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MCQs in Clinical Pharmacy

Edited by

Lilian M Azzopardi

BPharm (Hons), MPhil, PhD

Associate Professor

Department of Pharmacy

Faculty of Medicine and Surgery

University of Malta

Msida, Malta

London • Chicago

Published by the Pharmaceutical Press

An imprint of RPS Publishing

1 Lambeth High Street, London SE1 7JN, UK

100 South Atkinson Road, Suite 200, Grayslake, IL 60030–7820, USA

is a trade mark of RPS Publishing

RPS Publishing is the publishing organisation of the Royal

Pharmaceutical Society of Great Britain

First published 2007

Typeset by Type Study, Scarborough, North Yorkshire

Printed in Great Britain by TJ International, Padstow, Cornwall

ISBN 978 0 85369 666 7

in a retrieval system, or transmitted in any form or by any means,

without the prior written permission of the copyright holder.

The publisher makes no representation, express or implied, with regard to

the accuracy of the information contained in this book and cannot accept

any legal responsibility or liability for any errors or omissions that may

be made.

The right of Lilian Azzopardi to be identiﬁed as the author of this work

has been asserted by her in accordance with the Copyright, Designs and

Patents Act, 1988.

A catalogue record for this book is available from the British Library

Dedicated to the memory of Dr Cat and Mr Socrates, my

departed cats, who kept persistent company during long

hours of preparation of my publications

Contents

Foreword

Preface

xiii

Acknowledgements

About the editor

xvii

Contributors

xix

Introduction

xxi

Revision checklist

xxvii

Test 1 Questions 1

Answers 29

Test 2 Questions 55

Answers 85

Test 3 Questions 115

Answers 143

Test 4 Questions 171

Answers 193

Bibliography 223

Appendix A Deﬁnitions of conditions and terminology 225

Appendix B Abbreviations and acronyms 233

Appendix C Clinical laboratory tests reference limits 235

Appendix D Performance statistics 237

Generic drug names index 249

Conditions index 255

Subject index 265

Cases index 275

viii Contents

Foreword

The healthcare systems of most industrialised nations have a

problem that needs the attention of pharmacists, if it is to be solved

correctly. The problem is the poor quality of medicines use, and

the solution includes increased pharmacist participation in medi-

cines management.

Studies from many nations, conducted over many years, have

shown the need for better management of drug therapy. This ﬁrst

became clear from ‘process’ studies showing some inappropriate

prescribing, inadequate monitoring and advice, and patient non-

adherence. Other studies took this a step further, and conﬁrmed

not only the prevalence of adverse outcomes of drug therapy, but

also that such adverse outcomes often could have been prevented

by more careful management. For example, the median preventa-

bility rate in one review was 59%.

Mis-managed drug therapy may rank as one of the leading

causes of hospital admission, because of adverse reactions, under-

treatment, or non-treatment. The median rate of hospital

admissions from preventable drug-related morbidity (PDRM)* in

that review was 4.3%. This would rank PDRM with cancer,

coronary heart disease, diabetes mellitus and asthma as a leading

cause of hospital admissions in many countries. The rate of adverse

outcomes among inpatients typically was 1.5%, and adverse drug

events may prolong hospital stays by 2–4 days.

1,2

* PDRM is much broader than adverse drug reactions (ADR) and somewhat

broader than adverse drug events (ADE). Like ADE, PDRM includes errors and

other problems in drug use as well as injury caused by the ineffective use or

non-use of indicated drugs.

The possibilities of safer and more effective drug therapy have

been clear, and evidence has been mounting about how to improve

them. When pharmacists systematically cooperate with patients

and other healthcare providers, with the objective of improving the

outcomes of drug therapy, outcomes often improve and costs often

decrease.

3,4

The road to medicines management has not been like a broad,

smooth motorway. Parts of it are, so to speak, unpaved and even

unmarked. After nearly two decades of effort by practice

researchers, practitioners and pharmaceutical societies throughout

Europe and North America, some national programmes, for

example, in the USA and the UK, have in effect recognised the need

for pharmacists to participate fully in cooperative patient-centred

systems. Success on the road ahead will require commitment,

planning and effort.

How should pharmacists direct their efforts? Despite the

conventional wisdom, prescribing problems are not the leading

cause of preventable, drug-related hospital admissions. About 70%

of such admissions involved some aspect of the management of

ongoing drug therapy. Management of therapy included follow-up

monitoring and detection of therapeutic problems, for example,

treatment failures, laboratory tests not being done or not being

acted upon, and moderate adverse drug reactions that were

allowed to become so severe that they necessitated admission.

Problems with prescribing, including drug choice, dosage and route

accounted for about 16%; drug distribution and administration,

including patient non-adherence, accounted for about 13%.

Among inpatients, the situation was roughly the opposite: most

problems involved prescribing and the fewest involved follow up.

As prescribing is not a leading cause of PDRM in ambulatory

care, simple prescribing improvement programmes such as formu-

laries are ineffective when the goal is to improve patient outcomes

or reduce total costs or care. Likewise, compliance improvement

programmes may improve medication-taking behaviour but rarely

show a positive effect on outcomes. The outcomes of drug therapy

in ambulatory care can be improved by increasing organised

x Foreword

(systematic) cooperation among pharmacists, physicians and

patients. Such changes are associated with improved outcomes and

reduced total costs of care in many studies.

3,4

Even modest

improvements in customary arrangements may be associated with

improved outcomes, lower total costs of care, or both.

Pharmacists are strategically important, but they are not

essential. If pharmacy is not up to the task, others will surely step

forward. Our public image is favourable, but has been somewhat

dated. Patients and policymakers in some countries have now

begun to change their impression of pharmacists, from a dispenser

to a drug expert who can help patients make the best use of their

medicines.

Pharmaceutical education, and in some cases, re-education in

pharmacotherapeutics will be one essential ingredient in

pharmacy’s efforts. Some pharmacists, however, do not intervene,

even when they see and understand a drug therapy problem, its

causes and its solutions. I have long suspected that one underlying

cause of such inaction is a lack of conﬁdence, as if pharmacists do

not appreciate their own knowledge and how much they can

contribute to patient welfare. If this book helps pharmacists to

focus, recognise and appreciate their clinical knowledge, it will be

a useful addition to that enterprise.

The road to pharmaceutical care and medicines management

may be uncharted, but it does not go through a mineﬁeld where

we can lose everything from one error. We are not in a game that

we can lose if our failures outnumber our successes. We are like

the pilot in the ﬁrst chapter of Tom Wolfe’s The Right Stuff. We

need to keep trying until we ﬁnd what succeeds, and then take the

next step. We are succeeding.

Charles D Hepler, PhD

Distinguished Professor Emeritus

College of Pharmacy

The University of Florida

Gainesville, Florida, USA

February 2007

Foreword xi

References

1 Winterstein A, Sauer B C, Hepler C D et al. Preventable drug-related

hospital admissions and morbidity in hospitalized patients – a meta-

analysis of prevalence reports. Ann Pharmacother 2002; 36:

1238–1248.

2 Hepler C D, Segal R. Chapters 2–3 in Preventing Medication Errors

and Improving Drug Therapy Outcomes through System Manage-

ment. Boca Raton, Florida: CRC Press, 2003.

3 Hepler C D, Segal R. Chapter 9 in Preventing Medication Errors

and Improving Drug Therapy Outcomes through System Manage-

ment. Boca Raton, Florida: CRC Press, 2003.

4 MacKinnon N J. How much evidence is enough? Can Pharm J

2002; (July–Aug): 25–29.

xii Foreword

Preface

This book edited by Lilian Azzopardi is aimed at helping pharmacy

students and pharmacists to grasp the principles of clinical

pharmacy during their career development. The book presents 320

multiple-choice questions, and for each question a concise answer

is given. It is highly practical, short and to the point. As a seasoned

examiner, I would recommend it as a useful revision aid.

Another characteristic of the book is that it shifts the focus

from theory to clinical applications, reﬂecting the growing trend to

change critical appraisals into clinical action. The examples feature

real case histories, providing the opportunity to simulate actual

practice, where multiple problems are presented, decisions need to

be taken, and the required monitoring of the patient may be inﬂu-

enced by the occurrence of concurrent disease states.

This context, where multiple problem scenarios are

presented, stimulates the candidate to think and generate ideas

similar to those required in practice, where an holistic approach is

required for optimum management. The questions addressing the

cases are developed so as to stress the general principles and

concepts that can be applied to other situations, as well as to

discuss issues that are particular to the patient.

The uniqueness of this publication lies in the fact that the

authors were able to produce a book which presents problems that

are taken from contemporary clinical practice. It induces candi-

dates to acquire those skills that are needed to tackle clinical

pharmacy practice issues effectively.

I am conﬁdent that the book reﬂects the enthusiasm Lilian

and her colleagues have for the practice of clinical pharmacy and

for developing problem-based learning approaches in teaching and

career development. Clinical pharmacy is the basis for pharma-

ceutical care. Therefore it is very relevant that the book extends its

parameters to include practical issues related to the development

of pharmaceutical care plans, drug therapy selection and drug

therapy monitoring. Again, as it draws strongly on the practical

aspect, the book should also be used by pharmacists for continu-

ing professional development in the area of clinical pharmacy,

including those serving society in all aspects of pharmaceutical

care.

Professor Godfrey LaFerla

Dean, Faculty of Medicine and Surgery

Head, Department of Surgery

University of Malta

Malta

February 2007

xiv Preface

Acknowledgements

In the development of the concept of this publication, I have drawn

on my experience in teaching and practicing clinical pharmacy.

Looking back, I can state that I have been able to develop these

skills by working in collaboration with a number of colleagues,

mostly from the Faculty of Medicine and Surgery at the University

of Malta. Most importantly I am indebted to Professor Anthony

Serracino-Inglott and to Dr Maurice Zarb-Adami from the Depart-

ment of Pharmacy, who have inspired me through their dedication

for pharmacy to develop clinical pharmacy skills that put the

patient in focus and to perform effective teaching of students. They

had vision about my enthusiasm for providing useful student

revision aids.

Together with Professor Steve Hudson, University of Strath-

clyde and Professor Sam Salek, University of Cardiff, I have

discussed at length clinical pharmacy practice in different

scenarios. This book reﬂects the philosophies of my colleagues

Anthony Serracino-Inglott, Maurice Zarb-Adami, Steve Hudson

and Sam Salek. Indeed it was again a pleasure for all of us to work

together for a third publication.

I am especially indebted to Professor Roger Ellul-Micallef,

Head of the Department of Clinical Pharmacology and Thera-

peutics at the University of Malta for his very relevant comments

on the material presented in the book. Special thanks go to Dr

Bernard Coleiro, Senior Registrar, Department of Medicine at St

Luke’s Hospital, to my sister Louise Azzopardi, clinical pharma-

cist at St Luke’s Hospital and to Dr Mark Grech, Medical Ofﬁcer,

St Luke’s Hospital for reviewing the text.

My appreciation goes to Professor Godfrey LaFerla, Dean of

the Faculty of Medicine and Surgery at the University of Malta and

to Professor Charles Hepler, Emeritus Professor at the University

of Florida who dedicated time from their very demanding schedule

to contribute the preface and the foreword of the book. In addition

I would like to thank Professor Juanito Camilleri, Rector of the

University of Malta for his support.

Thanks go to colleagues and staff at the Faculty of Medicine

and Surgery and to pharmacy students for their enthusiasm

towards clinical pharmacy.

Completion of a book is not possible without the support of

the publisher. I would like to thank the team from Pharmaceutical

Press led by Christina DeBono and Louise McIndoe for their input

and for keeping up with my exacting demands.

Finally thanks go to my family for their support.

xvi Acknowledgements

About the editor

Lilian M. Azzopardi studied pharmacy at the University of Malta,

Faculty of Medicine and Surgery. In 1994 she took up a position

at the Department of Pharmacy, University of Malta as a teaching

and research assistant. Professor Azzopardi completed an MPhil

on the development of formulary systems for community

pharmacy in 1995, and in 1999 she graduated a PhD. Her PhD

thesis led to the publication of the book Validation Instruments for

Community Pharmacy: pharmaceutical care for the third millen-

nium published in 2000 by Pharmaceutical Products Press, USA.

She worked together with Professor Anthony Serracino-Inglott,

who was a pioneer in the introduction of clinical pharmacy in the

late sixties. In 2003 Dr Azzopardi edited the book MCQs in

Pharmacy Practice published by the Pharmaceutical Press, UK

which was followed in 2006 by the book Further MCQs in

Pharmacy Practice.

Lilian Azzopardi is currently an associate professor in

pharmacy practice at the Department of Pharmacy, University of

Malta and is responsible for coordinating several aspects of the

teaching of pharmacy practice, including clinical pharmacy for

undergraduate and postgraduate students, as well as supervising a

number of pharmacy projects and dissertations in the ﬁeld. She is

an examiner at the University of Malta for students following the

pharmacy course and is an assessor in determining suitability to

practice.

Lilian Azzopardi was, for a short period, interim director of

the European Society of Clinical Pharmacy (ESCP) and is currently

coordinator of the ESCP newsletter. She served as a member of the

Working Group on Quality Care Standards within the Community

Pharmacy Section of the International Pharmaceutical Federation

(FIP). She was a member of the Pharmacy Board, the licensing

authority for pharmacy in Malta for a number of years and

Registrar of the Malta College of Pharmacy Practice, which is

responsible for continuing education. In 1997 she was given an

award by the FIP Foundation for Education and Research, and in

1999 received the ESCP German Research and Education Foun-

dation grant. She has practised clinical pharmacy in the hospital

setting and she practises in community pharmacy.

Lilian Azzopardi has published several papers on clinical

pharmacy and pharmaceutical care, and has actively participated

at congresses organised by FIP, ESCP, the Royal Pharmaceutical

Society of Great Britain, the American Pharmaceutical Association

and the American Society of Health-System Pharmacists. She has

been invited to give lectures and short courses in this area in several

universities. In particular she is course organiser and tutor on the

Patient Centred Clinical Pharmacy course arranged annually by

ESCP in Malta since 2001, under the leadership of Professor Steve

Hudson, in which over 100 clinical pharmacy teachers and prac-

titioners from different countries have taken part.

xviii About the editor

Contributors

Lilian M Azzopardi BPharm (Hons.), MPhil, PhD

Associate Professor, Department of Pharmacy, Faculty of Medicine

and Surgery, University of Malta, Msida, Malta

Stephen A Hudson MPharm, FRPharmS

Professor of Pharmaceutical Care, Division of Pharmaceutical

Sciences, Strathclyde Institute of Pharmacy and Biomedical

Sciences, University of Strathclyde, Glasgow, UK

Sam Salek PhD, RPh, MFPM (Hon)

Professor and Director, Centre for Socioeconomic Research, Welsh

School of Pharmacy, Cardiff, UK

Anthony Serracino-Inglott BPharm, PharmD

Professor and Head of Department, Department of Pharmacy,

University of Malta, Msida, Malta

Maurice Zarb-Adami BPharm, PhD

Senior Lecturer, Department of Pharmacy, University of Malta,

Msida, Malta

Introduction

In the years following the Second World War, the contribution that

pharmacists could make to the successful treatment of patients, by

being involved in the selection of that treatment, began to be appre-

ciated.

The subject of clinical pharmacy was developed in the late

1960s to help pharmacists meet the challenge of acquiring an

education that places the patient at the centre of their professional

activity. This book should help to enhance the clinical aspects of

pharmacy education.

In today’s climate of burgeoning information and complex

clinical issues, a career in clinical pharmacy is more demanding

than ever. Increasingly, training in clinical aspects of pharmacy

must prepare pharmacists to seek and synthesise the necessary

information and to apply that information successfully. The ques-

tions in this book are designed not only to provide examples that

may be asked in clinical pharmacy examinations, but also to

provide a logical framework for organising, learning, reviewing

and applying the conceptual and factual information to the clinical

scenario.

The clinical pharmacist must be able to select the relevant

information and apply it effectively to the clinical situation. The

experienced clinical pharmacist has acquired some clinical perspec-

tive through practice: we hope that this book (especially the case

studies) imparts some of this to the relatively inexperienced. The

format and contents are designed for the examination candidate but

the same approach to problems should help the practising clinical

pharmacist in the lifelong education required in everyday work.

The book is not meant to be used as an introduction to

clinical pharmacy for the undergraduate, because the questions

assume much basic knowledge, and considerable detailed infor-

mation had to be omitted from the answers. Although the book

has a number of appendices giving deﬁnitions of conditions and

terminology, abbreviations and acronyms, and clinical laboratory

data, these are intended to serve as an aide-memoire; they are not

meant to replace the need for continually consulting references in

the ﬁeld.

The questions presented in the four tests are divided into two

parts: essential background information, which is covered in

approximately the ﬁrst 25% of the questions in each test; and the

clinical approach, as seen in the case studies. In the case studies we

have considered the situation that a candidate meets in a clinical

scenario. Although the cases are all speciﬁc, by ﬁnishing the four

tests the candidate should have learnt that the best way to carry

out these exercises is to follow a systematic approach.

