1. TP23 Mock Exam Paper 2 - Clinical paper with answers.pdf

BOOTS UK MOCK REGISTRATION ASSESSMENT PART 2 QUESTION PAPER April 2024 Instructions to candidates: 1. This assessment consists of 120 questions split into...

BOOTS UK MOCK REGISTRATION ASSESSMENT PART 2 QUESTION PAPER April 2024 Instructions to candidates: 1. This assessment consists of 120 questions split into three sections: Section 1: 45 'single-best-answer' questions Section 2: 45 'single-best-answer' questions Section 3: 30 'extended-matching' questions 2. For questions 1-90 there are five options. For questions 91-120 there are eight options. For each question, you are asked to select the most appropriate option from the list provided 3. The time allowance is 150 minutes (2.5 hours). 4. You will score one mark for each correct answer; no marks will be deducted for incorrect answers or omissions. 5. Answer all questions as though you are: − a pharmacist, not a trainee pharmacist − working in non-pandemic conditions. 6. For questions with this icon, you may find the resource pack useful. 7. A calculator is not permitted for Part 2 of the registration assessment.  SECTION 1 1. A breastfed baby is confirmed as having a cow’s milk allergy. Which is the most appropriate course of action? a) Continue breastfeeding but advise the mother to exclude all cow’s milk protein from her diet, and to take calcium and vitamin D supplements. b) Continue breastfeeding, but at a reduced capacity, and supplement the feeds with Aptamil Sensitive (a partially hydrolysed formula milk) until weaned. c) Stop breastfeeding and swap the child onto Neocate LCP (an amino acid formula milk) until weaned. d) Stop breastfeeding and swap the child onto Nutramigen 1 (an extensively hydrolysed formula milk) until the child is 1. e) Stop breastfeeding and swap the child onto Wysoy (a soya protein-based formula milk) until weaned. Scenario: Suspected cow's milk allergy | Management | Cow's milk allergy in children | CKS | NICE 2. A 34-year-old male has recently been prescribed citalopram for depression. He also has epilepsy but had been seizure free for several years until last week. Which of the following is most likely to have caused the seizure? a) Hypercalcaemia b) Hyperkalaemia c) Hypoglycaemia d) Hypomagnesaemia e) Hyponatraemia Antidepressant drugs | Treatment summary | BNF content published by NICE – see under hyponatraemia and antidepressant therapy 3. A 58 old Caucasian woman has been experiencing frequent headaches. She has type 2 diabetes and manages her diabetes with a healthy diet and lifestyle. A few weeks ago, she measured her blood pressure on her friend’s monitor and the result was 162/102. She realises that her blood pressure may be high but is worried that if she goes to her doctor they will put her on medication. Which of the following treatment options is the doctor most likely to prescribe?  a) Amlodipine b) Aspirin c) Bisoprolol d) Furosemide e) Ramipril NG136 Visual summary (nice.org.uk) 4. A 70-year-old patient is being treated for moderate heart failure associated with a reduced left ventricular ejection fraction. Their current medication is: Ramipril 5mg once daily Bisoprolol fumarate 10mg once daily The patient has tolerated the medication but continues to remain symptomatic and the consultant wishes to prescribe an additional drug to relieve symptoms. Which of the following is the most appropriate medication to be added to the patient’s treatment? a) amiloride hydrochloride 10mg daily b) bendroflumethiazide 2.5mg daily c) candesartan cilexetil 4mg once daily d) furosemide 40 mg daily e) spironolactone 25mg once daily Recommendations | Chronic heart failure in adults: diagnosis and management | Guidance | NICE 5. You are working in a community pharmacy on Boxing Day and a 30-year-old patient with epilepsy has asked if you can give an emergency supply of their epilepsy medication as they have run out. You do not have a locally commissioned emergency supply service, so you consider if they could have an emergency supply at the request of a patient. Which of the following drugs would you not supply as an emergency supply at the request of a patient? a) Carbamazepine b) Gabapentin  c) Lamotrigine d) Phenobarbital e) Sodium Valproate Emergency supply of medicines | Medicines guidance | BNF content published by NICE – Gabapentin is schedule 3 MEP 6. The doctor would like to prescribe a patient with a non-steroidal anti-inflammatory drug (NSAID). Which one of the following NSAIDs poses the greatest risk of gastro-intestinal toxicity? a) Celecoxib b) Diclofenac c) Ibuprofen d) Naproxen e) Piroxicam Non-steroidal anti-inflammatory drugs | Treatment summaries | BNF | NICE – see note about Piroxicam 7. A 79-year-old patient is taking morphine sulfate modified-release tablets 60mg twice daily, plus 10 mL of morphine sulfate 10mg/5mL oral solution, every four hours for breakthrough pain. The patient now requires their pain relief to be administered as parenteral diamorphine via a syringe driver. What would be the most appropriate dose of parenteral diamorphine to be given over a 24- hour period via the syringe driver? a) 120 mg b) 80 mg c) 60 mg d) 70 mg e) 140 mg Calculation: Daily dose being taken = 60mg twice a day + 20mg every 4 hours = (60 x 2) + (20 x 6) = 120 + 120 = 240mg  From the resource the appropriate conversion of 240mg oral morphine to parenteral diamorphine = 80mg 8. A 54-year-old male has been taking the following medication for the past four years: Amlodipine 10 mg tablets – Take one daily Cetirizine 10 mg tablets – Take one daily when required Indapamide 2.5 mg tablets – Take one daily Ramipril 10 mg capsules – Take one daily Paracetamol 500 mg tablets – Take two tablets four times a day when required The patient rings the pharmacy and tells you that they have been suffering with diarrhoea and vomiting that started this morning. Which one of these medicines would you recommend that they stop for 1 - 2 days until they recover? a) Amlodipine b) Cetirizine c) Indapamide d) Ramipril e) Paracetamol ACE inhibitors | Prescribing information | Heart failure - chronic | CKS | NICE The resource should be used for questions 9 and 10. Lithium can be used for the treatment of hypomania and manic episodes in bipolar disorder and has a narrow therapeutic window. 9. At which of the following concentrations should lithium toxicity most likely start to occur? a) 0.5 mmol/L b) 0.8 mmol/L c) 1.0 mmol/L d) 1.5 mmol/L e) 2.0 mmol/L 10. Which of the following is least likely to contribute to lithium toxicity?  a) Constipation b) Excessive sweating c) Furosemide d) Renal impairment e) Vomiting Lithium | Prescribing information | Bipolar disorder | CKS | NICE 11. A 36-year-old man comes into the pharmacy and asks to speak to the pharmacist. He tells you that he has been passing more frequent and watery stools than is normal for him over the last 24 hours and is worried that he may become dehydrated. You inform the patient that an oral rehydration solution will help to prevent him from getting dehydrated and he decides to buy Dioralyte® sachets. The patient needs to dissolve the contents of each sachet in 200 mL of drinking water. Each sachet contains 300 mg of sodium. The molecular weight of sodium is 23. How many millimoles of sodium ions will he have per sachet, to the nearest millimole? a) 3 millimoles b) 12 millimoles c) 13 millimoles d) 14 millimoles e) 23 millimoles Calculation: 300 /23 = 13.04 12. A 55-year-old woman comes into your pharmacy complaining of a sore throat, mouth ulcers and a fever. She is taking fluoxetine 30mg daily, carbamazepine 400mg twice a day, and has recently been put on cimetidine 400mg four times a day for reflux oesophagitis. What is the MOST appropriate advice for this patient? a) To attend A & E for investigation and possible blood tests. b) To have a clinical assessment of the throat at a walk-in centre/pharmacy to see if there is exudate on the tonsils which could be causing the sore throat and fever. c) To see the GP immediately, it’s likely the medication in causing the symptoms.  