthcare professional if their PRN / occasional use of ibuprofen is becoming regular. Methotrexate does not interact with metformin, nitrofurantoin and ramipril. PPI’s may increase the likelihood of limited MTX clearance increasing the chances of MTX toxicity, thus option B is correct.

Question 86

A 15-year-old patient has been experiencing pain in their left femur for the last seven days. Their mother explains that the pain has come and gone over the last three months. The pain is described as deep-seated and dull. Which one of the following options would be the most appropriate course of action? a. refer to a physiotherapist; adequate mobility may ease their symptoms b. refer to an urgent medical centre c. take regular paracetamol d. take regular paracetamol and ibuprofen e. use topical ibuprofen gel along with oral ibuprofen tablets

Answer 86

The patient scenario suggests that the pain is related to a bone. Bone pain is commonly known to be dull and deep seated. Bone pain can arise from osteosarcoma (‘cancer of the bone’) or be due to osteomyelitis, therefore referral to a medical doctor is essential and should be done urgently. Thus, option A, C, D and E are incorrect. Note that the use of topical ibuprofen gel with oral ibuprofen tablets is contra-indicated. Thus, this option could be immediately ruled out.

Question 87

You have recently joined a new NHS organisation and have new colleagues. You notice that a pharmacy technician has slurred speech and is frequently dropping items. Throughout the day they have made six dispensing errors. Which one of the following best describes the action that you should take? a. access the organisation’s intranet and fill out an incident / concerns form b. regardless of the cause of the individual’s presentation and errors, immediately share your observations with the team leader. Maintain confidentiality where possible; keep a record of your concerns and or observations c. share your observations with a colleague and be extra cautious when final checking medications. Keep a record of the type(s) of dispensing errors the individual is making d. the individual may be under the influence of alcohol or drugs, immediately share your observations with the team leader. Maintain confidentiality; it is the team leader’s responsibility to keep a record of concerns e. the individual may have a medical condition, ignore their presentation, and report their frequent dispensing errors to the team leader

Answer 87

regardless of the cause of the individual’s presentation and errors, immediately share your observations with the team leader. Maintain confidentiality where possible; keep a record of your concerns and or observations

Question 88

A 55-year-old man comes to your pharmacy asking for some advice about a new set of symptoms he has been experiencing. His symptoms consist of a burning-like sensation in the chest that sometimes travels up to the throat, mainly following meals for the last few days. Occasionally, the burning sensation radiates towards his right shoulder, arm, and neck. He has been taking amlodipine tablets for many years; recently the dose was increased to 10 mg once daily. Which one of the following is the most appropriate option for this patient? a. ask about their lifestyle and offer advice if appropriate b. dose increase of amlodipine may be contributing to their symptoms, take their blood pressure c. refer to GP d. suggest keeping a food diary so that it’s possible to identify any food-related triggers e. suggest taking Gaviscon Advance® oral suspension after meals

Answer 88

Refer to GP burning sensation radiating towards the right shoulder, arm and neck may be suggestive of a cardiac abnormality, thus patient should be referred to their GP. If the burning sensation was radiating towards his left shoulder, arm, or neck, that would be suggestive of a heart attack and would require urgent medical referral.

Question 89

One of your elderly patients with asthma has rheumatoid arthritis which affects the joints in her wrists and fingers, making it difficult for her to use her Clenil Modulite 100 mcg inhaler (beclometasone) at a dose of two puffs twice daily. Which one of the following would be the most suitable alternative? a. beclometasone 5 mg tablets – 20 tablets twice daily b. beconase aqueous 50 mcg / dose nasal spray (beclometasone) – four puffs twice daily c. Easyhaler beclometasone 200 mcg inhaler – one puff twice daily d. QVAR 100 Autohaler (beclometasone) – two puffs twice daily e. QVAR 100 Easibreathe inhaler (beclometasone) – two puffs twice daily

Answer 89

The nasal spray would not deliver the dose to the lungs. QVAR preparations are not bioequivalent to Clenil Modulite. The Easyhaler would therefore be the most appropriate alternative as the patient will not need to co-ordinate their breathing with pressing down on the device.

Question 90

A 67-year-old man has been discharged from hospital following a myocardial infarction. He is prescribed the following medicines: * aspirin 75 mg tablets ONCE daily * clopidogrel 75 mg tablets ONCE daily * atorvastatin 80 mg tablets ONCE daily * ramipril 5 mg tablets ONCE daily * bisoprolol 5 mg tablets ONCE daily A few weeks later, he brings in a new prescription explaining that the doctor has made changes to his anti- cholesterol therapy as he was experiencing cramps in his legs. Which of the following is the most likely to have been prescribed to the patient? a. atorvastatin 20 mg tablets od b. fluvastatin 80 mg tablets od c. rosuvastatin 20 mg tablets od d. rosuvastatin 40 mg tablets od e. simvastatin 80 mg tablets od

Answer 90

Fluvastatin 80 mg is a medium intensity drug. The others are high intensity similar to atorvastatin 80 mg