Most of the cases dealt with in these tests involve circum-

stances met with in daily practice, such as pulmonary oedema,

heart failure, hypothyroidism, dehydration and diabetes. A large

number of common diseases are included but certainly not all. We

highly recommend reading the short explanations of the answers,

even when a correct answer is achieved, as we emphasise points

that are understressed in some textbooks.

We have also included a couple of cases that are relatively not

so common in everyday practice. It is necessary for the clinical

pharmacist to know about these and to be capable of reaching a

solution to the presented problem. It is to be remembered that in

some scenarios clinical pharmacist services are available on an as-

and-when-required basis. In such a case, the clinical pharmacist is

often consulted when a rare case is met with, especially by junior

doctors. An example from this book is the case describing an

overdose of promethazine and alcohol withdrawal symptoms.

Supplementary reading is essential to understand the basic

pathology involved in these cases, but the information given in the

short answers is probably all that needs to be known by the

xxii Introduction

candidate, and should be sufﬁcient to provide the knowledge

required to reach the correct answer. It should be noted that an

awareness of some rare situations is essential, because it is often in

such cases that the availability of a clinical pharmacist could lead

to the correct treatment; it may be instrumental in improving the

prognosis and on occasions may even be life saving.

Questions on such conditions are also important for candi-

dates preparing for examinations, because examiners tend to

include a rare case or two, to avoid setting a stereotyped examina-

tion involving the same diseases.

We have not attempted to cover all aspects of clinical

pharmacy but – by cross-referencing between one case and another,

and by using the questions that do not involve case studies – only

a few subjects were omitted. This is reinforced by a cursory look

at the indices, on generic names, subject and conditions, in addition

to the cases index. Highly specialized situations, such as those

occurring in oncology, were thought to be unsuitable for inclusion

here. Psychiatry and dermatology are two areas that are often

forgotten by clinical pharmacy students during revision; both

subjects are very relevant to pharmacy.

Clinical pharmacists need to understand basic facts on

diseases and the relevance of laboratory tests (including common

abbreviations and acronyms), to be able to contribute their expert-

ise on therapeutic management in the clinical scenario. The ﬁrst

questions in each test cover these requirements, which are needed

to tackle the comprehensive case study questions.

Before tackling the case studies questions, it is worth ensuring

that you can answer correctly the questions in the beginning of the

test. Knowledge of the meaning of medical terms such as hypoxia,

tachypnoea, myopathy and dysphasia, the signiﬁcance of labora-

tory tests such as INR, HbA1c, BUN, TSH, LFT and MCV and of

the meaning of abbreviations such as PMH, O/E, PC and FH is

also tested in the questions. It may be wise to read through

appendices A, B and C, which give the meaning of medical terms,

abbreviations and the significance of laboratory tests, before

attempting the questions.

Introduction xxiii

Other short questions require a knowledge of side-effects of

medicines, disease symptoms and reasons for the occurrence of

certain reactions, such as resistance to drug therapy. The speciﬁc

advice that needs to be given to patients in relation to the use of

particular medicines, such as when dispensing isosorbide dinitrate,

is emphasised throughout the text. Clinical pharmacists ought to

have a thorough, detailed knowledge of drugs, including indica-

tions, contraindications, monitoring requirements, dosage

regimens, adverse effects and when reporting is required, and of

different classiﬁcations, such as chemical or therapeutic. A list of

all drugs mentioned in the text is conveniently presented in the

generic name index. You can use this index as a self-test to conﬁrm

your preparedness by answering these questions: (1) when is this

drug indicated?; (2) what are the contraindications or cautions?;

(3) what adverse effects may occur and which of these require early

or immediate attention?; (4) how is the drug classiﬁed and what is

its mechanism of action?; (5) does the drug have particular

properties that are of great relevance, such as tolerance, addiction,

teratogenicity and the possibility of resistance developing?

In this book our aim is to base questions on those aspects of

clinical pharmacy that bear most relevance to practice and which

enjoy wide general acceptance. It is hoped that the questions will

be useful not only to candidates preparing for examinations, both

undergraduate and postgraduate, but also to practitioners as a

means of continuing education. We have tried to avoid excessive

detail in the way of ﬁgures, laboratory investigations and in the

facts given; in general those that are included are of value and

essential to tackle the question.

The purpose of this book is to revise aspects of clinical

pharmacy, to prepare for examinations and to apply pharmacy

concepts in continued self-education at undergraduate and post-

graduate level. It has been our experience that students who under-

stand the basic pharmaceutical sciences such as physiology,

biochemistry, medicinal chemistry, pharmaceutics and pharmacol-

ogy have little difficulty in practising as clinical pharmacists,

whereas those who have learned their basic subjects in a parrot-

xxiv Introduction

like fashion are unlikely to thrive in clinical pharmacy, as making

good use of the basic sciences is a requirement. This book there-

fore also serves to show how essential the basic sciences are to

perform well in clinical pharmacy.

An advantage of having an MCQs book as a revision tool is

that during a revision exercise you must commit yourself to an

opinion – using MCQs you have the opportunity to conﬁrm that

the opinion is correct. When mistaken, with the aid of the Answers

section, you can pursue the matter until you understand why your

answer was incorrect. The Answers section should also serve to

reinforce the correct impressions. We do not profess that clinical

pharmacy could be reduced to a mere collection of question and

answer statements, which are all 100% true or false. However we

hope that you will ﬁnd, on investigation and reﬂection, that most

of the statements correlate to real-case scenarios, where a decision

often must be taken in the manner reﬂected in the text.

Introduction xxv

Revision checklist

For each test, write the number of the question and your answer

on a separate sheet of paper, then after going through all the

questions in the test, compare your answers with those in the book.

Refer to Appendix D for feedback on those questions that

you did not answer correctly, to be able to compare your ability

with a cohort of students.

Appendix A includes deﬁnitions of medical terms included in

the book, while Appendix B lists abbreviations and acronyms.

Appendix C presents laboratory test results for parameters that are

mentioned in the book.

Checklist

This checklist should help students identify areas that need to be

covered when preparing for an exam in clinical pharmacy.

● Patient assessment:physical assessment skills, laboratory and

diagnostic information

● Therapeutic planning:problem identiﬁcation, pharmaceutical

care plan, selection of therapeutic regimens, patient moni-

toring

● Monitoring drug therapy:patient counselling, adverse effects,

baseline tests

● Drug information: patient counselling, cautionary labels,

cautions, contraindications

● Responding to symptoms:presentation of conditions, diag-

nosis, referrals, use of non-prescription medicines, patient

counselling

Test 1

Questions

Questions 1–6

Directions:

Each group of questions below consists of five lettered

headings followed by a list of numbered questions. For each

numbered question select the one heading that is most closely

related to it. Each heading may be used once, more than once,

or not at all.

Questions 1–3 concern the following:

❏

MCHC

❏

lymphocytes

❏

HbA1c

❏

INR

❏

thrombocytes

Select, from

, which one of the above:

Q1 may be decreased in iron deﬁciency anaemia

Q2 may have an increased value in viral infections

Q3 may have a decreased value in idiopathic thrombocytopenia purpura

Questions 4–6 concern the following:

❏

tachypnoea

❏

hypoxia

❏

afterload

❏

myopathy

❏

dysphasia

Select, from

, which one of the above is manifested by:

Q4 muscle weakness and muscle wasting

Q5 rapid rate of breathing

Q6 an impairment of the language aspect of speech

Questions 7–26

Directions:

For each of the questions below, ONE or MORE of the

responses is (are) correct. Decide which of the responses is

(are) correct. Then choose:

❏

if 1, 2 and 3 are correct

❏

if 1 and 2 only are correct

❏

if 2 and 3 only are correct

❏

if 1 only is correct

❏

if 3 only is correct

2 Test 1: Questions

Directions summarised

ABCDE

1, 2, 3 1, 2 only 2, 3 only 1 only 3 only

Q7 Drugs that may cause plasma sodium electrolyte disturbances include:

❏

prednisolone

❏

salbutamol

❏

propranolol

Q8 Conditions that may give rise to muscular or joint pain include:

❏

Paget’s disease

❏

neuropathy

❏

haemophilia

Q9 Symptoms that may indicate neoplastic disease if unexplained include:

❏

skin ulceration

❏

unexplained fractures

❏

general debility

Q10 Possible causes of resistance to cytotoxic chemotherapy include:

❏

increased cellular uptake

❏

increased repair of DNA damage

❏

poor penetration into tumour

Q11 In Parkinson’s disease the patient could be referred for services from the:

❏

speech therapy department

❏

physiotherapy department

❏

pain management team

Q12 Ultrasound scanning:

❏

is associated with no radiation dose

❏

may be used to deﬁne organ size and shape

❏

can detect arterial blood ﬂow to the organ

Questions 7–26 3

Q13 Creatinine clearance:

❏

is an index used to measure glomerular ﬁltration rate

❏

measurement involves a 24-hour urine collection

❏

measurement requires 24-hour monitoring of plasma

creatinine

Q14 Patients receiving isosorbide dinitrate should be advised that:

❏

occurrence of headaches tends to decrease with continued

therapy

❏

tablets should be discarded 8 weeks after opening the

container

❏

tablets should be stored in glass containers

Q15 Adrenaline:

❏

is used in cardiac arrest

❏

administration requires monitoring of blood pressure

❏

results in a fall in blood pressure

Q16 Methadone:

❏

requires multiple dosing in a day

❏

is addictive

❏

is an opioid agonist

Q17 Patients receiving tamoxifen should be advised:

❏

that hot ﬂushes may occur

❏

that menstrual irregularities may occur

❏

to report sudden breathlessness and any pain in the calf

Q18 Parenteral sodium bicarbonate:

❏

raises blood pH

❏

is indicated in metabolic acidosis

❏

may be used in hypomagnesaemia

4 Test 1: Questions

Q19 Phytomenadione:

❏

is a lipid-soluble analogue of vitamin K

❏

promotes hepatic synthesis of active prothrombin

❏

is indicated in babies at birth to prevent vitamin K deﬁciency

bleeding

Q20 Enoxaparin:

❏

cannot be used at the same dose as heparin

❏

thrombocytopenia may occur with its use

❏

agents that affect haemostasis should be used with care

Q21 Patients receiving oral isotretinoin should be advised:

❏

to avoid pregnancy

❏

to avoid wax epilation during treatment

❏

to use a lip balm regularly

Q22 A patient who will be undergoing a colonoscopy is advised to:

❏

use a topical haemorrhoid preparation before admission

❏

take a bowel cleansing preparation

❏

avoid solid food on previous day

Q23 In which of the following cases is referral recommended:

❏

a paediatric patient with a history of asthma who presents

with a chest infection

❏

a patient receiving diuretics who presents with symptoms of

a heat stroke

❏

a tourist who presents with acute diarrhoea

Questions 7–26 5

Q24 Anti-infectives that are used in the triple-therapy regimens to eradicate

Helicobacter pylori

include:

❏

metronidazole

❏

clarithromycin

❏

telithromycin

Q25 In HIV infection:

❏

accumulation of mutations associated with drug resistance

may occur

❏

drug resistance testing is not possible

❏

monotherapy is preferred

Q26 Diabetic ketoacidosis:

❏

is associated with insulin deﬁciency

❏

may be precipitated by a severe infection

❏

causes retinopathy

Questions 27–80

Directions:

These questions involve cases. Read the case description or

patient proﬁle and answer the questions. For questions with

one or more correct answers, follow the key given with each

question. For the other questions, only one answer is correct

– give the corresponding answer.

Questions 27–31 involve the following case:

6 Test 1: Questions

PS is hospitalised with pulmonary oedema. Patient is started on metolazone

2.5 mg daily and bumetanide 2 mg bd iv

Q27 Signs and symptoms of pulmonary oedema include:

❏

weight loss

❏

dyspnoea

❏

cough

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q28 Precipitants of acute pulmonary oedema include:

❏

hypothyroidism

❏

excessive infusion rate

❏

heart failure

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q29 Parameters that are monitored during metolazone therapy include:

❏

body weight

❏

electrolytes

❏

LFTs

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 7

Q30 Metolazone and bumetanide:

❏

reduce the blood volume

❏

produce a euphoric state

❏

cause sedation

❏

control bronchospasm

❏

prevent embolisation

Q31 When PS is stabilised, the therapeutic plan should consider:

❏

stopping metolazone treatment

❏

changing bumetanide to an oral formulation

❏

starting co-amoxiclav

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 32–38 involve the following case:

8 Test 1: Questions

CA is a 77-year-old patient who is admitted to hospital with infected multiple sores

and who is complaining of polyuria and weakness. CA presented with reduced

skin turgor, dehydration, tremor and in a confused state. CA has a past medical

history of diabetes. Her general practitioner has started her the day before on

ciproﬂoxacin 250 mg bd and fusidic acid cream bd. Diabetes was managed

through dietary control and CA was not taking antidiabetic drugs. On admission,

CA is started on:

glibenclamide 2.5 mg daily

ciproﬂoxacin 500 mg bd

sodium chloride 0.9% iv infusion

haloperidol 0.5 mg bd

On admission: random blood glucose level 12 mmol/l

blood pressure 125/78 mmHg

Q32 Management aims for CA include:

❏

rehydration

❏

control of hyperglycaemia

❏

management of hypertension

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q33 Parameters that need to be monitored to assess outcomes of therapy

include:

❏

urine output

❏

blood glucose monitoring

❏

thyroid function tests

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q34 Signs which indicate that the diabetes in CA is uncontrolled include:

❏

infected sores

❏

reduced skin turgor

❏

tremor

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 9

Q35 Pharmacist intervention with regards to therapy started on admission

includes:

❏

increase dose of ciproﬂoxacin

❏

review sodium chloride infusion

❏

rationale for haloperidol treatment

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q36 As regards glibenclamide therapy:

❏

gliclazide is preferred in this patient

❏

the dose could be increased to 10 mg daily

❏

the drug is administered in the afternoon

❏

the drug reduces insulin secretion

❏

it restores beta-cell activity

Q37 When the patient is discharged, advice includes:

❏

consuming small, frequent regular meals

❏

taking glibenclamide regularly

❏

using fusidic acid cream daily

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

10 Test 1: Questions

Q38 Onset of hypoglycaemia in CA could be precipated by:

❏

missed doses of glibenclamide

❏

excess dietary intake

❏

skipped meals

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 39–41 involve the following case:

Q39 Symptoms that could occur due to promethazine overdose include:

❏

drowsiness

❏

headache

❏

blurred vision

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 11

BD is a 34-year-old patient admitted with an overdose of promethazine and

alcohol withdrawal symptoms. Patient has a history of alcohol abuse.

Q40 Promethazine is an:

❏

antidepressant

❏

antipsychotic

❏

antihistamine

❏

analgesic

❏

anxiolytic

Q41 A drug that can be used in alcohol withdrawal is:

❏

beclometasone

❏

chlorphenamine

❏

lithium

❏

diazepam

❏

risperidone

Questions 42–44 involve the following case:

Q42 MB is advised:

❏

to report any muscle pain or weakness

❏

to take simvastatin at night

❏

to stop taking atenolol

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

12 Test 1: Questions

MB is a 58-year-old woman who presents with a prescription for simvastatin

10 mg daily. Her current medication is atenolol 50mg daily. MB suffered a heart

attack last year.

Q43 Side-effects to be expected with simvastatin include:

❏

headache

❏

nausea

❏

abdominal pain

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q44 Recommendations made to MB include:

❏

follow moderate exercise

❏

adopt a low-fat diet

❏

take atenolol 2 h before simvastatin

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 45–47 involve the following case:

Questions 27–80 13

GD is a 72-year-old female whose current medication is:

aspirin 75 mg daily

dipyridamole 100 mg tds

timotol 0.5% both eyes 2 drops bd

lactulose 20 ml daily

Q45 Dipyridamole:

❏

cannot be used in combination with low-dose aspirin

❏

is used for prophylaxis of thromboembolism

❏

may cause increased bleeding during or after surgery

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q46 Lactulose:

❏

dose needs to be reviewed as the maximum adult daily dose

is 5 ml

❏

should not be used for more than 5 days

❏

is used to maintain bowel evacuation

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q47 GD is receiving medications for:

❏

glaucoma

❏

diarrhoea

❏

osteoporosis

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

14 Test 1: Questions

Questions 48–53 involve the following case:

Q48 The therapeutic aims for SP are:

❏

to control symptoms of heart failure

❏

to control oedema

❏

to control diabetes

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q49 Spironolactone:

❏

reduces symptoms and mortality

❏

dose may be increased to 25 mg daily

❏

is an aldosterone antagonist

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 15

SP is a 64-year-old patient who is admitted to hospital with tiredness, shortness of

breath and ankle oedema. She has a medical history of congestive heart failure.