d) To take OTC ibuprofen to reduce the inflammation causing the sore throat and reduce the fever. e) To use OTC lidocaine gel, benzydamine spray/rinse and paracetamol for the relief of the symptoms, rest and give the cimetidine time to work. Carbamazepine | Drugs | BNF | NICE Carbamazepine | Interactions | BNF | NICE – interaction between carbamazepine and cimetidine 13. A 54 old man has come to you as he would like some advice on how to reduce the risk of cardiovascular disease. He recognises he has put weight on since he gave up smoking. He lives alone and has a sedentary lifestyle. He tells you that he consumes roughly 3 units of alcohol per day. Which of the following statements is the most appropriate advice for this patient? a) Aiming for less than 6 g of salt in your diet per day can reduce the risk of cardiovascular disease b) Drinking up to 16 units of alcohol per week spread over at least 3 days is within the recommended guidelines and can reduce the risk of cardiovascular disease. c) Engaging in a minimum of 60 minutes of moderate-intense physical activity per day can reduce the risk of cardiovascular disease d) Men are less likely to develop cardiovascular disease at an earlier age than women e) Obesity is the only risk factor for cardiovascular disease. Cardiovascular disease - NHS (www.nhs.uk) 14. It is a cold winter’s morning, and a 9-year-old girl is being reviewed at an asthma clinic. During the review she is complaining of increased breathlessness at breaktimes when playing outside and when she goes for bike rides with her family at the weekend when the weather is cold. She is currently on a salbutamol inhaler which she needs to use daily. Her PEFR is 78% at best. She is on no other medication. Which of the following is the most appropriate to add to her current medication? a) Clenil modulate 100 micrograms one puff twice daily b) Clenil modulate 200 micrograms one puff twice daily c) Flixotide evohlaer 250 micrograms one puff twice daily d) Pulmicort turbohaler 400 micrograms one puff twice daily  e) Symbicort turbohaler 200 micrograms one puff twice Recommendations | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICE – NB the question asks for the most appropriate dose which is the lowest starting dose (100mcg) for a child of 9 years. 15. A 72-year-old man who takes medication for his COPD and ischaemic heart disease is admitted to hospital due to a fall. Upon discussion, he complains he has had a sore mouth for several weeks. Which of the following drugs is the most likely cause for his sore mouth? a) Aspirin b) Beclomethasone inhaler c) Paracetamol d) Ramipril e) Salbutamol Beclometasone dipropionate | Drugs | BNF | NICE 16. A 58-year-old male comes into your pharmacy asking for your advice. He has recently been prescribed a new glyceryl trinitrate (GTN) spray. Which of the following is the most appropriate advice to give the patient? a) Ensure you order your GTN spray on your prescription every month b) Discard the spray 8 weeks after opening c) Only use GTN spray when experiencing symptoms of angina d) Moisten the mouth with water before using GTN spray to ensure good absorption of the drug e) Sit down when using GTN spray How and when to take glyceryl trinitrate (GTN) - NHS (www.nhs.uk) Glyceryl Trinitrate Spray 400 micrograms/metered dose, sublingual spray - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk) 17. A 72-year-old man has been admitted to hospital following an acute ischaemic stroke. He is to be given alteplase, a fibrinolytic drug via intravenous infusion and is taking no other medication. Within what time frame must treatment with alteplase following an acute ischaemic stroke be given? a) 6 hours b) 12 hours c) 3.5 hours d) 4.5 hours e) 6-12 hours Stroke | Treatment summaries | BNF | NICE – see Ischaemic stroke 18. A member of the nursing staff of a local care home asks for your advice on a wound management dressing for one of their residents, who has a wound with some signs of infection, which is yellow with low exudate. The resident has commenced a course of systemic antibiotics for the infection. Which of the following dressing types would be the most appropriate for this wound type? a) An alginate dressing b) A capillary-acting dressing c) A foam dressing d) A hydrocolloid dressing e) A hydrocolloid-fibrous dressing See resource pack Wound management products and elasticated garments | BNF | NICE 19. A 66-year-old man has been discharged with a diuretic for oedema in renal disease. Which of the following thiazide or thiazide related diuretics are appropriate for a patient with an eGFR 27 mL/minute/1.73m2? a) Bendroflumethiazide b) Chlortalidone c) Indapamide d) Metolazone  e) Xipamide Metolazone | Drugs | BNF | NICE – See Renal impairment 20. A 42-year-old patient has presented to their GP with a history of anxiety, weight loss, hyperactivity, and difficulty sleeping. After routine blood tests, they have been diagnosed with hyperthyroidism and require appropriate treatment. Which of the following thyroid function test patterns is most likely to describe the patient? a) High TSH and normal FT4 b) High TSH and low FT4 c) Low TSH and high FT4 d) Low TSH and low FT4 e) Low TSH and normal FT4 Overactive thyroid (hyperthyroidism) - Diagnosis - NHS (www.nhs.uk) Assessment | Diagnosis | Hyperthyroidism | CKS | NICE 21. A 20-year-old woman presents with localised swelling on the upper right eyelid. Her eye is watering, but there is no pain or discharge from the eye. What is the most appropriate advice? a) Apply a warm compress up to 4 times a day b) Refer to an optometrist c) Sell and supply chloramphenicol eye drops d) Sell and supply dry eye drops e) Sell and supply sodium cromoglicate eye drops Stye - NHS (www.nhs.uk) 22. A 24-year-old woman comes into your pharmacy asking for advice about her sore throat. Upon questioning you find out that she is taking fluoxetine and methotrexate. She tells you that it started yesterday. She has taken paracetamol, but it hasn’t helped. What is the most appropriate advice you would you give her? a) Recommend benzocaine lozenges b) Recommend benzydamine spray c) Recommend ibuprofen d) Refer to GP as a non-urgent appointment e) Refer to GP for same day appointment Methotrexate | Drugs | BNF | NICE – see Important safety information 23. A patient brings in a prescription for some antibiotics. Upon handout, she explains that she enjoys drinking a glass of wine with her evening meal and asks whether this would be okay. Which one of the following antibiotics is least suitable to take when drinking alcohol? a) Amoxicillin b) Clarithromycin c) Co-amoxiclav d) Metronidazole e) Nitrofurantoin Metronidazole | Drugs | BNF | NICE – see Interactions 24. A 16-year-old girl brings in a prescription for doxycycline to the pharmacy to treat her acute sinusitis. Her PMR shows that this is her first time. You counsel the patient. Which of the following is the most likely to be mentioned upon handout? a) Do not take indigestion remedies, or medicines containing iron or zinc, 4 hours before or after you take this medicine b) Protect your skin from sunlight – even on a bright but cloudy day. Do not use sunbeds. c) Stop taking the medication as soon as you feel better d) Take on an empty stomach e) Take with a full glass of orange juice  Doxycycline | Drugs | BNF | NICE 25. A 44-year-old woman is being treated for Deep Vein Thrombosis (DVT) and has moderate renal impairment with a creatine clearance of 35 ml/min. She has completed 3 weeks of treatment and the doctor asks you what dose would be suitable for this patient given that she is at risk of bleeding. What is the most appropriate dose of rivaroxaban for this patient? a) Rivaroxaban 10 mg once daily b) Rivaroxaban 10 mg twice daily c) Rivaroxaban 15 mg once daily d) Rivaroxaban 15 mg twice daily e) Rivaroxaban 20 mg once daily Xarelto 15mg film-coated tablets - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk) 26. Migraines are a common form of headaches. Zolmitriptan can be used to treat a migraine. Which of the following patients is most likely to be prescribed zolmitriptan? a) An 18-year-old male with a BMI 30 b) A 32-year-old female taking fluoxetine c) A 43-year-old man who has recently had a heart attack d) A 47-year-old male alcoholic e) A 63-year-old mum whose blood pressure is 142/101 See resource pack - PACKAGE LEAFLET: INFORMATION FOR THE USER (medicines.org.uk) Zolmitriptan | Drugs | BNF | NICE – See Contra-indications, Interactions and Hepatic impairment 27. It is important to encourage patients with both Type 1 and type 2 diabetes to achieve their target glycated haemoglobin concentration through diet, lifestyle and drug treatment to avoid the development of complications. Which of the following is least likely to occur as a result of poorly controlled diabetes? a) Hepatitis  b) Myocardial Infarction c) Nephropathy d) Neuropathy e) Retinopathy Complications of diabetes | Guide to diabetes | Diabetes UK 28. A 45-year-old woman has been prescribed an antidepressant. She is concerned about weight gain. Which of the following is most likely to cause weight gain? a) Amitriptyline b) Escitalopram c) Lofepramine d) Mirtazapine e) Venlafaxine Mirtazapine | Drugs | BNF | NICE - NB This is the only antidepressant from the list that specifically mentions weight increased under its side effects. 29. A 41-year-old male patient has been prescribed Testogel 16.2 mg/g at a dose of three pumps per day for hypogonadism. Testogel 16.2 mg/g is out of stock and therefore you require the prescription to be changed. Which of the following would provide the most suitable alternative dose? a) 3g of Tostran b) One sachet of Testogel 50 mg/5 g c) One tube of Testim d) Three pumps of Testaven e) Two pumps of Testavan Testosterone | Drugs | BNF | NICE – see dose equivalence and conversions – NB 3 pumps of Testogel 16.2mg/g = 60.75mg, 3g of Tostran = 60mg 30. Sepsis is a life-threatening medical emergency.  Which of the following is least likely to be a common symptom of sepsis? a) Confusion b) Fever c) High blood pressure d) High heart rate e) Shortness of breath Assessment | Diagnosis | Sepsis | CKS | NICE 31. A 62-year-old man brings in a prescription to you to be dispensed. He tells you that he was reluctant to accept this prescription from the doctor because he doesn’t normally like taking medicines. Two weeks later you call him to see how he is getting on and he tells you that his ankles have begun to swell. Which of the following medicines is most likely contributing to swollen ankles? a) Candesartan b) Lercanidipine c) Lisinopril d) Simvastatin e) Spironolactone Lercanidipine hydrochloride | Drugs | BNF | NICE 32. After a visit to his local A&E department, a nine-year-old patient has undergone assessment by a specialist paediatrician and has been newly diagnosed with generalised tonic-clonic seizures. He was also observed to have some myoclonic seizures. He has no other medical conditions and takes no medication. Which is the most appropriate drug to initially prescribe? a) Carbamazepine b) Lamotrigine c) Levetiracetam d) Sodium Valproate e) Topiramate 5 Treating epileptic seizures in children, young people and adults | Epilepsies in children, young people and adults | Guidance | NICE - See section 5.1.1 in the resource pack  Epilepsy | Treatment summaries | BNF | NICE 33. A 62-year-old patient has a 10-year risk of cardiovascular disease of 14 %. Their GP wishes to prescribe a statin for primary prevention of cardiovascular disease. The patient takes over- the counter omeprazole and vitamin D. Which of the following would be the most appropriate treatment? a) Atorvastatin 20 mg tablets once daily b) Atorvastatin 80 mg tablets once daily c) Fluvastatin 80 mg tablets once daily d) Pravastatin 20 mg tablets once daily e) Simvastatin 20 mg tablets once daily Scenario: Lipid therapy - primary prevention of CVD | Management | Lipid modification - CVD prevention | CKS | NICE 34. A 21-year-old woman with type 1 diabetes visits your pharmacy for some advice. She is driving to see some relatives tomorrow but is worried about her glucose levels on the long 6-hour drive. Which is the most appropriate advice for this patient? a) Adjust her insulin dose before setting off on the journey b) Ensure her blood glucose concentration is below 8 mmol/L before driving c) Ensure she has a supply of long-acting carbohydrate in the vehicle d) Ensure she maintains her glucose levels at 5 mmol or more during the journey e) Ensure she tests her glucose less than 3 hours before driving Diabetes | Treatment summaries | BNF | NICE - See section titled: advice from the DVLA 35. Clinical governance is important to maintain accurate records in line with legislation. Which of the following statements relating to the responsible pharmacist regulations is incorrect? a) It is a legal requirement for the Responsible Pharmacist to display their name and registration number.  b) The Responsible Pharmacist Log can be written and/or electronic c) The Responsible Pharmacist Log must be retained for 2 years from the date of last entry d) The Responsible Pharmacist is permitted to be absent for up to 2 hours during business hours between midnight and midnight. e) The Responsible Pharmacist should make their own entry into the Responsible Pharmacist log. Responsible Pharmacist (RP) | RPS (rpharms.com) – NB RP log should be kept for 5 years 36. A mother requests a paracetamol suspension for her 4-year-old child who has had a high temperature and cold-like symptoms for the past 2 days. What is the most appropriate dose for this child? a) 60 mg every 4-6 hours, maximum 4 doses per day b) 120 mg every 4-6 hours, maximum 4 doses per day c) 180 mg every 4-6 hours, maximum 4 doses per day d) 240 mg every 4-6 hours, maximum 4 doses per day e) 500 mg every 4-6 hours, maximum 4 doses per day Paracetamol | Drugs | BNFC | NICE 37. A 4-year-old child has recently been prescribed montelukast 4 mg tablets one at night, for the prophylaxis of his asthma. He is unable to use inhalers. On collection of his prescription his father informs you that his son’s sleep patterns have been disrupted and he has started to stutter. What is the most appropriate advice to give to the father? a) To speak to the GP or Asthma nurse for further advice as soon as possible b) To discontinue treatment and to speak to the GP to switch to flixotide evohaler c) These are just side effects of the tablets, and they should continue as normal d) To continue treatment but speak to the GP or Asthma nurse about reducing the dose of Montelukast tablets e) To discontinue treatment and speak to the GP about having a short acting beta agonist instead  Montelukast | Drugs | BNFC | NICE - NB Sleep disorders are an uncommon side effect and speech disorders are a rare side effect of montelukast – see Important safety information 38. A 56 old woman has been prescribed oestrogen-only HRT and is aware that this can increase the incidence of certain cancers. What is the increase in risk of this patient developing endometrial cancer after 10 years of using oestrogen-only HRT? a) 2 - fold b) 4 - fold c) 6 - fold d) 8 - fold e) 9 - fold Sex hormones | Treatment summaries | BNF | NICE To calculate the increase in risk: The background cases over 10 years are 4 in 1000 The additional cases over 10 years using oestrogen only are 32 in 1000, making the total cases (32 + 4) = 36 in 1000 Therefore, the increase = 36/4 = 9, so it’s a 9-fold increase 39. A 3-year-old child weighing 14 kg has come into your pharmacy with their mother with a prescription for nitrofurantoin 25 mL/ 5 mL suspension at a dose of 10.5 mg four times a day for 7 days for an acute urinary tract infection. Three days later the mother returns with her child concerned that her child is passing urine of yellow-brown colour. What is the most appropriate advice to give to the mother of the child? a) The child can continue to take nitrofurantoin, but the GP must be notified of the discoloured urine within 24 hours. b) The child can stop taking the nitrofurantoin as long as the symptoms have resolved c) The child needs to drink more water d) The child needs to stop taking the antibiotic and attend A&E immediately – the dose prescribed is an overdose e) The urine can sometimes turn yellow brown in colour with nitrofurantoin and this is a harmless side effect. It is therefore safe for the child to continue taking nitrofurantoin.  