SP was intolerant to enalapril owing to the development of a cough. Her

medications on admission are:

spironolactone 12.5 mg daily

losartan 25 mg daily

Q50 Monitoring required because of spironolactone treatment involves:

❏

serum creatinine

❏

serum potassium

❏

thyroid function

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q51 Losartan:

❏

is an angiotensin-II receptor antagonist

❏

exhibits a lower incidence of cough as a side-effect

compared with enalapril

❏

dose may be increased to 50 mg daily

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q52 Digoxin is used in patients with heart failure:

❏

because it decreases myocardial intracellular ionic calcium

❏

when there is atrial ﬁbrillation

❏

because it exerts a positive inotropic effect

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

16 Test 1: Questions

Q53 Parameters to be monitored when digoxin therapy is started:

❏

plasma digoxin concentration

❏

plasma potassium measurement

❏

plasma sodium measurement

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 54–57 involve the following case:

Q54 The likely diagnosis for LB is:

❏

prickly heat

❏

herpes zoster infection

❏

herpes labialis infection

❏

cytomegalovirus infection

❏

hepatitis B infection

Q55 Patient should be advised:

❏

to take doses at regular intervals

❏

to avoid exposure to sunlight

❏

to wash hands thoroughly after drug administration

Questions 27–80 17

LB is a 55-year-old male patient who developed vesicles unilaterally around his

waist. LB complained of a stabbing irritation in the area. LB is prescribed aciclovir

800 mg ﬁve times daily for 5 days.

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q56 Side-effects that may be expected include:

❏

headache

❏

nausea

❏

diarrhoea

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q57 Adjuvant therapy that may be used for LB include(s):

❏

calamine lotion

❏

amitriptyline

❏

ergotamine

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

18 Test 1: Questions

Questions 58–63 involve the following case:

Q58 Penicillin G is:

❏

phenoxymethylpenicillin

❏

benzylpenicillin

❏

penicillin V

❏

piperacillin

❏

pivmecillinam

Q59 Penicillin G is available in 600 mg vials. How many vials are required

for each dose?

❏

0.5

❏

Q60 Penicillin G:

❏

is bacteriostatic

❏

is bactericidal

❏

can be given as an intramuscular injection

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 19

AD is a 39-year-old female with bacterial endocarditis. She is started on

gentamicin 80 mg iv twice daily and penicillin G iv 1.8 g every 6 h.

Q61 Gentamicin:

❏

has a broad spectrum of activity

❏

is contraindicated in hepatic impairment

❏

therapy may be changed to oral administration when the

patient is stabilised

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q62 A possible reason for these symptoms is:

❏

allergy to gentamicin

❏

allergy to penicillin G

❏

development of heat rash

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q63 Manifestations of bacterial endocarditis include:

❏

prolonged fever

❏

embolic phenomena

❏

renal failure

20 Test 1: Questions

Patient developed a rash and started complaining of generalised itch after the

administration of the drugs.

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 64–74 involve the following case:

Q64 Gout:

❏

may be due to excessive production of uric acid

❏

may be due to increased renal elimination of uric acid

❏

results in the deposition of crystals of xanthine in the joints

❏

is characterised by excessive calcium deposited in the joints

❏

is the result of hypouricaemia

Q65 Gout may be precipitated in JZ by:

❏

heart failure

❏

bendroﬂumethiazide

❏

excessive consumption of meat in the diet

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 21

JZ is a 78-year-old obese male who is diagnosed with an acute attack of gout.

PMH hypertension, heart failure

DH enalapril tablets 5 mg daily

atenolol tablets 100 mg daily

bendroﬂumethiazide tablets 5 mg daily

aspirin ec tablets 75 mg daily

He is started on colchicine tablets 500 μg twice daily for six days.

Q66 Gout:

❏

presents as a painful condition in the big toe

❏

onset is insidious

❏

recurrence is rare

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q67 Diagnosis of gout:

❏

is based on clinical signs

❏

requires conﬁrmation of urate crystals in the synovial ﬂuid of

affected joint

❏

requires a positive ESR level

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q68 Non-pharmacological measures for JZ include:

❏

resting the affected joint

❏

maintaining a high ﬂuid intake

❏

maintaining a high calcium intake

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

22 Test 1: Questions

Q69 Colchicine:

❏

reduces the inﬂammatory reaction to urate crystals

❏

provides dramatic relief from acute attacks of gout

❏

is also used in rheumatoid arthritis

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q70 Colchicine:

❏

should be used when there is a contraindication to NSAIDs

❏

is more toxic than NSAIDs

❏

occurrence of diarrhoea and vomiting are used as an index

to review therapy

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q71 Alternatives to colchicine in the management of gout include:

❏

indometacin

❏

diclofenac

❏

aspirin

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 23

Q72 To prevent further attacks, JZ should be advised to:

❏

lose weight

❏

follow a diet low in purines

❏

keep taking colchicine on a long-term basis

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q73 Allopurinol:

❏

should be started 2–3 weeks after the acute attack has

subsided

❏

reduces urate production

❏

is given once daily

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q74 Uricosuric agents:

❏

can be used instead of allopurinol

❏

are ineffective in patients with impaired renal function

❏

increase renal urate excretion

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

24 Test 1: Questions

Questions 75–80 involve the following case:

Q75 In view of the recent amendments to her treatment, HG should be

advised to:

❏

take thyroxine tablet in the morning

❏

take metformin tablet with food

❏

take dipyridamole tablets before food

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q76 Hypothyroidism:

❏

may have an insidious onset in the elderly

❏

may cause dry eyes

❏

may induce hypoglycaemia

Questions 27–80 25

HG is a 71-year-old female with a history of Sjögren’s syndrome. She presents

with complaints of dry eyes and dry mouth.

At the time the patient was on aspirin 150 mg daily, dipyridamole 25 mg tds,

glimepiride 1 mg daily and atenolol 100 mg daily. Recently hypothyroidism was

diagnosed and she was started on thyroxine 50 μg daily. During a recent follow

up, her diabetologist added metformin 500 mg daily because her blood glucose

level was 13.8 mmol/l. She was also started on simvastatin 10 mg nocte.

Her ESR is 109 mm/h and she has a positive rheumatoid factor.

Methylcellulose eye drops to be used as required are recommended to HG.

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q77 Drugs that could signiﬁcantly interact with thyroxine include:

❏

warfarin

❏

simvastatin

❏

ranitidine

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q78 Caution should be undertaken when starting thyroxine in:

❏

elderly patients

❏

diabetics

❏

patients with cardiovascular disorders

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

26 Test 1: Questions

Q79 Side-effects associated with thyroxine include:

❏

diarrhoea

❏

anginal pain

❏

bradycardia

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q80 Total thyroid hormones:

❏

concentration in plasma changes with alterations in the

amount of thyroxine-binding globulin in plasma

❏

concentration is used as the main diagnostic marker for

hypothyroidism

❏

act as antibodies to thyroglobulin

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 27

Test 1

Answers

Questions 1–3

Interpretation of clinical laboratory tests is useful during diagnosis and during

therapeutic monitoring. Common laboratory tests include electrolytes, haema-

tology, renal function tests and liver function tests. In interpreting clinical

laboratory tests, it is important to use different tests to corroborate information

because laboratory errors are not uncommon, caused by, for example, spoiled

specimens, incorrect amount of specimen and medications that could interfere

with test results. Furthermore, laboratory investigations are best collaborated

through supporting clinical evidence. When possible laboratory results are

best evaluated in an holistic approach.

A1 A

The mean corpuscular haemoglobin concentration (MCHC) is a red cell index

that forms part of haematology tests. It measures the average concentration

of haemoglobin in erythrocytes (red blood cells). It is decreased in different

presentations of anaemia, including iron deﬁciency anaemia and in thalas-

semia. In iron deﬁciency anaemia, the haematocrit value (space occupied by

packed erythrocytes) is decreased.

A2 B

The measurement of total and differential white blood cell (WBC) count is a

part of all routine laboratory diagnostic evaluations. It is helpful in the evalu-

ation of a patient with an infection, although a high WBC count may also be

found in other conditions such as neoplasma, allergy and immunosuppression.

One type of WBCs is the lymphocytes, their primary function being to ﬁght

chronic bacterial infection and acute viral infections. Lymphocytes can be

further classiﬁed into B cells and T cells. The mature B cells produce immuno-

globulins. The T cells have cell-mediated immunity as a major property, where

they act directly to eliminate certain microorganisms and regulate the activity

of B cells in producing immunoglobulins. An increased number of lymphocytes

(lymphocytosis) occurs with viral infections, such as in patients with upper

respiratory tract infections, mumps and infectious mononucleosis.

A3 E

Thrombocytes (platelets) are elements in blood, their main role being the

maintenance of vascular integrity. In idiopathic thrombocytopenia purpura

there is a deﬁciency of platelets leading to bruising and bleeding. Idiopathic

thrombocytopenia purpura is associated with the occurrence of antibodies to

platelets.

Questions 4–6

When approaching therapeutic management of a patient, it is essential to

familiarise yourself with background information on the disease state(s) and

on the patient’s presenting complaints.

A4 D

Myopathy is a condition affecting the skeletal muscle, and which is manifested

by muscle weakness and wasting. Histological changes occur in the muscle

tissues, similar to those that occur in muscular dystrophies.

A5 A

Tachypnoea is an abnormally fast breathing rate. It is characteristic of

respiratory diseases and occurs in hyperpyrexia. It occurs as a result of over-

activity at the level of the sympathetic nervous system.

30 Test 1 Answers

A6 E

Dysphasia (aphasia) is a condition resulting in impairment of the language

aspect of speech. It usually occurs as a result of cerebral cortex injury, such

as after surgery for a brain tumour or after a cerebral stroke. The presence of

dysphasia is frequently accompanied by writing disorders.

Questions 7–26

A7 D

Prednisolone is a corticosteroid with a predominantly glucocorticoid activity.

However, owing to minor mineralcorticoid activity, it may still cause electrolyte

imbalance, namely sodium and water retention and potassium loss. Salbuta-

mol and propranolol do not interfere with plasma sodium electrolyte levels.

Salbutamol may precipitate hypokalaemia, especially with parenteral adminis-

tration or after nebulisation. The risk of hypokalaemia with salbutamol therapy

may be increased with concomitant administration of certain drugs, such as

corticosteroids and diuretics.

A8 A

Paget’s disease, neuropathy and haemophilia are all conditions that are

associated with the occurrence of muscular or joint pain. Paget’s disease is a

disease of the bone where there is excessive bone destruction and abnormal-

ities in bone repair. The condition may be associated with bone pain, bone

deformity, fractures and pain caused by pressure on nerves. However, Paget’s

disease may be asymptomatic. Neuropathy is a condition where there is

inﬂammation or degeneration of the peripheral nerves. It may occur as a

complication of long-standing uncontrolled diabetes. Patients complain of

excruciating pain in the peripheries. In haemophilia there is a deﬁciency of

one of the factors necessary for blood coagulation. Patients with haemophilia

are prone to develop bleeding in joints, resulting in pain.

Test 1 Answers 31

A9 A

Several persistent unexplained symptoms may indicate neoplastic disease and

would require further assessment to understand the underlying pathology.

Symptoms such as skin ulceration, unexplained fractures and general debility

may indicate neoplastic disease. Skin ulceration could occur as a result of skin

carcinoma. Unexplained fractures may be due to carcinoma involving the

bone structure. This tumour usually occurs as a secondary tumour to a solid

tumour that has originated in another area. General debility may be a

characteristic of malignant disorders, such as chronic myelocytic leukaemia,

Hodgkin’s disease, non-Hodgkin’s lymphoma and various solid tumours.

A10 C

The administration of cytotoxic chemotherapy regimen may fail to achieve

remission in an individual patient compared with a cohort of patients owing

to drug resistance. Tumour cells may be inherently resistant or acquire resist-

ance after a number of treatment sessions. Tumour cell resistance may be

explained by a reduction of intracellular drug concentration, enzymatic

deactivation of the drug, and by increased repair of damaged DNA. If the

drugs fail to penetrate the solid tumour, then they are not in a position to

achieve cell death.

A11 B

In Parkinson’s disease patients have problems with postural stability, movement

and verbal communication. The involvement of physiotherapists and speech

therapists helps the patient to cope with the loss of mobility, to retain activity

as much as possible and to keep communication with carers. Patients with

Parkinson’s disease have a mask-like expression, a monotonous voice and may

experience fatigue, drooling of saliva, dysphagia, constipation, excessive

swelling, speech and depressive disorders. Severe chronic pain is not a

presentation that is related to the occurrence of Parkinson’s disease.

32 Test 1 Answers

A12 B

Ultrasound scanning is a non-invasive, non-toxic diagnostic procedure that can

be used to examine internal organs. It does not involve radiation. It is based

on sound waves that travel through the body tissues at different speed

depending on the density and elasticity of the organ tissues. Ultrasound

scanning is used to diagnose conditions such as tumours in areas such as

abdomen, heart, liver and kidneys. It is also used to assess the development

of the fetus.

A13 B

Creatinine clearance is the rate of removal of creatinine from the body by the

kidney during glomerular ﬁltration. It gives a measure of the glomerular ﬁltra-

tion rate (GFR). The measured creatinine clearance is more accurate in the

assessment of renal function compared with the calculated creatinine

clearance, which is based on a formula where the serum creatinine concen-

tration is used. To measure the creatinine clearance, a 24-h urine collection

and a serum sample are required.

A14 D

Isosorbide dinitrate is a nitrate that is a more stable preparation compared

with glyceryl trinitrate. Isosorbide dinitrate tablets are stable and do not require

special storage conditions. It is used in the prophylaxis and treatment of

angina and in left ventricular failure. The most common side-effect that may

occur is throbbing headache. Occurrence of this side-effect usually decreases

after a few days. The headache is associated with peripheral vasodilation.

Tolerance to the peripheral effects occurs early on in treatment.

A15 B

Adrenaline is a potent sympathomimetic agent that is used in cardiac arrest

by intravenous injection preferably through a central line. It is the ﬁrst-line

Test 1 Answers 33

treatment in anaphylaxis, where it is usually given intramuscularly. Stimulation

of the alpha-adrenergic receptors produces vasoconstriction that may result in

hypertension. Blood pressure should be monitored during administration of

adrenaline. It should be used with caution in patients with hypertension. Over-

dosage may cause a sharp rise in blood pressure.

A16 C

Methadone is an opioid agonist that is itself addictive and is used in the

management of patients who are physically dependent on opioids. Its

advantage in the management of opioid dependence is that it is administered

as a single daily dose, usually as an oral solution.

A17 A

Tamoxifen is an oestrogen-receptor antagonist that is used for breast cancer

and anovulatory infertility. Its side-effects are very similar to the menopausal

phase and hot ﬂushes are a common side-effect. Suppression of menstruation

may occur in premenopausal women. As the use of tamoxifen is associated

with an increased risk of endometrial changes, including hyperplasia, polyps,

cancer and uterine sarcoma, occurrence of menstrual abnormalities, including

abnormal vaginal bleeding and vaginal discharge, warrant immediate investi-

gation. Hence patients receiving tamoxifen should be advised that if menstrual

irregularities occur they should seek medical advice. Tamoxifen can increase

the risk of thromboembolism, and therefore patients should be advised about

the symptoms that may indicate onset of thromboembolism, such as sudden

breathlessness and pain in the calf, so that they seek advice immediately.

A18 B

Sodium bicarbonate as a parenteral preparation for ﬂuid and electrolyte

imbalance is used in severe metabolic acidosis, for example, in renal failure

when blood pH is less than 7.1. By administering sodium bicarbonate, in

34 Test 1 Answers

conjunction with sodium chloride when there is also sodium depletion, pH of

blood is increased. Sodium bicarbonate may also alkalinise the urine, which

will increase the excretion of weak acids. In hypomagnesaemia, magnesium

sulphate intravenous infusion is administered.

A19 A

Phytomenadione is vitamin K1. Vitamin K is a fat-soluble vitamin that is

required for the hepatic synthesis of prothrombin and other blood clotting

factors (factors VII, IX, X and proteins C and S). Neonates are particularly

prone to develop vitamin K deﬁciency and this may lead to haemorrhagic

disease including intracranial bleeding. It may be used in babies at birth as

a single intramuscular injection to prevent vitamin K deﬁciency bleeding.

Vitamin K deﬁciency may occur in underweight neonates owing to inadequate

synthesis.

A20 A

Enoxaparin is a low-molecular-weight heparin that has a longer duration of

action when compared with unfractionated heparin. The dose for enoxaparin

varies from the dose for heparin; for example, in the prophylaxis of deep vein

thrombosis before surgery, 2000 units of enoxaparin are administered 2 hours

before surgery, whereas for heparin 5000 units are administered 2 hours

before surgery. As with heparin, thrombocytopenia may occur with the

administration of low molecular weight heparins. Enoxaparin should be

avoided in patients who have developed thrombocytopenia with heparin.