Nitrofurantoin | Drugs | BNFC | NICE - See side effects and advisory label 14 40. A 48-year-old man has been diagnosed with H. Pylori and requires triple therapy. He is allergic to penicillin and is taking clopidogrel. Which of the following combination of drugs provides the most appropriate treatment for this patient? a) Esomeprazole, Amoxicillin and Clarithromycin b) Lansoprazole, Amoxicillin and Metronidazole c) Lansoprazole, Clarithromycin and Metronidazole d) Omeprazole, Amoxicillin and Metronidazole e) Omeprazole, Clarithromycin and Metronidazole Helicobacter pylori infection | Treatment summaries | BNF | NICE – See choice of treatment regimen – penicillin allergy 41. A 5-year-old girl is brought to your attention in the pharmacy by her mother who explains she is feeling “really itchy all over”. You see a rash on the child’s arm and neck and her speech is impaired suggesting her tongue has started to swell. Her mother explained that the symptoms have just started after lunch which she had 10 minutes ago. What is the most appropriate advice for the mother of the child? a) Call 999 immediately b) Explain this is self-limiting and will improve over the next hour c) Refer to GP within the next three days d) Refer to local walk-in centre within the next 24 hours e) Sell chlorphenamine solution (Piriton) and advise the monitor their child over the next few days Anaphylaxis - NHS (www.nhs.uk) 42. A 16-year-old girl asks to speak to you in private. She tells you that she had unprotected sex 96 hours ago and would like advice about obtaining emergency contraception. Upon questioning, you identify she suffers from severe asthma and is currently taking oral prednisolone to treat an exacerbation of her symptoms.  Which of the following is the most appropriate advice for this patient? a) Refer to the GP for a prescription for ellaOne b) Signpost to the GP or sexual health clinic to get a copper IUD fitted c) Supply ellaOne d) Supply one levonorgestrol 1.5 mg tablets e) Supply two levonorgestrol 1.5 mg tablets Ulipristal acetate | Drugs | BNF | NICE – See contra-indications 43. A 30-year-old male presents with the following rash. He explains it was tingling in the area a few days before the rash presented and is now itchy and painful. He tells you that he has some more spots and localised tracking around to his back, but he has no other symptoms. Which of the following conditions is the patient likely to have? a) Contact dermatitis b) Measles c) Ringworm d) Scabies e) Shingles Diagnosis | Diagnosis | Shingles | CKS | NICE 44. The bioavailability between different brands of antiepileptic drugs can vary resulting in loss of seizure control and side effects. Which of the following antiepileptic drugs are prescribers advised to prescribe by brand?  a) Clonazepam b) Gabapentin c) Lamotrigine d) Levetiracetam e) Primidone Epilepsy | Treatment summaries | BNF | NICE – See MHRA/CHM advice: updated advice on switching – primidone is Category 1 45. A 15-year-old girl has asked to speak to you in private for the ‘morning after pill’. You take her to the consultation room. What is the first most appropriate consideration in this situation? a) Establishing her legal age as you can only sell Levonorgestrel to over 16-year-olds. b) Establishing if a condom was used. c) Establishing if she has enough money on her to pay. d) Establishing if she’s Gillick Competent. e) Refer her to the family planning clinic. Consent to treatment - Children and young people - NHS (www.nhs.uk) Gillick competence and Fraser guidelines | NSPCC Learning SECTION 2 46. A 28-year-old female has been vaping for the last few years after previously smoking. She is now in a long-term relationship, and they are planning to start ‘trying for a baby’ soon. She acknowledges the risks of smoking during pregnancy and is equally aware that there may be many unknown risks associated with vaping, and so she would like to reduce her vaping with the intention of stopping as soon as she can. Which stage of the Prochaska & DiClemente cycle of change is she currently at? a) Action b) Contemplation c) Maintenance d) Pre-contemplation e) Preparation Stages of Change Model | Prochaska & DiClemente | Geeky Medics Prochaska and DiClemente's Transtheoretical Model of Change - Exploring your mind 47. One of your regular patients has been diagnosed with gastro oesophageal reflux disorder (GORD). She has been prescribed Omeprazole 20mg capsules and would like to know if it is safe to take this with her other medication Which of her current medication has a significant interaction with omeprazole? a) Atenolol b) Metformin c) Methotrexate d) Ramipril e) Simvastatin Methotrexate | Interactions | BNF | NICE Omeprazole | Interactions | BNF | NICE 48. There are many different insulin regimens available. The onset and duration of action varies between the different types of insulin preparations. Which of the following is an example of a long-acting insulin? a) Insulin aspart b) Insulin glargine c) Insulin glulisine d) Insulin isophane e) Insulin lispro Insulin | Treatment summaries | BNF | NICE 49. A 45-year-old male has been diagnosed with type 2 diabetes. He was previously taking metformin, but this caused chronic diarrhoea, so he was unable to continue. The GP has decided to change him to dapagliflozin 10mg daily as monotherapy. What is the mode of action of Dapagliflozin? a) An inhibitor of intestinal alpha glucosidases which delays the absorption of starch and sucrose. b) Binds to and activates the glucagon-like peptide-1 receptor to increase insulin secretion. c) Decreases gluconeogenesis and increases peripheral utilisation of glucose.  d) Inhibits dipeptidylpeptidase-4 to increase secretion and lower glucagon secretion. e) Reversibly inhibits sodium-glucose co-transporter 2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion. Dapagliflozin | Drugs | BNF | NICE – see drug action 50. A 72-year-old man has been prescribed digoxin for his atrial fibrillation. Digoxin has a narrow therapeutic window and patients should be monitored for signs and symptoms of digoxin toxicity. Which of the following is the patient least likely to experience in the event of an overdose of digoxin? a) Constipation b) Dizziness c) Tachycardia d) Vomiting e) Yellow vision Digoxin | Prescribing information | Atrial fibrillation | CKS | NICE – see adverse effects The following two questions (q51 and q52) refer to a 23-year-old woman who started taking clozapine tablets for schizophrenia 5 weeks ago. The patient was informed that they will need to register with a patient monitoring service. 51. Which of the following statements best describes the sequential use of antipsychotics that would precede the use of clozapine therapy in the treatment of schizophrenia, if schizophrenia is not controlled despite their use? a) At least 2 different antipsychotic drugs (one of which should be a first-generation antipsychotic drug), each for an adequate duration. b) At least 2 different antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for an adequate duration c) At least 3 different antipsychotic drugs (one of which should be a first-generation antipsychotic drug), each for an adequate duration. d) At least 3 different antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for an adequate duration. e) At least 4 different antipsychotic drugs. Psychoses and related disorders | Treatment summaries | BNF | NICE – See Schizophrenia 52. After initiating Clozapine, what is the most appropriate time frame to monitor blood counts? a) Every 3 months b) Every 6 weeks c) Fortnightly for the first year d) Monthly for the first year e) Weekly for the first 18 weeks Clozapine | Drugs | BNF | NICE – See Monitoring requirements – for clozapine 53. A 55-year-old man has been newly prescribed ramipril and would like to know more information. Which of the following is least likely to be a side effect of ramipril? a) Angiodema b) Constipation c) Dizziness d) Dry persistent cough e) Hypokalaemia Ramipril | Drugs | BNF | NICE – see side effects 54. You have a summer placement student with you who asks you about the destruction of controlled drugs. Which of the following statements is true? a) All patient returned schedule 2 and 3 controlled drugs should be locked in the CD cupboard alongside the dispensing stock. b) An entry should be made in the controlled drugs register when expired schedule 2 controlled drugs are destroyed c) An entry should be made in a separate register to the controlled drugs register for patient returned schedule 2 and schedule 3 controlled drugs d) Expired schedule 2 and 3 controlled drugs must be destroyed in the presence of an authorised witness e) Patient returned schedule 2 and 3 controlled drugs should be destroyed in the presence of an authorised witness.  3.6.10 Destruction of Controlled Drugs (rpharms.com) 55. A 67-year-old man has been recently diagnosed with mild Parkinson’s disease dementia. Which of the following is most likely to be prescribed? a) Co-beneldopa b) Co–careldopa c) Pergolide d) Rivastigmine e) Ropinirole Parkinson's disease | Treatment summaries | BNF | NICE – see Parkinson’s disease dementia Recommendations | Parkinson’s disease in adults | Guidance | NICE – see Parkinson’s disease dementia 56. A 66-year-old man comes into the pharmacy and tells you that he is coughing up coloured sputum. Sputum colour can be a good indicator for diagnosing certain conditions. What colour sputum could indicate congestive heart failure? a) Clear b) Green c) Pink d) Red e) Yellow Chronic Heart Failure (CHF) | Geeky Medics – See Clinical features 57. A 53-year-old-woman presents at your pharmacy, concerned that one of her legs has swollen.  Which of the following is least likely to indicate deep vein thrombosis? a) Current cancer treatment b) Fever c) Skin changes - Redness d) Tenderness e) Throbbing pain DVT (deep vein thrombosis) - NHS (www.nhs.uk) 58. A doctor would like to initiate a 72-year-old patient on an antipsychotic to treat non-cognitive symptoms of dementia. Which one of the following antipsychotics is licenced to manage non-cognitive symptoms of dementia? a) Aripiprazole b) Clozapine c) Haloperidol d) Olanzapine e) Quetiapine Scenario: Suspected dementia | Management | Dementia | CKS | NICE – see Drug treatments for non-cognitive symptoms 59. A 37-year-old woman with gestational diabetes who is currently on metformin is not meeting her blood glucose target. What is the most appropriate next step in her treatment? a) Add gliclazide b) Add insulin lispro c) Add isophane insulin d) Add soluble human insulin e) Replace with Liraglutide  Recommendations | Diabetes in pregnancy: management from preconception to the postnatal period | Guidance | NICE - See Managing diabetes during pregnancy section 1.3.12 60. A 62-year-old patient has recently been admitted to the hospital after an NSTEMI. As part of their management, they have undergone an angiogram and had two stents inserted. Previously only taking amlodipine for hypertension, the GP has been asked to prescribe the following in addition to amlodipine: Aspirin 75 mg once daily Clopidogrel 75 mg once daily (for 12 months) Bisoprolol 2.5 mg once daily Ramipril 2.5 mg once daily GTN 200 mcg spray when required They have no known drug allergies. Which of the following would be the most appropriate to lower cholesterol as secondary prevention as per NICE guidance? a) Atorvastatin 40mg once daily b) Atorvastatin 80mg once daily c) Ezetimibe 10mg once daily d) Simvastatin 20mg once daily e) Simvastatin 40mg once daily Cardiovascular disease risk assessment and prevention | Treatment summaries | BNF | NICE - See secondary prevention, lipid lowering therapy. 61. A patient would like advice on limiting their alcohol intake. Which one of the following statements regarding alcohol intake is correct? a) It's recommended to drink no more than 10 units of alcohol a week, spread across 2 days or more. b) It's recommended to drink no more than 12 units of alcohol a week, spread across 3 days or more. c) It’s recommended to drink no more than 14 units of alcohol a week, spread across 2 days or more. d) It’s recommended to drink no more than 14 units of alcohol a week, spread across 3 days or more.  e) It's recommended to drink no more than 18 units of alcohol a week, spread across 5 days or more. Drink less - Better Health - NHS (www.nhs.uk) 62. Thrush is a common yeast infection that affects both men and women and can be treated with over-the-counter antifungal medicines. It is not always safe to treat, and some patients need referral to their GP or sexual health clinic. Which one of the following patients can be safely treated through a community pharmacy? a) A 15-year-old girl, who was first diagnosed with thrush six months ago by her GP. She is a type 1 diabetic. b) A 23-year-old woman, who is 30 weeks pregnant. Her midwife diagnosed thrush at 12 weeks pregnant. It cleared up but has now come back. c) A 35-year-old-man who had thrush 5 years ago. He reports burning around the head of the penis. He smokes and takes citalopram 10mg daily for the treatment of depression. d) A 47-year-old man who has had thrush for the first time. e) A 61-year-old woman who suffered from thrush 6 months ago. She reports she has high blood pressure and takes atenolol. Thrush in men and women - NHS (www.nhs.uk) 63. A 35 old patient has been taking carbimazole for an overactive thyroid for 3 months and their TSH level is now in the reference range. Which of the following is not true concerning carbimazole? a) Blood tests should be carried out every 6 months b) If the patient has a sore throat, it should be investigated without delay c) It can be taken with or without food d) It can be used for Graves’ disease e) They should discuss with their doctor if they are pregnant or trying for a baby Carbimazole: medicine for treating overactive thyroid (hyperthyroidism) - NHS (www.nhs.uk) Scenario: Management | Management | Hyperthyroidism | CKS | NICE 64. A mother brings in a prescription for her 8-year-old son to the pharmacy. She tells you that her son is still “wetting the bed” even though they have tried to avoid drinking water before his bedtime and have tried desmopressin in the past. She tells you that the doctor has prescribed a new medicine to take in addition. What is the most appropriate initial dose of oxybutynin tablets for this patient? a) 2.5 mg daily b) 2.5 mg three times daily c) 2.5 mg twice daily d) 5 mg three times a day e) 5 mg twice daily Oxybutynin hydrochloride | Drugs | BNFC | NICE Nocturnal enuresis in children | Treatment summaries | BNFC | NICE 65. A 30-year-old woman of average weight presents in the pharmacy requesting malaria prophylaxis for herself. Chloroquine is recommended for malaria prophylaxis for the country she is visiting, and she will be away for 3 weeks. Chloroquine is available for OTC sale in packs of 20 tablets What is correct dose, advice for this patient and number of tablets to be supplied to complete the treatment? a) 155 mg once weekly, started 1 week before entering endemic area and continued for 4 weeks after leaving. Supply 8 tablets b) 225 mg once weekly, started 1 week before entering endemic area and continued for 4 weeks after leaving. Supply 12 tablets c) 310 mg once weekly, started 1 week before entering endemic area and continued for 4 weeks after leaving. Supply 16 tablets d) 310 mg once weekly, started 1 week before entering endemic area and continued for 4 weeks after leaving. Supply 20 tablets e) 310 mg once weekly, started 1 week before entering endemic area and continued for 8 weeks after leaving. Supply 40 tablets Chloroquine | Drugs | BNF | NICE See resource pack 66. A 37-year-old man brings in a prescription for 112 sulfasalazine 500 mg tablets, a new medicine that has been prescribed to help manage his ulcerative colitis. Which one of the following is NOT an appropriate counselling point? a) Close monitoring of full blood counts is necessary initially, and at monthly intervals during the first 3 months. b) Renal function should be monitored before starting this medication, at 3 months of treatment, and then annually during treatment. c) Sulfasalazine can stain bodily fluids red d) Sulfasalazine is contraindicated in salicylate hypersensitivity e) Sulfasalazine may stain contact lenses Sulfasalazine | Drugs | BNF | NICE 67. You are undertaking a medication review with a 72-year-old man, who was admitted to hospital the previous evening following a fall at their home. They are stabilised on warfarin at a dose of 3.5mg on Tuesdays and Fridays and 3mg on the remaining 5 days a week. During their review, they discuss their diet, lifestyle, and other medicines they take, with you. Which of the following is LEAST likely to affect the patient’s INR control whilst on warfarin? a) Addition of clarithromycin for a respiratory tract infection b) Chronic diarrhoea c) Drinking grapefruit juice every morning d) Increase in levels of kale and spinach in diet e) Taking a multivitamin supplement each day Warfarin sodium | Drugs | BNF | NICE – see Important safety information and