Regular monitoring is required when the patient is also taking any drugs that

interfere with haemostasis. The use of oral anticoagulants, dipyridamole,

aspirin and other non-steroidal anti-inﬂammatory drugs (NSAIDs) should be

reviewed. Care should be taken when used in conjunction with thrombolytic

enzymes and high doses of penicillins and cephalosporins.

Test 1 Answers 35

A21 A

Isotretinoin is a retinoid that may be used orally in the specialist management

of severe acne vulgaris. Retinoids have many contraindications and serious

side-effects. Isotretinoin is teratogenic and therefore women of child-bearing

age should be advised to avoid pregnancy and to practise effective contra-

ception. Retinoids should only be used in premenopausal women if they have

severe disabling skin disease that is resistant to other treatment and if

pregnancy has been excluded. Treatment with oral isotretinoin should be

started only during the second or third day of a menstrual cycle and contra-

ceptive precautions should be continued for at least 4 weeks after the end of

treatment. Common side-effects of oral isotretinoin treatment include dryness

of the skin presenting with dermatitis, scaling, thinning, erythema and pruritus,

epidermal fragility and dryness of the lips, pharyngeal mucosa and nasal

mucosa. During treatment and for at least 6 months from stopping treatment,

patients should be advised to avoid wax epilation because of a risk of

epidermal stripping, and to avoid dermabrasion and laser skin treatment as

there is risk of scarring. Patients should be advised to avoid exposure to ultra-

violet light and to use sunscreens, emollients and lip balms regularly during

treatment.

A22 C

Colonoscopy is a diagnostic procedure that is carried out to examine the colon

and terminal ileum. To aid the direct observation of the bowel, bowel cleansing

is required before the procedure. Patients are advised to follow a clear-liquid

diet before the procedure at least for one day. Bowel cleansing preparations

containing magnesium salts are administered orally on the day before the

procedure. They produce rapid evacuation of the bowels. Patient should not

consume any food or ﬂuids from 6–8 hours before the procedure.

A23 B

Patients with a history of asthma presenting with a chest infection should be

referred for assessment about the need to use antibacterial agents and the

36 Test 1 Answers

necessity of reviewing asthma treatment. A paediatric patient is at a higher

risk of rapid deterioration. Patients who are using diuretics are more prone to

dehydration in a hot climate. If they present symptoms of a heat stroke they

should be referred for assessment of their medical condition, as they are at

higher risk of developing complications. Acute diarrhoea may be treated by

recommending oral rehydration salts. The patient is asked to contact a pharma-

cist, should the situation get worse or if it is not managed within a few days.

A24 B

Helicobacter pylori

, a Gram-negative bacterium, is implicated as a cause of

chronic gastritis and peptic ulceration. Its eradication in the stomach entails a

triple-therapy regimen that is based on a proton pump inhibitor such as

omeprazole, and two anti-infective agents, namely amoxicillin and either clari-

thromycin or metronidazole. In patients who are penicillin sensitive, the triple

therapy regimen considered consists of a proton pump inhibitor, clarithromycin

and metronidazole. Telithromycin is a derivative of erythromycin that is not

used in

Helicobacter pylori

eradication therapy.

A25 D

In patients affected by the human immunodeﬁciency virus (HIV), the aim of

treatment is to decrease the plasma viral load as much as possible for the

longest possible time. Before starting treatment or when changing drug

therapy, viral sensitivity to antiretroviral agents should be established. The

onset of drug resistance is reduced by using combination of drugs so as to

have a synergistic or additive effect. Care should be taken to ensure that the

combination used does not have an additive toxicity as antiretrovirals are

toxic. Common combinations include two nucleoside reverse transcriptase

inhibitors and either an HIV-protease inhibitor or a non-nucleoside reverse

transcriptase inhibitor. In HIV, viral replication leading to accumulation of

mutations results in the emergence of drug-resistant variants and consequently

disease progression.

Test 1 Answers 37

A26 B

Diabetic ketoacidosis is a condition where there is acidosis and an accumu-

lation of ketones in the body resulting from extensive breakdown of fat. It

occurs in patients with hyperglycaemia and ketosis as a result of insulin

deﬁciency. Normally diabetic patients with hyperglycaemia do not progress

to diabetic ketoacidosis. Factors that could precipitate the condition include

infection, dehydration, surgery, sustained strenuous exercise, trauma. Patients

with diabetic ketoacidosis present with a fruity odour of acetone on the breath,

mental confusion, dyspnoea, nausea, vomiting, and dehydration. The

condition may lead to coma. Retinopathy is a complication of diabetes that

could lead to blindness.

Questions 27–31

Pulmonary oedema may result from the failure of a number of homeostatic

mechanisms and it is a condition that can develop acutely and can be fatal.

It most commonly occurs as a result of chronic heart failure. Diuretics provide

a dramatic improvement of the condition.

A27 C

Signs and symptoms of pulmonary oedema include dyspnoea, cough, orthop-

noea, and tachypnoea. Owing to the accumulation of extravascular ﬂuid in

lung tissues, alveoli and in the extremities, the patient may present with an

increase in weight.

A28 C

An acute attack of pulmonary oedema may develop due to progressive heart

failure or when the patient is not compliant with medication, particularly the

diuretic therapy. It may also occur due to hypervolaemia, such as when

compromised and non-compromised patients are exposed to an excessive ﬂuid

38 Test 1 Answers

infusion rate or to a high sodium intake. Conditions that lead to an increased

metabolic demand, such as high fever and hyperthyroidism, may also precipi-

tate acute pulmonary oedema.

A29 B

Metolazone is a diuretic that is associated with profound diuresis, especially

when it is combined with a loop diuretic. Patients receiving metolazone should

be monitored for electrolyte imbalance and outcome of therapy may be

assessed by measuring change in body weight and urine production.

A30 A

Metolazone is a diuretic with actions similar to a thiazide diuretic, and

bumetanide is a loop diuretic. Metolazone has a long duration of action of

about 12–24 h compared with intravenous bumetanide, which has a duration

of action of 0.5–1 h. Diuretics increase diuresis and result in a reduction of

blood volume.

A31 B

Once PS is stabilised, a long-term therapeutic plan should be carried out.

Metolazone treatment should be withdrawn, after which a change from

bumetanide to oral therapy should be attempted. The patient should be

advised about the importance of compliance with bumetanide, and that the

unwanted effect of increased diuresis with oral treatment usually decreases

with time. The patient should be advised to take the drug in the morning.

Potassium levels should be monitored and, if the patient is not taking any

drugs with a potassium-sparing effect, then potassium supplements should

be considered when bumetanide therapy is given long-term.

Test 1 Answers 39

Questions 32–38

CA is a diabetic patient whose blood glucose level needs monitoring. Upon

discharge the pharmacist needs to advise the patient on her condition and on

her medication so as to avoid future deterioration. She is showing signs of

dehydration and uncontrolled blood glucose levels.

A32 B

Rehydration and control of hyperglycaemia are the primary aims. Her skin

condition is a secondary complication of uncontrolled diabetes. The anti-

bacterial agent is continued and patient is started on an antidiabetic drug

(glibenclamide) to control blood glucose levels. CA is also administered

haloperidol (an antipsychotic).

A33 B

In patients who are dehydrated, urine output is very much decreased. The

extent of rehydration, which is being undertaken using intravenous infusion of

sodium chloride, should be assessed by monitoring urine output. Regular blood

glucose monitoring is required and, if necessary, antidiabetic therapy should

be reviewed.

A34 B

Clinical features of hyperglycaemia include thirst, dry mouth, reduced skin

turgor, polyuria, nocturia. A diabetic complication is an increased suscepti-

bility to infection especially in the skin, vaginal area and peripheries.

A35 C

Ciproﬂoxacin may be administered at a dose of 500 mg orally twice daily.

As CA has been started on this antibacterial agent only the day before her

40 Test 1 Answers

admission, there is no indication that warrants a need to increase the dose

or review the therapy because the drug is ineffective. The sodium chloride

infusion is required to rehydrate the patient, and should be continued until

normal urine ﬂow is achieved. The pharmacist could monitor the patient’s

progress and advise the prescribing team when to withdraw the infusion. There

is no apparent rationale for the use of haloperidol in this elderly patient. Her

state of confusion is due to her hyperglycaemic state, which has precipitated

dehydration. Correction of these complications should improve her confusion.

Haloperidol has a rapid effect on hyperactive states and initial doses may help

to calm down the patient. However, continued use may precipitate hypo-

glycaemia. Continued treatment with haloperidol should be reviewed.

A36 A

Glibenclamide and gliclazide are oral sulphonylureas that are used in

diabetes to augment secretion of insulin. They are effective only in patients

with residual pancreatic beta-cell activity. Gliclazide is a shorter-acting

product. It has a duration of action of about 12 h whereas glibenclamide has

a duration of action of up to 24 h. The shorter-acting product is less likely to

cause hypoglycaemia. CA is an elderly patient, who may present with a

slower metabolism of the drug; she may be living alone and may have

problems with maintaining regular meals. The dose of glibenclamide for

elderly patients is usually 2.5 mg after breakfast.

A37 B

CA should be advised to consume small, frequent regular meals that are low

in fat and carbohydrate content. She should be educated on the foods to

include in her diet and about the importance of having a regular schedule of

food intake to avoid hypoglycaemic attacks. She should be reminded that she

has to continue taking the glibenclamide tablet daily at breakfast to avoid

recurrence of hyperglycaemia.

Test 1 Answers 41

A38 E

Hypoglycaemia with sulphonylureas may occur either because of excessive

doses or skipped meals. If CA continues to take her glibenclamide tablets and

she skips meals, there is a higher risk of hypoglycaemia.

Questions 39–41

Alcohol is a central nervous system depressant. Conditions that are associated

with alcoholism include liver disease, cardiomyopathy, pancreatitis and gastro-

intestinal disease. Signs and symptoms of alcohol withdrawal include tremor,

tachycardia, diaphoresis, labile blood pressure, anxiety, nausea and vomiting,

hallucinations and seizures.

A39 A

Promethazine is a sedating antihistamine, which BD was probably using

initially for the insomnia and sleep disorders that are associated with alcohol

withdrawal syndrome. Side-effects that could occur with the use of pro-

methazine, especially in overdosage include drowsiness, headache, and

antimuscarinic effects such as blurred vision and urinary retention.

A40 C

Promethazine is a sedating antihistamine that could be used in the symptom-

atic relief of allergy of nasal or dermatological origin, as a hypnotic and in

motion sickness. It can be used in adults and children over 2 years.

A41 D

Long-acting benzodiazepines such as diazepam could be used in alcohol

withdrawal to counteract the withdrawal symptoms. In alcohol withdrawal,

42 Test 1 Answers

symptoms of the initial phases do not necessarily diminish as withdrawal

advances. This depends on the amount of alcohol consumed, on the abrupt-

ness of discontinuation and on the patient’s general well-being. When the

patient is started on a benzodiazepine, advice on alcohol abstinence should

be provided. Also the patient should be referred to patient-support groups, to

provide the necessary psychosocial support for the management of alcohol

abuse.

Questions 42–44

A myocardial infarction, also referred to as a heart attack, is the necrosis of

a portion of the cardiac muscle and occurs due to occlusion of the coronary

artery, either because of atherosclerosis or thrombus or a spasm. The patient

presents with a crushing chest pain that may radiate to the left arm, neck and

epigastrium. Statins are used as lipid-lowering agents in conjunction with diet

to reduce total cholesterol and low-density-lipoprotein cholesterol as a

secondary prevention of the recurrence of cardiovascular disease. They reduce

morbidity and mortality in these patients.

A42 B

Simvastatin is a statin and it may cause rare but signiﬁcant side-effects of

myalgia, myositis and myopathy. Patient should be advised to report any

muscle pain, tenderness and weakness as they could be signs of these side-

effects. Higher efﬁcacy has been shown with the administration of simvastatin

at night, compared with in the morning, probably because cholesterol bio-

synthesis reaches a peak during the night.

A43 A

Common side-effects associated with statins include headache, gastrointestinal

symptoms and altered liver function tests.

Test 1 Answers 43

A44 B

The use of lipid-regulating drugs, including statins, should be combined with

a low-fat diet and moderate exercise such as walking so as to reduce the risk

of cardiovascular disease.

Questions 45–47

Medication review, particularly for elderly patients, is useful to evaluate

rationale for drug therapy, to monitor outcomes, to identify problems with the

medications and to re-inforce patient counselling. GD is receiving dipyri-

damole and aspirin as antiplatelet drugs; timotol, a beta-blocker; and

lactulose, an osmotic laxative.

A45 C

Dipyridamole is used as an oral preparation for the prophylaxis of thrombo-

embolism and for the secondary prevention of ischaemic stroke and transient

ischaemic attacks. It may cause increased bleeding during or after surgery

and it may induce bleeding in patients receiving oral anticoagulants without

altering the prothrombin time. It may be used in combination with low-dose

aspirin as this combination may further reduce the risk of ischaemia.

A46 E

Lactulose is a semi-synthetic disaccharide that can be safely used on a long-

term basis in elderly patients to maintain regular bowel evacuation, especially

in patients with limited mobility. The initial adult dose of lactulose is 15 ml

twice daily and this may be adjusted according to the individual’s needs.

Therefore 20 ml daily dose is an acceptable dosage regimen.

44 Test 1 Answers

A47 D

GD is receiving prophylactic therapy for secondary prevention of cerebro-

vascular and cardiovascular disease, timotol for glaucoma and lactulose to

maintain regular bowel movements.

Questions 48–53

SP is presenting with a deterioration of congestive heart failure presenting

mainly as oedema. Management of congestive heart failure may include an

angiotensin-converting enzyme inhibitor (ACE) such as enalapril, a diuretic if

there is ﬂuid overload, spironolactone, beta-blockers and digoxin.

A48 B

SP is presenting the classic symptoms of heart failure, namely tiredness,

shortness of breath and oedema. In SP the aims are to control the symptoms

of heart failure and limit the deterioration of the condition leading to oedema.

A49 A

Spironolactone is a potassium-sparing diuretic that acts by antagonising aldos-

terone. It can be used in patients already receiving an ACE inhibitor to reduce

the symptoms and mortality associated with congestive heart failure. Low

doses of spironolactone are used and the maximum dose is 25 mg daily.

A50 B

In patients with congestive heart failure receiving spironolactone, the moni-

toring of serum creatinine and potassium is necessary. Spironolactone should

not be used in patients with hyperkalaemia or in severe renal impairment.

Test 1 Answers 45

A51 A

Losartan is an angiotensin-II receptor antagonist which may be used as an

alternative to ACE inhibitors in patients who develop cough. The usual main-

tenance dose for losartan is 50 mg daily.

A52 C

Digoxin is a cardiac glycoside that may be used in patients with heart failure

when there is atrial ﬁbrillation. It is a positive inotropic drug and it increases

contractility of the heart thus increasing cardiac output. It has a long halﬂife.

A53 B

Digoxin has a narrow therapeutic margin and treatment may lead to digitalis

toxicity, which may be manifested by nausea, vomiting, anorexia, diarrhoea

and abdominal pain. This may progress to cardiac toxicity resulting in heart

block. Hypokalaemia in patients receiving digoxin increases risk of digitalis

toxicity. It is necessary to monitor plasma potassium levels and plasma digoxin

concentrations. In patients who are already receiving spironolactone or an

ACE inhibitor, risk of hypokalaemia is minimal.

Questions 54–57

LB has herpes zoster infection, also known as shingles. Antiviral treatment

reduces the severity and duration of pain, reduces complications and reduces

viral shedding. Complications of shingles include postherpetic neuralgia which

lasts months to years, eye or ear involvement. Treatment with antiviral drugs

should be started within 72 h of the onset of the rash.

46 Test 1 Answers

A54 B

LB has herpes zoster infection. It is an acute infection due to re-activation of

the varicella zoster virus which is latent in the body. It affects mainly adults

and is characterised by the development of painful vesicles that follow the

underlying route of a nerve. The vesicles are usually unilaterally distributed

over the body.

A55 B

The patient should be advised to take aciclovir tablets at regular intervals and

to complete the prescribed course. The patient should be advised to avoid

exposure to sunlight, as aciclovir may cause photosensitivity.

A56 A

Gastrointestinal side-effects of aciclovir include nausea, vomiting, abdominal

pain and diarrhoea. Other side-effects are headache, fatigue, rash, urticaria

and pruritus.

A57 B

Calamine lotion may be used by LB to reduce itching and to provide symptom-

atic relief of the pain. Amitriptyline may be used as an adjuvant analgesic,

particularly if the patient develops postherpetic neuralgia. In addition an

analgesic such as a non-steroidal product and a topical corticosteroid to

reduce severe inﬂammation may be considered.