interactions 68. A 52-year-old patient is being treated for moderate, active rheumatoid arthritis with methotrexate at a dose of 7.5 mg once weekly. You are counselling the patient about the adverse effects and which ones should be reported immediately if experienced. Which of the following is NOT a sign of liver toxicity in a patient taking methotrexate? a) abdominal discomfort b) dark stools c) dark urine  d) nausea e) vomiting Methotrexate | Drugs | BNF | NICE – See Important safety information 69. A 46-year-old woman comes in to collect her monthly prescription. She reminds you that there is a Fostair inhaler in the fridge for her. Which one of the following statements relating to the Fostair 100/6 inhaler is incorrect? a) Fostair contains extra-fine particles of beclomethasone which makes it more potent than traditional inhalers b) Fostair is a pressurised metered dose inhaler c) Headache is listed as a common side effect of Fostair d) Once open, patients must store Fostair in a refrigerator for no more than 3 months e) Patients should be advised to rinse their mouth after using Fostair Fostair 100/6 micrograms per actuation pressurised inhalation solution - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk) 70. A 30-year-old woman comes into the pharmacy and speaks to you about her options for contraception. Following a check on her records you notice she is taking Carbamazepine 400mg tablets twice a day for epilepsy Which is the most suitable contraceptive for this patient? a) Depo-Provera (medroxyprogesterone acetate 150 mg/1 mL) deep intramuscular injection b) Desogestrel 75 mcg tablets c) Ethinylestradiol 35 mcg, Norgestimate 250 mcg tablets d) Etonogestrel 68 mg subdermal implant e) Norelgestromin 6 mg, ethinyl estradiol 600 mcg transdermal patch Scenario: Comorbidities and personal characteristics | Management | Contraception - assessment | CKS | NICE – See What methods of contraception are suitable foe women taking drug treatments 71. A patient’s target blood pressure may vary from patient to patient. Which one of the following is the most appropriate target for a 68-year-old man with chronic kidney disease and diabetes who has a urine albumin to creatinine ratio (ACR) of 75 mg/mmol? a) < 130/80 mmHg b) < 135/85 mmHg c) < 140/90 mmHg d) < 150/90 mmHg e) < 180/70 mmHg Scenario: Management of chronic kidney disease | Management | Chronic kidney disease | CKS | NICE – See How should I manage a person in primary care 72. The local primary school has noticed a recent rise in the number of children suffering with asthma and requiring a salbutamol inhaler. The headteacher has contacted your store by phone to place an order for six Ventolin inhalers. What will be the information you need to tell the headteacher? a) A signed order, ideally on appropriately headed notepaper, is required before supply can be made b) Only secondary school head teachers can make this request c) The signed order must have a named pupil(s) so the inhalers can be labelled correctly d) They cannot obtain a supply for the school without a prescription from the doctor e) You can only supply a maximum of four inhalers to the school in any one year Supply of salbutamol inhalers to schools | RPS (rpharms.com) 73. A worried mum comes into the pharmacy you’re working in and requests an emergency supply of a salbutamol inhaler for her 8-year-old daughter as they have run out. She explains that the child is short of breath and it’s affecting their ability to talk, as they’re gasping mid- sentence. Before they came out the mum checked their peak flow rate a couple of times and it was 45% at best. You have a pulse oximeter in store and find that her oxygen level is 89% and heart rate is 132bpm, and respiration rate is 33/minute. Which of the following statements is correct? a) The patient needs referring to A&E as they are experiencing life threatening acute asthma  b) The patient needs referring to A&E as they are experiencing moderate acute asthma c) The patient needs referring to A&E as they are experiencing severe acute asthma d) The patient needs referring to their GP as they are experiencing moderate acute asthma e) The patient needs referring to their GP as they are experiencing severe acute asthma Asthma, acute | Treatment summaries | BNF | NICE 74. A 42-year-old lady with breast cancer has been diagnosed with bone metastases in her spine and has been prescribed ibandronic acid 50mg tablets Which of the following is the LEAST appropriate counselling point when handing this medicine out to her? a) Remain upright for at least one hour after taking b) Report any sign of ear discharge c) Report any sign of groin pain d) Take at least one hour before first food of the day e) Take one tablet every day Ibandronic acid | Drugs | BNF | NICE – see Directions for administration and Patient and carer advice 75. An 84-year-old man has been taking donepezil at night for 3 years for the management of mild Alzheimer’s disease. His condition has progressed to moderate Alzheimer’s disease and the GP would like your advice on prescribing an additional treatment. Which of the following is most likely to be added to the patient’s initial treatment? a) Co-beneldopa b) Galantamine c) Memantine d) Olanzapine e) Rivastigmine Dementia | Treatment summaries | BNF | NICE 76. You are conducting a ward round and review an 81-year-old man’s medication. He has paroxysmal Atrial Fibrillation and is being anticoagulated with apixaban 5 mg twice daily.  His recent blood test results are as follows: Sodium = 140mmol/L Potassium = 3.8mEq/L Creatinine = 145mmol/L eGFR = 51ml/min What is the most appropriate dosage of Apixaban for this patient to continue on? a) Apixaban 2.5 mg tablets once daily b) Apixaban 2.5 mg tablets twice daily c) Apixaban 5 mg tablets once daily d) Apixaban 5 mg tablets twice daily e) Apixaban 10 mg tablets once daily Apixaban | Drugs | BNF | NICE – See Renal impairment See resource pack 77. A 55-year-old man has been prescribed glyceryl trinitrate 400 mg/metered dose spray for angina that he experiences during physical activity. Glyceryl trinitrate can cause dizziness and headache due to causing a hypotensive effect. Which of the following is least likely to potentiate the hypotensive effect of glyceryl trinitrate? a) Alcohol b) Amitriptyline c) Citalopram d) Lisinopril e) Tadalafil Glyceryl Trinitrate Spray 400 micrograms/metered dose, sublingual spray - Summary of Product Characteristics (SmPC) - (emc) (medicines.org.uk) 78. A 35-year-old woman has recently started a new medication and is now suffering from facial flushing. Which of the following is this patient most likely to have been initiated on? a) Carvedilol  b) Diltiazem c) Doxazosin d) Enalapril e) Moxonidine Diltiazem hydrochloride | Drugs | BNF | NICE – See under side effects - Common or very common Doxazosin | Drugs | BNF | NICE – See under side effects – Rare or very rare 79. A 36-year-old male has been feeling persistently sad for weeks. He has a loss of appetite and sleep disturbance. He has just been diagnosed with moderate depression. Which anti-depressant is most likely to be prescribed as first line treatment? a) Amitriptyline b) Citalopram c) Lofepramine d) Mirtazapine e) Venlafaxine Recommendations | Depression in adults: treatment and management | Guidance | NICE – See treatment of a new episode of more severe depression 80. A 32-year-old woman comes into your pharmacy requesting to buy treatment for her wife who has been suffering with constipation over the last 4 days. Her wife hasn’t tried anything yet, has no known allergies and has no other medical conditions. Which one of the following would be the most suitable course of action? a) Advice on dietary and lifestyle measures b) Referral to her GP c) Sale and supply of Ispaghula husk d) Sale and supply of Lactulose e) Sale and supply of Senna tablets Constipation | Treatment summaries | BNF | NICE Scenario: Adults | Management | Constipation | CKS | NICE – See How should I manage short- duration constipation 81. A diabetic patient, who has recently been complaining of heart palpitations and shortness of breath, has received a diagnosis of hyperkalaemia after having blood tests. Which one of the following medicines is the most likely to cause this electrolyte imbalance? a) Furosemide b) Insulin c) Paracetamol