Questions 58–63

Bacterial endocarditis is an infective condition affecting the endocardium and

the cardiac valves. It is more common when there are cardiac abnormalities

Test 1 Answers 47

such as aortic valve disease, pulmonary stenosis and mitral stenosis or in the

presence of prosthetic valves. In infective endocarditis, it is essential to identify

causative organism, to eradicate the organism and to prevent recurrence of

infection. It usually occurs when bacteria are released from an infected site

such as a tooth or skin abscess or after a surgical intervention.

A58 B

Benzylpenicillin is Penicillin G.

A59 D

Each vial contains 0.6 g and therefore for a dose of 1.8 g, three vials are

required.

A60 C

Penicillin G, as with all penicillins, is a bactericidal and acts by interfering

with bacterial cell-wall synthesis. Penicillin G is inactivated by bacterial beta-

lactamases. As it is inactivated by gastric acid, and absorption from the gut

is very low, it is administered as an intramuscular injection or by slow intra-

venous injection or by infusion.

A61 D

Gentamicin is an aminoglycoside that has a bactericidal action against Gram-

negative and Gram-positive bacteria. It is excreted primarily by the kidneys,

so in renal impairment, the dose should be reduced or the dosing intervals

increased. Aminoglycosides are not absorbed from the gastrointestinal tract,

and therefore for a systemic effect, parenteral administration is required.

48 Test 1 Answers

A62 A

Hypersensitivity to antibacterial agents and the development of a heat rash

are possible.

A63 A

The clinical presentation of bacterial endocarditis varies. Usually there is an

insidious onset and the patient’s condition starts to deteriorate gradually. Fever

is the most common ﬁnding, usually occurring at a relatively low grade. Initial

symptoms are fatigue, low-grade fever, weakness, anorexia and weight loss.

Embolic phenomena such as splenic or renal infarction and skin manifesta-

tions occur in a large number of cases. Peripheral manifestations of endocardi-

tis may occur, such as petechiae and ﬁnger clubbing. In some patients signs

of renal failure are also manifested.

Questions 64–74

JZ presents with an acute attack of gout. He is on medication to control his

hypertension and heart failure. He is taking an angiotensin-converting enzyme

inhibitor (enalapril), a beta-adrenoceptor blocker (atenolol), a thiazide diuretic

(bendroﬂumethiazide) and aspirin as an antiplatelet agent to prevent occur-

rence of cerebrovascular disease and myocardial infarction.

A64 A

Gout is a condition associated with either an increased production of uric acid

or a decreased excretion of uric acid. Excess uric acid in the body is converted

to sodium urate crystals that are deposited in joints, most commonly in the big

toe. Increased levels of serum uric acid may be due to excessive production

of uric acid or to excessive destruction of cells and therefore breakdown of

nucleic acids, resulting in the production of uric acid.

Test 1 Answers 49

A65 A

Heart failure is a condition that may increase risk of hyperuricaemia. Diuretics

interfere with the excretion of uric acid and alter the concentration of uric acid

in blood. This results in precipitation of uric acid salts from the blood which

become deposited in the joints. A diet that consists of excessive consumption

of purine-rich food such as meat and organ meat increases production of uric

acid.

A66 D

An acute attack of gout is characterised by a rapid onset of pain, swelling

and inﬂammation usually affecting the ﬁrst metatarsophalangeal joint in the

big toe. Initially, the attack is monoarticular but it may progress to include other

joints. Attacks could recur with no clear provocation.

A67 D

The clinical signs are so characteristic of the condition that diagnosis could be

based on their presentation. Concentration of urate crystals in the synovial

ﬂuid of joints correlates very closely with serum levels. Serum uric acid levels

may be measured, particulary to monitor treatment. Hyperuricaemia also tends

to be present in other arthritic disease states. The erythrocyte sedimentation

rate (ESR) is a non-speciﬁc test that indicates occurrence of infection or inﬂam-

matory diseases. As it is a non-speciﬁc test, its relevance to the diagnosis of

gout is minimal.

A68 B

JZ should be advised to rest the affected joint, maintain good ﬂuid intake and

to take the prescribed drug. The use of colchicine in older people may precipi-

tate dehydration and electrolyte imbalance because of the common occurrence

50 Test 1 Answers

of nausea, vomiting and diarrhoea as side-effects. JZ should be advised to

report side-effects immediately.

A69 B

Colchicine is an effective drug, which is used in the acute management of gout

or for short-term prophylaxis during initial therapy with allopurinol or other

uricosuric agents. Its use is limited by the occurrence of side-effects, especially

at high doses or in patients with renal or hepatic disease. It produces a

dramatic response in acute gout probably by acting as an antimitotic and

inhibiting leucocyte mobility to the inﬂamed areas.

A70 A

Usually non-steroidal anti-inﬂammatory drugs are used as ﬁrst-line treatment in

the management of acute attacks of gout. They counteract the pain and reduce

the inﬂammation. JZ suffers from heart failure and colchicine is preferred to

avoid the ﬂuid retention that may occur with NSAIDs. Also, NSAIDs may

interact with the medications that JZ is taking, namely the diuretics and anti-

hypertensive agents, causing a decrease in the hypotensive effect. Although

this interaction is usually not of clinical signiﬁcance, it is worth considering

other therapeutic options. The disadvantage of colchicine is that it is commonly

associated with side-effects, particularly signs of gastrointestinal toxicity mani-

fested as diarrhoea and vomiting. Occurrence of these side-effects indicates

that the dose should be reviewed. Colchicine is associated with cumulative

toxicity and diarrhoea, nausea, vomiting and abdominal pain are the ﬁrst

signs of toxicity. The dose should be stopped or reduced depending on the

patient’s symptoms.

A71 B

Non-steroidal drugs such as indometacin and diclofenac are considered in the

management of acute attacks of gout. Aspirin and its derivatives should be

Test 1 Answers 51

avoided during an acute attack as these agents compete with uric acid for

excretion and may worsen rather than decrease the symptoms. In fact it is

worth considering stopping the aspirin 75 mg daily dose until the acute attack

subsides. The dose is relatively low but the patient already has other factors

that may be contributing to the condition and the aspirin is used as a prophyl-

actic agent in JZ.

A72 B

Obesity, heart failure and drug therapy are all factors in JZ which increase

susceptibility to gout. JZ should be advised on how to counteract the factors

that may be corrected. He should be advised to lose weight, which will help

him to manage his cardiovascular risk better, as well as to decrease the recur-

rence of gout. He should be advised to take regular exercise that is not very

strenuous, such as short walks and to follow a healthy diet that is based on

fruit and vegetables, which will be low in purines.

A73 A

Allopurinol is used for the long-term prophylaxis of gout and is considered

for patients who have a high incidence of recurrence. It reduces uric acid

production by inhibiting the enzyme xanthine oxidase, which brings about

the oxidation of hypoxanthine to xanthine and of xanthine to uric acid. As

allopurinol may prolong an attack or precipitate it, it should not be started

during an acute attack. It should be started 2–3 weeks after the acute attack

has subsided. It is given in a once-daily dose. It has an active metabolite,

oxipurinol, which has a plasma halﬂife of 15 or more hours.

A74 A

Uricosuric drugs include sulﬁnpyrazone and probenecid. Like allopurinol, they

may be used as prophylactic agents. They should be avoided in patients with

overproduction of uric acid and are ineffective in patients with poor renal

52 Test 1 Answers

function. They inhibit the renal tubular re-absorption of uric acid and therefore

increase urinary excretion of uric acid. Patients should be advised to consume

a good ﬂuid intake of at least two litres a day. This will decrease the risk of

uric acid stone formation.

Questions 75–80

HG suffers from Sjögren’s syndrome, a condition that is frequently associated

with rheumatoid arthritis and Raynaud’s phenomenon. The condition presents

with a deﬁcient moisture production of the lacrimal, salivary and other glands

resulting in dryness of the mouth, eyes and other mucous membranes. The

patient may also have the classic characteristics of rheumatoid arthritis. HG

is a diabetic and is taking a sulphonylurea (glimepiride) and a biguanide

(metformin). She is on a beta-blocker (atenolol) and an antiplatelet drug (dipyri-

damole) indicating possibility of a history of cardiovascular disease. She is

taking simvastatin as a lipid-regulating drug. HG has recently been diagnosed

with hypothyroidism and she was prescribed thyroxine. Her ESR is elevated

(>30 mm/h) and she is seropositive for rheumatoid factor.

A75 A

Thyroxine, levothyroxine, is a thyroid hormone used in hypothyroidism.

Because it increases metabolic rate, it should be taken in the morning to

minimise the occurrence of insomnia. Common side-effects of metformin are

gastrointestinal, such as nausea and vomiting. By taking the tablet with or after

food, these side-effects are minimised. Dipyridamole should be taken three

times daily before food, as dipyridamole is incompletely absorbed from the

gastrointestinal tract.

A76 D

Hypothyroidism occurs in the older population and may have an insidious

onset. Signs and symptoms of hypothyroidism tend to be subacute and presen-

tation may be related to non-speciﬁc symptoms.

Test 1 Answers 53

A77 D

When thyroxine is administered to patients receiving warfarin, it enhances the

anticoagulant effect of warfarin.

A78 A

Caution should be undertaken when thyroxine is started in elderly patients and

in patients with cardiovascular disorders, as there could be a rapid increase

in metabolic rate leading to problems including anginal pain, arrhythmias,

palpitations, tachycardia. In diabetic patients, caution should be used, as its

introduction may interfere with antidiabetic therapy. It should be started in

small doses at small increments.

A79 B

Side-effects resemble symptoms of hyperthyroidism and include diarrhoea,

anginal pain, tachycardia, skeletal muscle cramps, tremors, restlessness,

excitability, insomnia, headache and ﬂushing.

A80 D

The thyroid hormones T

and T

are transported in the blood by three proteins:

the thyroid-binding globulin; thyroid-binding prealbumin; and albumin. Hence

the total thyroid hormones concentration in plasma changes with alterations

in amount of thyroxine-binding in plasma. Only the unbound thyroid hormone

is able to diffuse into the thyroid cell and elicit a biological response. For this

reason the concentration of total thyroid hormones in plasma is not considered

a good diagnostic marker. Laboratory investigations to diagnose and monitor

management of hypothyroidism are based on free T

, free T

and thyroid-stimu-

lating hormone (TSH). In the early stages of hypothyroidism, free T

and free

concentrations may be normal and a modest increase in TSH is detected.

Free T

and free T

may decline as the disease progresses.

54 Test 1 Answers

Test 2

Questions

Questions 1–6

Directions:

Each group of questions below consists of five lettered

headings followed by a list of numbered questions. For each

numbered question select the one heading that is most closely

related to it. Each heading may be used once, more than once,

or not at all.

Questions 1–3 concern the following abbreviations:

❏

PMH

❏

O/E

❏

Select, from

EE,,

which one of the above:

Q1 is a description of conditions that the patient has experienced previously

Q2 is symptoms presented by the patient

Q3 is the ﬁndings of examination of the patient

Questions 4–6 concern the following abbreviations:

❏

HbA1c

❏

BUN

❏

TSH

❏

LFT

❏

MCV

Select, from

EE,,

which one of the above:

Q4 is carried out as part of kidney function monitoring

Q5 is carried out in thyroid function monitoring

Q6 is used to monitor diabetic patients

Questions 7–26

Directions:

For each of the questions below, ONE or MORE of the

responses is (are) correct. Decide which of the responses is

(are) correct. Then choose:

❏

if 1, 2 and 3 are correct

❏

if 1 and 2 only are correct

❏

if 2 and 3 only are correct

❏

if 1 only is correct

❏

if 3 only is correct

Q7 INR:

❏

is monitored in patients with arthritis

❏

is monitored in patients receiving warfarin

❏

stands for international normalised ratio

56 Test 2: Questions

Directions summarised

ABCDE

1, 2, 3 1, 2 only 2, 3 only 1 only 3 only

Q8 Lung function tests:

❏

always involve administration of bronchodilators before the

procedure

❏

are used to determine severity of respiratory disease

❏

are used to monitor outcomes of therapy

Q9 In heart failure:

❏

chest radiographs may show cardiac enlargement

❏

the pulse rate may indicate arrhythmias

❏

body extremities are very hot

Q10 Colonoscopy:

❏

is an artiﬁcial opening between the colon and skin

❏

should not be performed in periods of less than ﬁve years

❏

requires the patient to perform bowel cleansing

Q11 EEG:

❏

is carried out to conﬁrm the occurrence of cardiovascular

disease

❏

procedures require patients to be totally sedated

❏

stands for electroencephalography

Q12 Chronically elevated arterial pressure may cause:

❏

renovascular disease

❏

haemorrhagic stroke

❏

nasal congestion

Q13 Atherosclerosis:

❏

can occur in different organs

❏

may result in myocardial infarction

❏

causes chest pain

Questions 7–26 57

Q14 Patients with angina pectoris may be advised that factors which precipi-

tate an attack include:

❏

exercise

❏

anxiety

❏

light meals

Q15 After a myocardial infarction, a patient should be advised:

❏

that normal activity can never be re-achieved

❏

to attain normal body weight

❏

to undertake moderate exercise

Q16 Common complications of gallstones include:

❏

biliary colic

❏

jaundice

❏

appendicitis

Q17 Patients with osteoarthritis should be informed that:

❏

disease progression is very gradual

❏

weight loss is recommended

❏

prolonged bed-rest is advisable

Q18 Patients receiving cytotoxic chemotherapy should be advised that:

❏

nausea and vomiting may occur before treatment

❏

hair loss may occur

❏

any signs of infection should be reported to a health

professional

Q19 When a patient presents with a fall and a blackout:

❏

the incident has to be investigated

❏

the patient has epilepsy

❏

the incident should raise the alarm only if it occurs in

paediatric patients

58 Test 2: Questions

Q20 Hypokalaemia may be due to:

❏

vomiting

❏

drugs

❏

renal failure

Q21 Clinical features of hypoglycaemia include:

❏

sweating

❏

hunger

❏

blurred vision

Q22 An anaphylactic shock could present with:

❏

rash

❏

bronchoconstriction

❏

hypertension

Q23 Diabetic patients should be advised to monitor their condition because

they are prone to develop:

❏

retinopathy

❏

chronic renal failure

❏

ischaemic heart disease

Q24 Normal saline:

❏

is 0.9% sodium chloride

❏

may be used in electrolyte imbalance

❏

may be applied as nasal drops

Q25 Disadvantages of the administration of corticosteroids in the eye include:

❏

corneal thinning

❏

glaucoma

❏

cataracts

Questions 7–26 59

Q26 In which of the following cases is referral recommended?

❏

an asthmatic patient who presents with fever, chesty cough

and wheezing

❏

a patient receiving antihypertensive medication who presents

with nasal congestion

❏

a patient presenting with allergic rhinitis

Questions 27–80

Directions:

These questions involve cases. Read the case description or

patient proﬁle and answer the questions. For questions with

one or more correct answers, follow the key given with each

question. For the other questions, only one answer is correct

– give the corresponding answer.

Questions 27–38 involve the following case:

60 Test 2: Questions

AB is a 74-year-old male admitted to a medical ward.

PMH diabetes mellitus controlled by diet

hypertension

congestive heart failure

DH bumetanide 1 mg daily

potassium chloride 600 mg bd

isosorbide dinitrate 10 mg tds

atenolol 100 mg bd

aspirin 75 mg daily

lorazepam 1 mg tds

metoclopramide 10 mg prn

PC increasing shortness of breath

dyspnoea, cyanosis, tachycardia

O/E BP 160/100 mmHg

pulse 100 bpm

Q27 What condition(s) does AB have?