d) Salbutamol e) Spironolactone Spironolactone | Drugs | BNF | NICE – see Side effects 82. A mother brings in prescriptions for her 6-year-old twins who have been prescribed different steroid inhalers for their asthma. What is the clinical difference between Clenil modulate and Qvar? a) Clenil is twice as potent as Qvar b) Qvar is twice as potent as Clenil c) Qvar must be kept in the fridge. d) The potency is identical e) They contain different active ingredients Beclometasone dipropionate | Drugs | BNF | NICE – See Qvar preparations - Potency 83. It is a requirement for all pharmacists and pharmacy professionals to fulfil certain criteria in order to remain registered. Which of the following is an essential component for continued registration as registered pharmacy professional? a) Clinical audit b) CPD c) First Aid training d) Risk assessment e) Safeguarding training Declarations to be made on renewal (pharmacyregulation.org) standards_for_pharmacy_professionals_may_2017_0.pdf (pharmacyregulation.org) 84. Following a review, a 35-year-old male who is a type 1 diabetic and weighs 80 kg brings in a repeat prescription for isophane insulin 100 units/ml, which comes as 3 ml pre-filled pens. Their current daily dose equates to 0.8 units/kg. How many pens will be needed for a 30-day supply? a) 2 b) 5 c) 6 d) 7 e) 10 0.8 units/kg x 80kg x = 64 units per day 64 units x 30 days = 1920 units required for 30 days. 1920units ÷300 units per pen = 6.4 pens. Round up to 7. 85. A 45-year-old woman comes into the pharmacy seeking your advice, as she has been experiencing nightmares and sleep disturbances after starting a new medication. Which of the following beta blockers is she least likely to have been prescribed? a) Bisoprolol b) Metoprolol c) Nebivolol d) Propranolol e) Sotalol Beta-adrenoceptor blocking drugs | Treatment summaries | BNF | NICE 86. A 65-year-old woman is due to have a mechanical heart valve replacement in three days. The consultant cardiologist asks for your advice regarding anticoagulation for this patient post- surgery. Which of the following would be the most appropriate to give this patient? a) Apixaban b) Dabigatran c) Edoxaban  d) Rivaroxaban e) Warfarin Oral anticoagulants | Treatment summaries | BNF | NICE NaPSA-DOAC-Heart-Valve-FINAL-v2.pdf (england.nhs.uk) 87. A 50-year-old woman has recently been diagnosed with trigeminal neuralgia, experiencing sudden severe facial pain which she describes as a shooting pain along one side of her face. She is on no other medication. What is the most appropriate treatment for this patient? a) Amitriptyline b) Carbamazepine c) Codeine d) Gabapentin e) Pregabalin Neuropathic pain | Treatment summaries | BNF | NICE – See Trigeminal neuralgia 88. You have been contacted by a prescriber who would like to prescribe treatment for dyspepsia for a woman who is 16-weeks pregnant and has already tried the lifestyle changes suggested to her. Which one of the following would be the most suitable option for this patient? a) Cimetidine b) Esomeprazole c) Famotidine d) Gaviscon advance e) Omeprazole Scenario: Management | Management | Dyspepsia - pregnancy-associated | CKS | NICE 89. A young couple come and ask your advice about using insect repellent with sunscreen as they are going on safari in Kenya. Their GP has told them they will need to get antimalarials,  but also to make sure that they use an insect repellent containing >20% DEET and they’re concerned about the effect the DEET will have on the sunscreen or vice versa. Which of the following statements is true regarding DEET and sunscreen application? a) Apply insect repellent with a DEET concentration >20% first followed by SPF 30-50 sunscreen b) Apply SPF 15-30 sunscreen first followed by insect repellent with a DEET concentration of >20% c) DEET dilutes sunscreen so apply SPF 30-50 sunscreen first followed by insect repellent with a DEET concentration >20% d) DEET dilutes sunscreen so they should not be used together. Using antimalarial tablets alone should be enough e) DEET does not affect sunscreen, so it doesn’t matter which way around they are used Guidelines for malaria prevention in travellers from the UK 2023 (publishing.service.gov.uk) – see Deet and sunscreen page 21 Malaria Prevention: Antimalarial Medicine and Advice | Patient 90. Vincristine is indicated for many cancers including leukaemia and some solid tumours. Through which route should vincristine be administered? a) Intramuscular b) Intrathecal c) Intravenous d) Oral e) Subcutaneous Vincristine sulfate [Specialist drug] | Drugs | BNF | NICE SECTION 3 Direction for questions 91 to 120. For each question in this section select one answer from the list of eight options above it. Each option may be used once, more than once, or not at all. Theme: Antidiabetic Drugs a. Acarbose  b. Canagliflozin c. Dulaglutide d. Glimepiride e. Liraglutide f. Metformin g. Pioglitazone h. Saxagliptin From the list above, which drug is most likely to have been prescribed by the prescriber? Each answer may be used once, more than once, or not at all. 91. A 48-year-old man has been newly diagnosed with diabetes and brings in a prescription to you with a dose that states take one tablet daily for one week, then take one tablet twice daily for one week, then take one tablet three times a day thereafter. Take with or after food. Metformin (F) Scenario: Management - adults | Management | Diabetes - type 2 | CKS | NICE Metformin hydrochloride | Drugs | BNF | NICE 92. A regular patient comes in to pick up their repeat prescription. You ask how they are getting on with their medicines and they mention they have been passing blood in their urine for the past 3 days. Pioglitazone (G) Pioglitazone | Drugs | BNF | NICE – See Important Safety Information 93. A 56-year-old man has a BMI of 31 kg/m2 and brings in a private prescription for a drug that is licensed to help him lose weight alongside a healthy diet and physical activity. Liraglutide (E) Liraglutide | Drugs | BNF | NICE – See Saxenda 94. A 62-year-old woman has come in with a prescription to be dispensed. She was diagnosed with diabetes many years ago. You counsel her to monitor any foot problems such as pain or ulcers and explain that she should stay hydrated due to an MHRA warning of the risk of lower limb amputation. Canagliflozin (B) Canagliflozin | Drugs | BNF | NICE – See Important Safety Information  Theme: Cardiovascular drugs a) Alteplase b) Amlodipine c) Atenolol d) Bendroflumethiazide e) Glyceryl trinitrate f) Labetalol g) Lisinopril h) Simvastatin For each of the following patients, select the drug most likely to be prescribed from the list above. Each option may be used once, more than once or not at all. 95. A 27-year-old Caucasian woman who is 24 weeks pregnant and has been diagnosed with gestational diabetes. Her total (serum) cholesterol level is 4 mmol/L and she has a sustained blood pressure of 140/90 mmHg. Labetalol (F) Hypertension | Treatment summaries | BNF | NICE – see Hypertension in pregnancy. 96. A 52-year-old man comes to the pharmacy and tells you that he is experiencing chest pain. He has felt this pain before, and it sometimes radiates to the neck, shoulders and arms. The pain usually occurs when he runs and eases at rest. He is generally well and has no other co- morbidities. Glyceryl trinitrate (E) Scenario: New diagnosis | Management | Angina | CKS | NICE Stable angina | Treatment summaries | BNF | NICE 97. A 56-year-old Caucasian woman phones you in the pharmacy for some advice. You are unable to understand what she is saying as her speech is slurred so you invite her for a video consultation instead. When the consultation begins, you notice that her face has drooped on one side and she informs you that since she has woken up, she is unable to lift both arms and keep them there. Alteplase (A)  Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE – See section 1.4 Alteplase | Drugs | BNF | NICE Theme: Infections a. Chicken pox b. Hand, foot and mouth c. Impetigo d. Meningitis e. Molluscum contagiosum f. Mumps g. Scabies h. Shingles For each of the following patients, select the condition most likely to be being described from the list above. Each option may be used once, more than once or not at all. 98. A 3-year-old child has a high temperature and is refusing to eat. You can visibly see that they have some honey-coloured sores around the mouth and nose some of which have crusted over. Impetigo (C) Impetigo | Doctor | Patient Clinical features | Diagnosis | Impetigo | CKS | NICE 99. A 10-year-old boy has small clusters of raised spots under his left armpit and further down his side. He has had them for around 4 months. They are not painful but can sometimes be itchy. On closer inspection you can see they have a dimple in the middle. Molluscum contagiosum (E) Molluscum contagiosum - NHS (www.nhs.uk) Molluscum Contagiosum: Causes, Symptoms, and Treatment | Patient 100.An 8-year-old boy has swelling on one side of his face and is complaining of ear pain and headache. This began with a fever a few days ago. Mumps (F) Mumps | Doctor | Patient Diagnosis of mumps | Diagnosis | Mumps | CKS | NICE 101.A 20-year-old man has been advised to buy permethrin cream due to an itchy rash predominantly between the fingers. Scabies (G) Scabies | Doctor | Patient Diagnosis | Diagnosis | Scabies | CKS | NICE Theme: Contraceptives a) Copper IUD b) Desogestrel 75 mcg c) Ethinylestradiol 20 mcg/Gestodene 75 mcg d) Ethinylestradiol 30 mcg/Gestodene 75 mcg e) Ethinylestradiol 30 mcg/Gestodene 75 mcg and seven placebo tablets f) Levonorgestrel 1.5 mg g) Medroxyprogesterone acetate I/M Injection h) Ulipristal acetate 30 mg For each of the following patients, select the most appropriate contraceptive from the list above. Each option may be used once, more than once or not at all. 102.An 18-year-old patient weighing 76 kg who requires a tablet form of emergency contraception 64 hours after unprotected sexual intercourse. Ulipristal acetate 30mg (H) Emergency contraception | Treatment summaries | BNF | NICE – See Hormonal methods – NB weight is >70kg so ulipristal or 3g levonorgestrel is recommended 103.A 35-year-old woman with circulatory disease who requires a combined oral contraceptive. Ethinylestradiol 20 mcg/Gestodene 75 mcg (C) Contraceptives, hormonal | Treatment summaries | BNF | NICE – see Preparation choice Scenario: Combined oral contraceptive | Management | Contraception - combined hormonal methods | CKS | NICE – NB As there is a cardiovascular risk you need to give the reduced oestrogen dose. 104.A 36-year-old woman who smokes and has high blood pressure who is looking for short term contraception for the next two months. Desogestrel (B) Scenario: Comorbidities and personal characteristics | Management | Contraception - assessment | CKS | NICE – See what methods of contraception are suitable for women with multiple risk factors for cardiovascular disease Which method of contraception suits me? - NHS (www.nhs.uk) Theme: Legal Timeframes A. Five days B. Five years C. One day D. Seven days E. Six months F. Thirty days G. Twenty-eight days H. Two years For each of the following, select the most appropriate duration of time from the list above. Each option may be used once, more than once or not at all. 105.Length of validity of a prescription for chlordiazepoxide hydrochloride Twenty-eight days (G) Isotretinoin | Drugs | BNF | NICE – See prescribing and dispensing information 106.Maximum duration of treatment permitted for phenobarbital under an emergency supply Five days (A) Emergency supply of medicines | Medicines guidance | BNF | NICE 107.Length of time required to keep an invoice for a schedule three controlled drug. Two years (H)  Controlled drugs and drug dependence | Medicines guidance | BNF | NICE – see Schedule 3 108.Duration of time a veterinary prescription should be retained for Five years (B) 3.5.4 Record keeping (rpharms.com) Theme: Endocrine Disorders a) Acromegaly b) Cushing’s Syndrome c) Goitre d) Hyperthyroidism e) Hypoparathyroidism f) Hypothyroidism g) Type 1 Diabetes h) Type 2 Diabetes For each of the following patients, select the most likely diagnosis from the list above. Each option may be used once, more than once or not at all. 109.A 47-year-old man reporting general tiredness and frequently feeling thirsty, despite urinating more than was previously normal. This is particularly troublesome at night. Symptoms built up slowly but are starting to become quite noticeable to the patient. Type 2 diabetes (H) Diabetes (Diabetes Mellitus): Symptoms, Diagnosis, and Treatment | Patient Diabetes - NHS (www.nhs.uk) 110.A 37-year-old woman reporting paraesthesia in her fingertips, toes and lips. She also reports experiencing stomach cramps and feeling tired. Her skin feels rough and dry, and her fingernails are breaking easily. Hypoparathyroidism (E) Hypoparathyroidism - NHS (www.nhs.uk) Hypoparathyroidism: Causes, Symptoms, and Treatment | Patient 111.A 12-year-old girl reports over the last couple of months recurrent thrush infections, fruit smelling breath with no obvious cause, unintentional weight loss and feeling tired, which she puts down to having to get up in the night more frequently to urinate Type 1 diabetes (G) Diabetes (Diabetes Mellitus): Symptoms, Diagnosis, and Treatment | Patient Type 1 diabetes – Symptoms and getting diagnosed - NHS (www.nhs.uk) Theme: High Risk Drugs A. Amiodarone B. Carbamazepine C. Digoxin D. Lithium E. Methotrexate F. Phenytoin G. Sodium Valproate H. Vancomycin For each of the following statements, select the drug most likely described from the list above. Each option may be used once, more than once, or not at all. 112.The plasma drug concentration assay for this drug should be taken at least 6 hours after a dose has been administered. Digoxin (C) Digoxin | Drugs | BNF | NICE – See Monitoring requirements 113.A patient taking this drug should be instructed to maintain a constant and adequate salt intake. Lithium (D) Lithium carbonate | Drugs | BNF | NICE – See Patient and carer advice 114.This medicine is to be taken once weekly, on the same day each week. Methotrexate (E)  Methotrexate | Drugs | BNF | NICE – see Indications and dose 115.Whether this drug should be prescribed by brand for the treatment of epilepsy is based on clinical judgment Sodium Valproate (G) Epilepsy | Treatment summaries | BNF | NICE – See MHRA/CHM advice: Antiepileptic drugs: updated advice on switching Theme: Childhood Vaccinations a) Diphtheria vaccine b) Hepatitis A vaccine c) Human papillomavirus vaccine d) Influenza vaccine e) Measles, mumps and rubella vaccine f) Meningococcal group B vaccine g) Meningococcal group C conjugate vaccine h) Rotavirus vaccine Which of the above vaccinations do the following childhood vaccination schedules refer to? Select the most appropriate answer from the options above. Each option may be used once, more than once or not at all. 116.A first dose of vaccine should be given at 12-13 months of age and a second dose before starting school at 3 years and 4 months to 5 years of age. Measles, mumps and rubella vaccine (E) 117.A first dose of vaccine should be given at 2 months of age and the second at 3 months of age. The vaccine should not be started in children of 15 weeks of age or older. Rotavirus vaccine (H) Scenario: Children up to 1 year of age | Management | Immunizations - childhood | CKS | NICE – See what should I do if a child younger than one year of age hbas not been immunised… 118.For primary immunisation of children aged between 2 months and 10 years, vaccination is recommended in the form of 3 doses, separated by 1-month intervals and given in a combination vaccine with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenza type b. Diphtheria vaccine (A) See resource pack for questions 116-118 The routine childhood immunization schedule | Background information | Immunizations - childhood | CKS | NICE Theme: vitamins A. Vitamin A B. Vitamin B1 C. Vitamin B6 D. Vitamin B12 E. Vitamin C F. Vitamin D G. Vitamin E H. Vitamin K For each of the following patients, select the vitamin most likely described from the list above. Each option may be used once, more than once, or not at all. 119.A 44-year-old man using this vitamin at high doses for prolonged periods can have an increased risk of neuropathy Vitamin B6 (C) Pyridoxine hydrochloride | Drugs | BNF | NICE – See important safety information Vitamins and minerals - B vitamins and folic acid - NHS (www.nhs.uk) – See Vitamin B6 120.All adults in the UK are recommended to take 10 ug per day of this vitamin during the autumn and winter. Vitamin D (F) Vitamin D - NHS (www.nhs.uk)