❏

asthma

❏

diabetes mellitus

❏

congestive heart failure

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q28 Signs and symptoms of congestive heart failure include:

❏

oedema

❏

dyspnoea

❏

insomnia

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 61

Diagnosis congestive heart failure

Lab sodium 130 mmol/l (135–145)

potassium 3.2 mmol/l (3.5–5.0)

chloride 95 mmol/l (96–106)

fasting blood glucose 15.6 mmol/l (3.6–6.0)

Drug treatment on discharge:

bumetanide 1 mg daily

isosorbide dinitrate 10 mg tds

enalapril 5 mg nocte

aspirin 75 mg daily

lorazepam 1 mg tds

metoclopramide 10 mg prn

Q29 Bumetanide is a (an):

❏

thiazide diuretic

❏

loop diuretic

❏

potassium-sparing diuretic

❏

aldosterone antagonist

❏

osmotic diuretic

Q30 Isosorbide dinitrate:

❏

is used for prophylaxis of angina

❏

is metabolised to isosorbide mononitrate

❏

can only be administered sublingually

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q31 Atenolol:

❏

is a beta-adrenoceptor blocking drug

❏

is contraindicated in uncontrolled heart failure

❏

maximum daily dose is 100 mg

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

62 Test 2: Questions

Q32 Lorazepam:

❏

has a sedative effect

❏

is used to alleviate anxiety

❏

may cause ataxia in AB

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q33 AB was started on enalapril because it:

❏

has a valuable role in heart failure

❏

lowers blood pressure

❏

prevents myocardial infarction

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q34 When starting AB on enalapril, the following parameters should be

monitored:

❏

blood pressure

❏

serum potassium levels

❏

kidney function

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 63

Q35 Upon discharge patient is informed that:

❏

his medication has been reviewed

❏

instead of atenolol he is prescribed enalapril to be taken

daily at night

❏

he should take metoclopramide only as required

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q36 Regarding bumetanide, AB should be advised to take:

❏

one tablet daily

❏

dose in the morning

❏

dose on an empty stomach

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q37 The patient should be advised to take isosorbide dinitrate tablets at:

❏

8 am, 2 pm, 6 pm

❏

8 am, 4 pm, 1 am

❏

8 am, 3 pm, 10 pm

❏

7 am, 3 pm, 2 am

❏

7 am, 3 pm, midnight

64 Test 2: Questions

Q38 Follow-up of AB includes monitoring of:

❏

blood pressure

❏

blood glucose levels

❏

development of oedema

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 39–40 involve the following case:

Q39 Which of the following antibacterial agents is the most appropriate for

XY:

❏

ﬂucloxacillin

❏

cefuroxime

❏

nalidixic acid

❏

ﬂuconazole

❏

isoniazid

Q40 When XY is started on the new treatment:

❏

development of a rash should be monitored

❏

signs of anaphylaxis should be detected

❏

an allergic reaction could develop after a month after last

drug administration

Questions 27–80 65

XY is a 49-year-old patient who is allergic to penicillin. She was prescribed

erythromycin for cellulitis. She developed a rash and erythromycin was withdrawn.

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 41–42 involve the following case:

Q41 The presenting complaint could be:

❏

akathisia

❏

tardive dyskinesia

❏

agranulocytosis

❏

purpura

❏

hypomania

Q42 A review of medication could propose changing amitriptyline to:

❏

imipramine

❏

venlafaxine

❏

reboxetine

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

66 Test 2: Questions

PS is a 69-year-old patient who presents with orofacial unwanted movements. His

medication includes diazepam 5 mg nocte and amitriptyline 25 mg tds

Questions 43–47 involve the following case:

Q43 Pharmacist intervention includes:

❏

suggesting cessation of co-codamol

❏

reviewing the dose of ferrous sulphate

❏

reviewing the isosorbide dinitrate dose as the maximum

daily dose is 5 mg daily

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q44 The maximum adult daily dose of paracetamol is:

❏

1 g

❏

2 g

❏

3 g

❏

4 g

❏

8 g

Questions 27–80 67

QR is a 75-year-old male whose current medication is:

co-codamol 2 tablets qid

paracetamol 1 g qid

gliclazide 80 mg bd

ferrous sulphate 800 mg tds

dipyridamole 25 mg tds

isosorbide dinitrate 20 mg tds

Q45 Gliclazide:

❏

augments insulin secretion

❏

can only be used as monotherapy

❏

promotes weight loss

❏

causes hyperglycaemia

❏

inhibits intestinal alpha-glucosidases

Q46 The patient should be advised:

❏

to take small, frequent meals

❏

to avoid a high-calorie diet

❏

to consume food with a high fat content

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q47 QR is receiving medication to achieve:

❏

analgesia

❏

an antiplatelet effect

❏

coronary vasodilation

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

68 Test 2: Questions

Questions 48–51 involve the following case:

Q48 Use of bisacodyl in MR requires assessment because it can:

❏

precipitate atonic colon

❏

precipitate hypokalaemia

❏

cause intestinal obstruction

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q49 In MR bisacodyl could be replaced with:

❏

senna

❏

docusate sodium

❏

liquid parafﬁn

❏

magnesium hydroxide

❏

lactulose

Questions 27–80 69

MR is an 82-year-old female hospitalised at the ophthalmic ward. Her current

medication is:

framycetin eye drops 1 drop both eyes tds

dorzolamide eye drops 1 drop left eye bd

acetazolamide tablets 125 mg bd

timolol eye drops 0.5% 1 drop left eye bd

ranitidine tablets 150 mg nocte

bisacodyl tablets 5 mg daily

Q50 Framycetin drug therapy:

❏

is used to treat eye infection

❏

may be used for prophylaxis following eye surgery

❏

is used short-term

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q51 Condition(s) being treated in the left eye only:

❏

cataract

❏

infection

❏

glaucoma

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 52–53 involve the following case:

70 Test 2: Questions

CB, a 59-year-old male was admitted to hospital with a severe chest infection. His

current medication is

lactulose 30 ml daily

warfarin 4 mg daily adjusted according to INR

paracetamol 500 mg prn

CB is allergic to penicillin and suffers from tinnitus and hearing loss.

Q52 Which of the following antibacterial preparations is the most appro-

priate?

❏

co-amoxiclav

❏

cefuroxime

❏

gentamicin

❏

ciproﬂoxacin

❏

sodium fusidate

Q53 Lactulose:

❏

treatment in CB should be withdrawn

❏

is used for chronic constipation

❏

may cause ﬂatulence

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 54–58 involve the following case:

Questions 27–80 71

JM is a 40-year-old female in the terminal stages of carcinoma. Her current

medication is:

paroxetine 20 mg daily

tamoxifen 20 mg daily

co-codamol 2 tabs tds

diazepam 2 mg nocte

JM is still complaining of pain.

Q54 Which of the following is an alternative treatment to co-codamol?

❏

domperidone

❏

paracetamol

❏

morphine

❏

aspirin

❏

ibuprofen

Q55 What side-effects could be expected from analgesics used for palliative

care?

❏

nausea

❏

vomiting

❏

constipation

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q56 Tamoxifen:

❏

is used in breast cancer

❏

is associated with the occurrence of hot ﬂushes

❏

is administered every 2 weeks

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

72 Test 2: Questions

Q57 Paroxetine:

❏

is used in JM to alleviate depression and anxiety

❏

dose is given in the morning

❏

is administered with or after food

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q58 In JM the disadvantages of diazepam are:

❏

withdrawal symptoms

❏

dependence

❏

confusion

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 59–60 involve the following case:

Questions 27–80 73

LX is an 82-year-old female who is admitted with an infection in the right toe. On

admission her medication is:

dipyridamole 100 mg tds

aspirin 75 mg daily

glibenclamide 5 mg bd

Q59 Reasons for the change in antidiabetic therapy:

❏

diabetes is not controlled

❏

to remove oral drug administration

❏

LX has stopped intake of food

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q60 Metronidazole was included in the therapeutic regimen:

❏

to cover against anaerobic bacteria

❏

to potentiate cefuroxime

❏

for a topical effect

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

74 Test 2: Questions

Her fasting blood glucose level was 12 mmol/l (3.6–6.0 mmol/l). LX was started

on:

cefuroxime 750 mg iv 8 hourly

metronidazole 500 mg iv 8 hourly

insulin according to blood glucose levels

Glibenclamide was stopped.

Questions 61–62 involve the following case:

Q61 How many morphine sulphate tablets need to be dispensed for a

morning dose?

❏

one 30 mg tablet

❏

two 10 mg tablets

❏

three 10 mg tablets

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q62 How many morphine sulphate tablets need to be dispensed for the

evening dose?

❏

one 60 mg tablet

❏

one 10 mg tablet

❏

one 30 mg tablet

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 75

FS has been prescribed 50 mg morphine sulphate in the morning and 100 mg

morphine sulphate at night. The preferred route of administration for FS is oral

tablets and morphine sulphate is available as tablets of 10 mg, 30 mg, and

60 mg.

Questions 63–65 involve the following case:

Q63 A likely cause of anaemia in CP is:

❏

gastrointestinal haemorrhage

❏

splenomegaly

❏

inadequate diet

❏

autoimmune disease

❏

congenital disease

Q64 Actions to be taken for CP include:

❏

start ferrous sulphate tablets

❏

administer iron sorbitol injection

❏

carry out gastric lavage

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q65 On discharge CP should be advised:

❏

to avoid NSAIDs

❏

to take small frequent meals

❏

to reduce intake of ﬁbre

76 Test 2: Questions

CP is a 28-year-old male who presents with complaints of weakness, dizziness and

sweating. CP had undergone a gastroscopy, which revealed a duodenal ulcer. He

tested negative to the

Helicobacter pylori

urea breath test. Laboratory tests conﬁrm

that CP is found to have anaemia. His medication on admission is

gliclazide 40 mg daily

esomeprazole 20 mg daily

aluminium–magnesium containing antacid 10 ml qid

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 66–72 involve the following case:

Questions 27–80 77

MC is an 84-year-old female referred to the A&E department with gradual

deterioration in her general condition. Patient is not eating or drinking for the past

few days.

PMH diabetes mellitus, congestive heart failure, ischaemic heart disease,

dementia

DH perindopril 2 mg daily

digoxin 0.0625 mg daily

bumetanide 1 mg daily

metformin 500 mg bd

amitriptyline 20 mg nocte

ranitidine 150 mg daily

SH lives alone,

smoking,

alcohol

O/E

SOB,

sputum,

cough

pressure sore over sacrum and heels

BP: 170/110 mmHg

pulse: 120 bpm

sparse bilateral inspiratory crackles

poor respiratory effort

abdomen soft non tender

oedema

LaB WBC 8 ⫻10

/l (5–10 ⫻ 10

/l)

Impression dehydrated ++, early parkinsonian features

Patient is started on intravenous 0.9% saline 1 litre, alternating with 5% dextrose

1 litre 8 hourly at the A&E department and admitted to hospital.

Q66 Features that could have caused the onset of dehydration in MC:

❏

amitriptyline

❏

bumetanide

❏

low ﬂuid intake

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q67 The poor health, poor respiratory effort and bilateral inspiratory

crackles suggest the need to start:

❏

prednisolone iv

❏

budesonide by inhalation

❏

co-amoxiclav iv

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q68 What measures need to be undertaken during parenteral rehydration?

❏

monitor blood sodium levels

❏

monitor blood glucose 6 hourly

❏

stop bumetanide

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

78 Test 2: Questions

Q69 With regards to the use of metformin, MC should be advised:

❏

to take tablets with meals

❏

to avoid alcoholic drink

❏

that soft stools occur usually as a long-term side-effect

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q70 Amitriptyline:

❏

is more sedative than imipramine

❏

a reduced dose is recommended for older persons

❏

its use in MC should be revised because of her medical

history

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q71 Early parkinsonian features include:

❏

bradykinesia

❏

incontinence

❏

postural instability

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 79

Q72 In MC:

❏

parkinsonian symptoms may be precipitated by amitriptyline

❏

physiotherapy may provide patient support to counteract

onset of parkinsonian symptoms

❏

signs of dementia exclude occurrence of Parkinson’s disease

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 73–75 involve the following case:

Q73 Possibilities of diagnosis include:

❏

exacerbation of atopic eczema

❏

impetigo

❏

ringworm infection

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

80 Test 2: Questions

BC is a 9-year-old female who has been on holiday at a seaside resort for a week.

She presents with her parents and is complaining of a red, scaly skin area on both

her elbows. The area has a golden-yellow crust and BC complains that it is very

itchy. BC suffers from atopic eczema.

Q74 Drugs that could be recommended for use in BC include:

❏

hydrocortisone 1% cream

❏

mepyramine cream

❏

miconazole cream

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q75 The parents of BC should be reminded to:

❏

avoid use of soaps and bubble baths

❏

use hypoallergenic sun protection cream

❏

ensure good hydration

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 76–80 involve the following case:

Q76 Tension headache:

❏

tends to have a chronic pattern

❏

is due to arterial vasoconstriction

❏

occurs only in young adults

Questions 27–80 81

GM is a 28-year-old female who suffers from tension headache. She would like to

have a medication that is stronger than paracetamol.

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q77 Characteristic complaints of patients with tension headache are:

❏

feeling of a bilateral ‘hatband’

❏

pain is non-throbbing

❏

sound intolerance

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q78 GM could be advised to:

❏

adopt a less stressful life

❏

avoid consumption of cheese

❏

change employment

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q79 Analgesics that could be recommended to GM include:

❏

co-codamol

❏

ibuprofen

❏

amitriptyline

82 Test 2: Questions

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Q80 The use of aspirin would not be recommended if GM:

❏

has hypertension

❏

has a history of gastric ulceration

❏

is breast-feeding

❏

1, 2, 3

❏

1, 2 only

❏

2, 3 only

❏

1 only

❏

3 only

Questions 27–80 83

Test 2

Answers

Questions 1–3

Abbreviations are commonly encountered in case notes. They are standard-

ised to help exchange of information between different health care settings

and so that case notes can be used by different health professionals.

A1 A

PMH stands for

past medical history

, where information on conditions experi-

enced previously by the patient is reported.

A2 D

PC stands for

presenting complaint

, where the symptoms that are reported by

the patient are included.

A3 B

O/E stands for

on examination

, where the information observed by health

professionals is noted.

Questions 4–6

Clinical laboratory tests are signiﬁcant in chronic disease management to

monitor outcomes of therapy and compliance with pharmacotherapy and

lifestyle measures.

A4 B

BUN stands for

blood urea nitrogen

. It provides an indirect measure of renal

function and glomerular ﬁltration rate, and also gauges liver function. Urea is

formed in the liver as an end-product of protein metabolism. Urea is trans-

ported to the kidneys for excretion. For kidney function monitoring it should

not be used as a stand-alone test, because changes in the metabolic function

of the liver could affect the BUN results. BUN is used together with creatinine

levels in the monitoring of kidney function.

A5 C

TSH stands for

thyroid-stimulating hormone

, and its concentrations are

monitored in thyroid disease.

A6 A

HbA1c, also referred to as glycosylated haemoglobin, is used to monitor

diabetes. It measures the blood glucose bound to haemoglobin. As erythro-

cytes have a life span of 120 days, the test reﬂects the average blood sugar

level in the 2–3 months preceding the test. It gives an indication of the blood

glucose levels over the past 90 days.

Questions 7–26

A7 C

INR stands for

international normalised ratio

. It is a ratio value comparing a

patient’s prothrombin time against the prothrombin time of normal control

patients. It is used as a monitoring index in patients receiving warfarin. INR

levels for patients on warfarin are aimed at between two and three, depending

on the goal of treatment and other factors, such as recurrent deep vein

thrombosis or use of prosthetic heart valves.

86 Test 2: Answers

A8 C

Lung function tests involve the use of a spirometer to measure lung volumes

and air ﬂow rates. Measurements include forced expiratory volume, vital

capacity, forced vital capacity and residual volume. Lung function tests are

used to determine the severity of the respiratory disease and to monitor

outcomes of therapy. Patients may be educated to use a patient-friendly

spirometer device to monitor their condition and adjust their therapy accord-

ingly as advised by the healthcare team. Lung function tests may be used to

determine the reversibility of airway disease. Sometimes a bronchodilator may

be administered before the procedure after baseline pulmonary function tests

have been carried out, to evaluate the degree of disease reversibility.

A9 B

Heart failure results in a reduced cardiac output leading to impaired oxygena-

tion and a compromised blood supply to muscles. A common cause of heart

failure is left ventricular systolic dysfunction. Sustained heart failure results in

compensatory mechanisms by the body to maintain circulation. These result in

long-term sequelae such as remodelling of the left ventricle and cardiac

enlargement. A chest radiograph may reveal an enlarged cardiac shadow

and consolidation in the lungs. Due to the occurrence of cardiomegaly,

arrhythmias may occur. Patients with heart failure present with dyspnoea or

orthopnoea, may appear pale and may have cold extremities.

A10 E

Colonoscopy is a diagnostic procedure that is used in the assessment of gastro-

intestinal disorders of the colon. It may be used to diagnose inﬂammatory

bowel disease and carcinoma. It is used to assess the management of patients

with inflammatory bowel disease; for example, in patients who have

undergone surgery for ulcerative colitis, regular colonoscopy is undertaken to

evaluate recurrence of the disease. It is also used as a diagnostic screening

tool in familial colon cancer. It may be repeated as necessary. A disadvantage

Test 2: Answers 87

is that bowel cleansing is required before the procedure and if this is not done

efﬁciently then the results are compromised.

A11 E

EEG stands for

electroencephalography

and it is a test carried out to measure

and record electrical impulses in the brain. It is used to diagnose seizures.

However the EEG has limitations and patients with epilepsy may present with

a normal EEG, but the EEG helps in classifying seizures. The procedure may

be carried out in a sleep-induced state or in a sleep-deprived state.

A12 B

Arterial pressure reﬂects the stress exerted by the circulating blood on the

arterial walls. It is directly related to the cardiac output and the systemic

vascular resistance. In chronically elevated arterial blood pressure, direct

organ and vascular damage may result, caused by increased peripheral

resistance and by arteriosclerosis. Organs commonly affected include the

heart, kidneys, brain and retina. Manifestations of the sustained damage are

renovascular disease, such as renal failure; cerebrovascular disease, such as

thrombotic stroke; retinal damage resulting in visual defects; and cardio-

vascular disease, such as ischaemic heart disease.

A13 B

Atherosclerosis is a common arterial disorder characterised by deposits of

plaques consisting of cholesterol, lipids and cellular debris on the inner layers

of walls of large- and medium-sized arteries. It may occur in any artery and

increases the risk of thrombosis. It is a cause of coronary artery disease,

angina and myocardial infarction. Its occurrence increases with age and is

related to smoking, obesity, hypertension, diabetes mellitus and elevated low-

density lipoprotein cholesterol levels.

88 Test 2: Answers

A14 B

Angina pectoris is thoracic pain, most often caused by myocardial anoxia.

Symptoms of angina pectoris may occur with activities or circumstances that

increase cardiac workload such as: exertion following exercise, like climbing

stairs; emotion, such as anxiety, which results in an increased heart rate; heavy

meals, because of the requirement of increased gastrointestinal perfusion; and

exposure to cold temperatures owing to peripheral vasoconstriction, which

leads to increased peripheral resistance.

A15 C

A myocardial infarction occurs because of a coronary vessel occlusion for a

duration of about 6 h. Infarct size may be limited by dilatation of neighbour-

ing vessels brought about by a mechanism of autoregulation. Myocardial

infarction is caused by atherosclerosis and the patient presents with severe,

crushing, retrosternal pain. In the absence of complications, patients resume

mobilisation within 2 or 3 days of a myocardial infarction. Subsequently

patients should be advised to follow a healthy diet which is low in fats, to

undertake routine exercise and to attain a normal body weight. They should

be reassured that a gradual re-establishment of normal activity will be

achieved. Family and friends should be counselled how to help the patient

achieve this.

A16 B

Gallstones consist of cholesterol and bile pigments that are calciﬁed. Common

complications of gallstones include biliary colic, cholestatic jaundice, acute

pancreatitis and acute cholecystitis and cholangitis. In biliary colic the patient

complains of moderate to severe pain in the epigastric area. Jaundice occurs

because of obstruction of the bile ducts and presents with generalised pruritus.

In acute pancreatitis there is reﬂux of the bile up the pancreatic duct and it

causes pain and vomiting. Acute cholecystitis and cholangitis are due to

inﬂammation of the gall bladder and common bile duct.

Test 2: Answers 89

A17 B

In osteoarthritis degenerative changes including subchondral bony sclerosis,

loss of articular cartilage and proliferation of bone spurs occur in one or many

joints. As the disease progresses inﬂammation of the synovial membrane takes

place. The disease is not reversible except where joint replacement is under-

taken. However, disease progression is very gradual and patients should be

advised how to rest and support involved joints through proper physiotherapist-

guided exercises. Losing weight helps to reduce stress on the joints.

A18 C

A major disadvantage of cytotoxic chemotherapy is that it interferes with

cellular activity in cancerous and normal tissues. It is associated with unwanted

effects because of its effect on normal cells. Nausea and vomiting after

treatment are very common side-effects. Their extent depends on the emeto-

genic potential of the drugs used. When these side-effects are not very well

controlled, there is a risk that the patient develops anticipatory nausea and

vomiting before treatment. However, this effect is psychologically and not

chemically induced. Alopecia, which is usually reversible, is another common

side-effect. Because of the suppressive effects on the bone-marrow caused by

cytotoxic chemotherapy, patients are prone to develop infections. Patients

should be advised to report any signs of an infection, such as sore throat or

fever, to a health professional.

A19 D

When there is temporary loss of consciousness leading to a fall, it may indicate

a brief cerebral hypoxia, which could be caused by a number of factors

including emotional stress, vascular pooling in the legs, diaphoresis or a

sudden change in body position. Such an incident may also indicate serious

disease states, such as brain tumours. The patient should be assessed and

medical and drug histories should be reviewed.

90 Test 2: Answers

A20 B

Hypokalaemia is a decreased serum potassium level. Normally the potassium

loss from the body through renal and faecal excretion and from loss in sweat

is miminal. Hypokalaemia may result because of a high loss from the gastro-

intestinal tract, as gastrointestinal secretions contain high levels of potassium.

Vomiting, diarrhoea and laxative abuse could result in hypokalaemia. An

increased renal clearance due to drugs, alkalosis and aldosteronism may also

result in hypokalaemia. Drugs that could induce hypokalaemia include

thiazide and loop diuretics and steroids. Hyperkalaemia is the excess of

potassium in serum. It is commonly caused by renal failure.

A21 A

Hypoglycaemia is a blood glucose level below 3 mmol/l. It is a condition that

develops rapidly and usually occurs in diabetics either because of an excessive

antidiabetic dose or owing to changes in lifestyle. Patients should be educated

to identify symptoms of hypoglycaemia so that they can counteract it by taking

carbohydrates, to prevent neuroglycopenic symptoms such as drowsiness,

disorientation and confusion progressing to convulsions, coma and death.

Symptoms of hypoglycaemia indicating an activated sympathetic nervous

system are sweating, tremor, pallor and anxiety. Other effects are hunger,

blurred vision, salivation and weakness.

A22 B

An anaphylactic shock occurs because of a hypersensitivity reaction. Presen-

tation includes development of a rash, acute bronchoconstriction, profound

hypotension and collapse.

A23 A

Diabetes is associated with microvascular complications, the incidence of

which may be reduced with optimal blood glucose control. It may lead to

Test 2: Answers 91

microvascular damage in the retina causing dilatation, haemorrhage and

infarction leading to retinopathy. Retinopathy is managed with laser photo-

coagulation. Its occurrence is usually associated with diabetic nephropathy.

Nephropathy occurs because of sclerosis of the glomerular basement

membrane. Initial signs of nephropathy are microalbuminuria, proteinuria and

hypertension. ACE inhibitors are used in diabetic patients to treat hypertension

as well as to dilate intrarenal vessels and thus minimise glomerular hyper-

tension. Macroangiopathy occurs in cardiac vessels leading to onset of

ischaemic heart disease. To decrease the effects of macroangiopathy, lipid-

lowering drugs such as statins are considered in diabetic patients.

A24 A

Normal saline consists of 0.9% sodium chloride as an isotonic solution. It is

used as a parenteral preparation in electrolyte and ﬂuid imbalance such as

sodium depletion. It is also available as nasal drops in nasal congestion and

as a nebuliser diluent. It may be used in eye and wound irrigation and for

oral hygiene.

A25 A

Topical administration of corticosteroids in the eye is associated with thinning

of the cornea and sclera, steroid glaucoma and steroid cataract. These side-

effects occur particularly after prolonged use. The use of a topical preparation

containing only a corticosteroid in a patient presenting with a red eye may

lead to aggravation of the underlying infection resulting in corneal ulceration

with a possible loss of vision.

A26 D

Asthmatic patients who present with fever, chesty cough and wheezing

indicate onset of a chest infection where the use of antibacterials may

be necessary to counteract bacterial infections or to cover against the

92 Test 2: Answers

development of secondary bacterial infections. Referral of the patients is

recommended. Patients on antihypertensive agents complaining of nasal

congestion may be recommended a topical sympathomimetic drug such as

xylometazoline, which will act as a vasoconstrictor and reduce the congestion

with minimal systemic effects. Patients presenting with allergic rhinitis could

be recommended use of systemic non-sedating antihistamine drugs such as

loratidine.

Questions 27–38

AB is an elderly male patient with congestive heart failure, hypertension and

diabetes. On admission he is taking bumetanide (a loop diuretic), potassium

chloride, isosorbide dinitrate (a nitrate), atenolol (a beta-adrenoceptor drug),

aspirin (an antiplatelet), lorazepam (an anti-anxiety drug) and metoclopramide

(an anti-emetic). Potassium chloride, isosorbide dinitrate and bumetanide may

cause nausea, though it is not a common side-effect. This may be the rationale

behind the use of metoclopramide at night. On admission he presents with

symptoms of deterioration of congestive heart failure, a high blood pressure

and an elevated fasting blood glucose level.

A27 C

AB has diabetes mellitus and congestive heart failure. In elderly and diabetic

patients it is very common to ﬁnd multiple disease states. Metabolic stress such

as deterioration of congestive heart failure may precipitate an acute distur-

bance in diabetic control. In AB even though there is an elevated fasting blood

glucose level, this should be monitored but no therapeutic action should be

taken until his cardiac condition is stabilised.

A28 B

In congestive heart failure there is generalised oedema and usually the term

implies bilateral failure resulting in reduced cardiac contractility. Symptoms

Test 2: Answers 93

include oedema, dyspnoea (sensation of uncomfortable breathing) and

fatigue.

A29 B

Bumetanide is a loop diuretic, which acts by inhibiting re-absorption from the

ascending limb of the loop of Henle in the renal tubule. It has an onset of

action within 1 h of oral administration and a duration of action of about 6 h.

With regular use the impact on frequency of diuresis after drug administration

tends to decrease. One of the side-effects of bumetanide is the development

of hypokalaemia. Potassium supplements are administered to counteract this

unwanted effect. Loop diuretics are used in the management of heart failure

as they provide a symptomatic relief from the oedema. They reduce circulat-

ing blood volume and therefore decrease preload and afterload in the heart.

They do not have an impact on disease progression. Had oedema been severe

in AB on admission, changing bumetanide to an intravenous administration

for a few days until oedema is decreased could have been an option.

A30 B

Isosorbide dinitrate is a nitrate that is used in the prophylaxis and treatment

of angina and in left ventricular failure. In AB isosorbide dinitrate is being

used for the management of heart failure. Nitrates cause vasodilatation and

lead to a decrease in preload. Isosorbide dinitrate is metabolised to active

metabolites, the most important of which is isosorbide mononitrate. It is

available as short-acting tablets which may also be used sublingually in

angina, as an aerosol spray, as modiﬁed-release oral dosage forms and as

injection for intravenous infusion. The dose for isosorbide dinitrate in heart

failure is 30–160 mg in divided doses but the dose may be increased to

240 mg daily.

94 Test 2: Answers

A31 A

Atenolol is a cardioselective beta-adrenoceptor blocker that is used in hyper-

tension and in angina. The recommended daily dose for atenolol in hyper-

tension is 25–100 mg, although the 50 mg dose is usually adequate. As a

beta-blocker it may mask symptoms of hypoglycaemia. However, this is of no

concern in AB as the patient is not taking any antidiabetic agents but is control-

ling diabetes through diet. Beta-blockers have negative inotropic properties

and therefore may cause bradycardia and they should not be used in patients

with uncontrolled heart failure. Treatment with beta-blockers such as atenolol

should be started with care in patients with heart failure. It has been demon-

strated that three beta-blockers namely bisoprolol, carvedilol, and metoprolol

reduce heart failure disease progression, decrease symptoms and mortality

when used in stable heart failure. In AB it is an option to consider changing

atenolol to an alternative therapeutic approach which better tackles the

concomitant occurrence of hypertension and congestive heart failure. Use of

one of these three beta-blockers (bisoprolol, carvedilol, and metoprolol) is an

option.

A32 A

Lorazepam is a short-acting benzodiazepine that has anti-anxiety and hypnotic

properties. Use of benzodiazepines in older people is associated with alter-

ations in the pharmacokinetic parameters of the drug that lead to clinical

consequences such as drowsiness, confusion and ataxia (a condition charac-

terised by an inability to coordinate movement). The probability of occurrence

of these side-effects is higher with drugs that have a long halﬂife. The use of

lorazepam in AB raises concern as it appears that there is no clear rationale

for its use. More data is required as to reasons for its use and duration of

therapy. It may have been started recently when the patient was becoming

agitated because of the insidious deterioration of his wellbeing. Owing to the

onset of benzodiazepine dependence, lorazepam should not be stopped

abruptly if the patient has been taking the drug for a few weeks. Abrupt with-

drawal is associated with the benzodiazepine withdrawal syndrome charac-

terised by anxiety, depression, impaired concentration, insomnia, headache

and loss of appetite.

Test 2: Answers 95

A33 B

Enalapril is an angiotensin-converting enzyme (ACE) inhibitor, which causes

a decreased arterial and venous vasoconstriction and a decreased blood

volume. ACE inhibitors are considered as ﬁrst-line therapy in the management

of heart failure because it has been shown that they reduce symptoms and

improve prognosis. They are also used in hypertension as they reduce salt and

water retention. The addition of enalapril to AB’s therapy was an important

therapeutic intervention undertaken during hospitalisation. Before admission

the patient had a deterioration in the heart failure condition and required

further therapeutic intervention to correct progression of the disease. By

choosing to include enalapril in AB’s therapy, the ﬁrst-line management of

congestive heart failure is now being followed.

A34 A

ACE inhibitors may cause a rapid fall in blood pressure. This may be quite

relevant to AB as the patient is already being administered other drugs that

have a hypotensive effect. For this reason, the ﬁrst dose of ACE inhibitors

should preferably be started at night so that the risk of injury caused by

hypotension is lower because the patient is lying in bed. ACE inhibitors may

cause hyperkalaemia and in fact the potassium chloride supplement has been

stopped. ACE inhibitors may cause a deterioration in renal function, especi-

ally in patients with pre-existing disease, hypovolaemia and heart failure.

When initiating treatment in AB, blood pressure, serum potassium levels and

renal function should be monitored.

A35 A

Upon discharge, the changes carried out in his medications should be

discussed with AB. It should be particularly pointed out that atenolol and

potassium chloride have been stopped and instead enalapril has to be taken

daily at night. AB should be advised to use the metoclopramide only when he

has symptoms of nausea.

96 Test 2: Answers

A36 B

Regarding bumetanide, AB should be advised to take one tablet daily in the

morning to avoid waking up at night because of the increased diuresis that it

causes. Bumetanide is almost completely and quite rapidly absorbed from the

gastrointestinal tract and there is no need to advise patients to take the drug

on an empty stomach.

A37 A

Tolerance is associated with nitrates. By reducing the nitrate concentration

levels during the night, occurrence of tolerance is reduced and effectiveness

maintained. Patient should receive the three doses between 7 am and 6 pm.

A38 A

Monitoring the outcome of therapy in AB is based on the measurement of

blood pressure, the assessment of development of oedema and dyspnoea, and

the measurement of blood glucose levels and HbA1c. A lipid proﬁle and renal

function tests could be carried out from time to time as well.

Questions 39–40

XY presents with cellulitis, which is an acute infection of the skin and sub-

cutaneous tissue. It is characterised by erythema, oedema, swelling and pain

and may be sometimes associated with fever, malaise and headache. Occur-

rence of the condition is higher where there is damaged skin, compromised

circulation and in diabetics. The infection is commonly caused by Gram-

positive cocci. Penicillins are the preferred antibacterial agents as ﬁrst-line

treatment.

Test 2: Answers 97

A39 B

In penicillin-allergic patients, macrolides are usually the preferred drugs.

Alternatively, a cephalosporin such as cefuroxime may be used with care.

Some patients who are sensitive to penicillins may be also cephalosporin

hypersensitive. Cephalosporins have a similar spectrum of activity to penicillins

and macrolides and are usually effective against Gram-positive cocci. Cefur-

oxime is a second generation cephalosporin that is less susceptible to inacti-

vation by beta-lactamases compared with ﬁrst-generation cephalosporins.

Flucloxacillin is a penicillinase-resistant penicillin. Nalidixic acid is a quinolone

with activity predominantly against Gram-negative bacteria. Fluconazole is

a triazole antifungal agent and isoniazid is an antituberculous drug. In

cellulitis, when therapy is unsuccessful or inadvisable because of drug sensi-

tivity, vancomycin may be considered.

A40 B

Hypersensitivity reactions may occur with any antibacterial agent. They are

more commonly recognised with penicillins. Hypersensitivity reactions vary in

presentation and may include development of a rash, an urticarial rash, fever

or an acute anaphylactic reaction. Onset of allergic reaction may occur up to

14 days from ﬁrst dose administration.

Questions 41–42

PS is taking diazepam, which is a benzodiazepine, and amitriptyline, which

is a tricylic antidepressant. Tricyclic antidepressants may cause movement

disorders and dyskinesias. There are few reports where patients using benzo-

diazepines developed extrapyramidal symptoms. Elderly patients may be

particularly sensitive to the side-effects of benzodiazepines and tricyclic anti-

depressants; low doses should be used. PS is receiving the maximum dose

recommended for elderly patients for amitriptyline and the lowest recom-

mended dose for the use of diazepam in insomnia.

98 Test 2: Answers

A41 B

PS has developed tardive dyskinesia, which is characterised by involuntary

repetitive movements of muscles in the face, limbs and trunk. They may occur

as a drug-induced side-effect after prolonged therapy and elderly patients are

more prone to their occurrence. Withdrawal of the causative agent may result

in an improvement in the condition after some time.

A42 C

Venlafaxine and reboxetine are antidepressant drugs that are less likely to be

associated with the development of movement disorders. Venlafaxine is a

serotonin and noradrenaline re-uptake inhibitor, whereas reboxetine is a

selective inhibitor of noradrenaline. Both drugs should be used with care in

patients with a history of cardiovascular disease, epilepsy, urinary retention,

prostatic hypertrophy, glaucoma, renal and hepatic impairment.

Questions 43–47

QR is an elderly patient who is taking a compound preparation of codeine

and paracetamol (co-codamol), paracetamol, gliclazide (sulphonylurea),

ferrous sulphate, dipyridamole (antiplatelet) and isosorbide dinitrate (nitrate).

A medication review is required.

A43 B

Co-codamol is a compound preparation containing paracetamol, a non-opioid

analgesic, and codeine, an opioid analgesic. At the same time that he is taking

this product, QR is also taking paracetamol tablets. There is overlap of therapy

which could result in overdosage with paracetamol and use of codeine may

lead to constipation. Pharmacist should advise QR to stop the co-codamol and

continue taking only two paracetamol tablets every four hours. When normal-

release ferrous sulphate tablets are used, the dose of 200 mg three times daily

Test 2: Answers 99

is recommended. For modiﬁed-release preparations, one or two tablets daily

are taken. Hence the product that is being used by QR should be veriﬁed and

the dose adjusted accordingly. QR could be advised to take the ferrous

sulphate tablets after meals so as to decrease the occurrence of gastrointestinal

irritation. QR is receiving daily 60 mg of isosorbide dinitrate, which is within

the recommended dosage for isosorbide dinitrate (up to a maximum dose of

240 mg).

A44 D

The maximum adult dose of paracetamol is 4 g, administered as 0.5–1 g

every 4–6 h. Overdosage with paracetamol leads to hepatic damage, which

may have a delayed presentation of up to 6 days. The resulting hepatic

damage may lead to encephalopathy, haemorrhage, hypoglycaemia,

cerebral oedema and death. The hepatic damage is caused by a hydroxyl-

ated metabolite,

-acetyl-

-benzoquinoneimine, which is usually produced in

very small amounts and is detoxiﬁed by conjugation with gluthatione. In over-

dosage the amount of this metabolite exceeds the gluthatione potential for

detoxiﬁcation.

A45 A

Gliclazide is a sulphonylurea that is used as an oral antidiabetic agent. It

increases insulin secretion from functioning islet beta cells in the pancreas.

Gliclazide may be used in combination with metformin (biguanide) and

acarbose. Side-effects that may occur include mild gastrointestinal distur-

bances such as nausea, vomiting, diarrhoea and constipation. They increase

appetite and weight gain may occur. Hypoglycaemia may occur and this is

relatively uncommon unless associated with overdosage or skipped meals.

A46 B

QR should be advised on healthy lifestyle measures to counteract complica-

tions associated with diabetes and cardiovascular disease. These include

100 Test 2: Answers

small, frequent meals. Foods high in calories and sugar content should be

avoided. QR has a higher risk of developing atherosclerosis and he should

receive advice to follow a low-fat diet.

A47 A

QR is receiving analgesics (paracetamol), an antiplatelet agent (dipyrid-

amole), and a nitrate (isosorbide dinitrate), which promote coronary vaso-

dilation. Patient should be asked to visit health professionals regularly to have

blood glucose levels, glycosylated haemoglobin, blood pressure and lipid

proﬁle assessed.

Questions 48–51

MR is receiving treatment for glaucoma with dorzolamide and acetazolamide

(carbonic anhydrase inhibitors) and timolol (beta-blocker). She is receiving

ranitidine, an H

-receptor antagonist and bisacodyl which is a stimulant

laxative. MR is also receiving framycetin eye drops as an antibacterial

preparation.

A48 B

Bisacodyl is a diphenylmethane stimulant laxative and it acts mainly on the

large intestine. Prolonged use of bisacodyl should be avoided as it may precip-

itate diarrhoea, hypokalaemia and atonic non-functioning colon. It may be

used for the short-term management of constipation and its advantage is that

it is very rapid in action. It should be avoided in intestinal obstruction and it

may cause abdominal discomfort such as colic and cramps.

A49 E

In MR constipation may be a chronic problem. This is not unusual in elderly

patients who have a less physically active life, may be dehydrated and may

Test 2: Answers 101

not include ﬁbre in their diets. The problem is even more prominent if the

patient is bedridden. Lactulose, which is an osmotic laxative, is a semi-synthetic

disaccharide which is not absorbed from the gastrointestinal tract. It can be

used in the long-term management of constipation. Senna and docusate

sodium are very similar to bisacodyl. They are also stimulant laxatives.

Magnesium hydroxide is not indicated for regular use. It is absorbed system-

ically, causes signiﬁcant bowel evacuation and may cause dehydration and

electrolyte imbalance. Use of liquid parafﬁn as a laxative is not recommended

as oral administration results in anal seepage and irritation and it may give

rise to foreign-body granulomatous reactions.

A50 A

Framycetin is an aminoglycoside antibacterial agent which has a bactericidal

action against Gram-negative aerobic bacteria excluding

Pseudomonas

species and against some strains of staphylococci. As it is not absorbed from

the gastrointestinal tract, it is used as a topical agent in skin, eye and ear

infections. Usually in eye infections, topical administration of antibacterial

drugs results in a positive outcome. Topical antibacterials, including

framycetin, may be used for prophylaxis following ophthalmic surgical inter-

ventions. The antibacterials are used for acute management or for short-term

use in prophylaxis.

A51 E

MR is receiving treatment for glaucoma, which is a raised intraocular pressure

caused by obstruction of the outﬂow of aqueous humour. It is presented with

loss of visual ﬁeld. Drug therapy is aimed at decreasing intraocular pressure.

Timolol, a beta-blocker, reduces intraocular pressure by reducing the rate of

production of aqueous humour. Dorzolamide and acetazolamide are carbonic

anhydrase inhibitors, which again interfere with the production of aqueous

humour by inhibiting the enzyme involved in the process. Dorzolamide and

timolol are applied topically, whereas acetazolamide is administered system-

ically. In glaucoma, drug therapy usually starts with monotherapy, usually

102 Test 2: Answers

either a beta-blocker or a prostaglandin analogue such as latanoprost. As the

condition is monitored, combination therapy is resorted to until an optimum

intraocular pressure and symptom reduction occur.

Questions 52–53

The term chest infection is usually used to refer to a lower respiratory tract

infection. CB is receiving lactulose as a laxative, warfarin as an oral anti-

coagulant and paracetamol as an analgesic when required. CB has ear

problems with tinnitus and hearing loss.

A52 D

Ciproﬂoxacin is a quinolone that is active against Gram-positive and Gram-

negative bacteria. It is an appropriate preparation for CB. A macrolide

product such as clarithromycin is also a suitable option. As CB has a history

of penicillin sensitivity, co-amoxiclav and cefuroxime should be avoided.

Cefuroxime is a cephalosporin and cross-sensitivity with penicillins is possible.

Gentamicin is an aminoglycoside that is not absorbed from the gastrointestinal

tract and requires parenteral administration. Its use in CB is not recommended

when there are other options because it may cause otoxocity as a side-effect,

resulting in a deterioration in CB’s ear disorders. Sodium fusidate is a narrow-

spectrum product that is indicated in penicillin-resistant staphylococci infections

such as osteomyelitis and in staphylococcal endocarditis.

A53 C

Lactulose is a semi-synthetic disaccharide that produces osmotic diarrhoea. It

can be used for the management of chronic constipation. Its use in the acute

attack is limited by the delayed onset of action (around 48 h). Side-effects of

lactulose include ﬂatulence, cramps and abdominal discomfort.

Test 2: Answers 103

Questions 54–58

In the terminal stages of carcinoma, pain may occur because of disease

progression, the debility it causes and owing to co-existing conditions. The

pathophysiology of pain in terminal carcinoma may be multiple because of

the varied factors leading to its occurrence. In breast cancer, bone metastases

are quite common. A multidisciplinary approach should be adopted in pallia-

tive care. The pharmacist could monitor the use of drugs to maintain the patient

as pain free as possible and to manage other problems such as the nausea

that may arise.

A54 C

Co-codamol consists of a mixture of paracetamol, a non-opioid and codeine,

an opioid drug. Codeine is effective for the relief of mild to moderate pain.

An opioid drug such as morphine is required for JM. Tramadol is an opioid

analgesic that is associated with fewer side-effects compared with other

opioid drugs. However its use may increase risk of CNS toxicity when used

together with SSRIs. Aspirin and ibuprofen are non-opioid drugs that have an

anti-inﬂammatory and an analgesic effect. They may be of value in patients

with bone pain and may be used in addition to an opioid analgesic. Domperi-

done is used as an anti-emetic drug. It may be required with the use of opioid

drugs.

A55 A

Opioid drugs used in palliative care include tramadol and morphine. Opioids

may cause nausea and vomiting especially during the initial doses, constipa-

tion and drowsiness.

A56 B

Tamoxifen is an oestrogen-receptor antagonist available as an oral formulation

that is administered daily. It is used in adjuvant treatment of early breast

104 Test 2: Answers

cancer, in the palliative treatment of advanced disease and for prophylaxis in

women at increased risk. The most frequent side-effect of tamoxifen is hot

ﬂushes.

A57 A

Paroxetine is a selective serotonin re-uptake inhibitor (SSRI) that is used in JM

to alleviate depression and anxiety associated with terminal carcinoma.

Paroxetine should be administered in the morning to minimise insomnia,

anxiety and nervousness during the night. Common side-effects of SSRIs are

nausea, vomiting, dyspepsia, abdominal pain, diarrhoea or constipation.

Occurrence of these side-effects is reduced by administering the drug with or

after food.

A58 E

Diazepam is a benzodiazepine that is associated with tolerance and depen-

dence. The occurrence of dependence results in withdrawal symptoms, should

the drug be discontinued abruptly. However, these disadvantages are not of

concern in the management of JM. The aim is to keep JM pain free and in a

relatively good mental state. The advantage of using diazepam as an anxio-

lytic outweighs the disadvantages of tolerance and dependence. A disadvan-

tage of diazepam which is of concern in JM is the occurrence of confusion.

Questions 59–60

LX is taking dipyridamole (antiplatelet), aspirin (antiplatelet) and glibenclamide

(antidiabetic agent). A complication of diabetes mellitus is vascular disease in

the peripheries, which predisposes patients to the development of an infection

following trauma to the area. This occurs very commonly in the feet, a

condition referred to as the diabetic foot. For this reason diabetics are advised

to take good care of their feet, avoid injuries and foot maceration from

footwear. Diabetics should immediately seek advice about injuries to the feet

to avoid development of infections in the area.

Test 2: Answers 105

A59 D

Currently, blood glucose level is not controlled in LX. At the moment LX has an

infection that is causing metabolic stress and precipitating an acute distur-

bance in blood glucose control. Antidiabetic treatment is changed to insulin

for better control in such circumstances. Blood glucose is measured regularly

for LX and insulin dose adjusted accordingly.

A60 D

Metronidazole is an anti-infective that is active against anaerobic bacteria and

protozoa. It is included in the therapeutic regimen, together with cefuroxime,

to expand the spectrum of activity of the anti-infectives used. Infection caused

by anaerobic bacteria occurs in diabetic feet infections.

Questions 61–62

Morphine is an opioid analgesic that is widely used in the management of

moderate to severe pain. It is the standard drug against which other opioid

analgesics are compared. It is particularly useful in postoperative analgesia

and palliative care. In addition to an analgesic effect it also induces a sense

of euphoria and mental detachment. Its use may result in nausea, vomiting

and constipation. Morphine may be administered as standard tablets,

modiﬁed-release tablets, oral solution and injections.

A61 B

For the morning dose, FS should be given 50 mg, which can be administered

as one 30 mg tablet and two 10 mg tablets. This gives the least number of

tablets that the patient needs to take.

106 Test 2: Answers

A62 A

For the evening dose, FS should be given 100 mg, which can be adminis-

tered as one 60 mg tablet, one 10 mg tablet and one 30 mg tablet. This gives

the least number of tablets required to be taken by the patient to achieve the

required dose.

Questions 63–65

CP is receiving gliclazide (sulphonylurea), esomeprazole (proton pump

inhibitor) and an antacid preparation. From this medication proﬁle it is under-

stood that CP is a diabetic. He has a history of duodenal ulcer disease. In the

majority of cases this is caused by the organism

Helicobacter pylori

and a

triple-therapy eradication regimen is recommended in these cases. However,

in some patients there may be other factors that lead to duodenal ulceration.

These include use of non-steroidal anti-inﬂammatory drugs (NSAIDs) and

family history, especially when it occurs at an early age such as in the case

of CP.

A63 A

In CP a cause of anaemia is gastrointestinal haemorrhage, a complication of

gastric or duodenal ulcer disease, which may occur either as a minor chronic

blood loss leading eventually to anaemia or as moderate bleeding leading to

melaena or haematemesis. The bleeding results because of erosion of an ulcer

into an artery.

A64 D

A priority in the management of CP is to correct the anaemia by administer-

ing iron supplements. Iron salts should be administered by the oral route, unless

this has been unsuccessful because of non-compliance, intolerance to side-

effects, malabsorption and continued blood loss. CP should be started on

Test 2: Answers 107

ferrous sulphate tablets and haemoglobin levels monitored. Iron is absorbed

mostly as the ferrous state in an acidic environment and hence absorption

takes place mostly in the stomach. Modiﬁed-release preparations are not

recommended for CP as they do not undergo sufﬁcient dissolution until

reaching the small intestines where absorption of iron is poor. Absorption may

be reduced by food; however, many patients experience nausea and

diarrhoea when iron is administered on an empty stomach.

A65 B

CP should be advised to avoid non-steroidal anti-inﬂammatory drugs such as

aspirin and to inform prescribers and pharmacists of his condition before using

other medications. NSAIDs are very likely to cause gastrointestinal distress and

precipitate an acute attack. He should be advised to take regular small meals,

avoid strong tea, coffee and spicy food and limit food intake late at night as

this increases nocturnal gastric secretion. Anxiety, stress, alcohol and smoking

all contribute to precipitate duodenal ulcer disease.

Questions 66–72

MC is receiving treatment for diabetes mellitus, congestive heart failure and

ischaemic heart disease. She also has a history of dementia. She is taking

perindopril (angiotensin-converting enzyme inhibitor), digoxin (cardiac

glycoside), bumetanide (loop diuretic), metformin (biguanide), amitriptyline

(tricyclic antidepressant) and ranitidine (H

-receptor antagonist). MC is

presenting poor respiratory effort, sparse bilateral inspiratory crackles and

poor general health, indicating the possibility of an underlying infection. The

white blood cell count indicates that there is no leucocytosis. However, in

elderly patients, bacterial infections may not necessarily induce leucocytosis.

A66 C

Onset of dehydration may be precipitated by decreased ﬂuid intake and by

loop diuretics. Risk of dehydration increases with environmental factors that

108 Test 2: Answers

support ﬂuid and electrolyte loss, such as heat exposure caused by hot temper-

atures and inadequate ventilation at home. Amitriptyline may cause dry mouth

and sweating but these effects are not related to sufﬁcient ﬂuid loss to cause

dehydration.

A67 E

In elderly patients a normal white blood cell count is not sufﬁcient to eliminate

the presence of an infection and MC has clinical signs that may indicate an

infection. MC should be started on co-amoxiclav therapy intravenously. When

her general condition and the respiratory features improve, treatment may be

continued orally. The use of corticosteroids without the use of anti-infective

agents will present a general improvement in MC but will leave the infection

untreated. This is very dangerous and should be avoided.

A68 A

When MC is started on parenteral rehydration with intravenous 0.9% sodium

chloride 1 litre alternating with 5% dextrose 1 litre every 8 h, blood sodium

levels and blood glucose should be monitored. The bumetanide should be

stopped until dehydration status is corrected, and then it should be re-

introduced carefully. MC was started on sodium chloride and dextrose as she

has combined electrolyte and ﬂuid deﬁciency. Dextrose used alone is intended

when there is ﬂuid loss without signiﬁcant loss of electrolytes. This is very

uncommon.

A69 B

Metformin is an antidiabetic drug that has the advantages that it does not

increase appetite and that occurrence of hypoglycaemia is very low. Its disad-

vantage is that it may provoke lactic acidosis, especially in patients with renal

impairment. In MC renal function should be monitored, and signs and

symptoms of lactic acidosis should be noted as dehydration poses a higher

risk of lactic acidosis. Side-effects of metformin include anorexia, nausea,

Test 2: Answers 109

vomiting, abdominal pain. To reduce gastrointestinal symptoms, the patient

should be advised to take the drug with meals. Diarrhoea may occur initially

and is only transient. When alcohol is consumed with metformin, the risk of

lactic acidosis is increased. MC should be advised to avoid alcohol as it may

interfere with her medications, it may precipitate dehydration and cause a

deterioration in her general condition because of her dementia.

A70 A

Amitriptyline and imipramine are tricyclic antidepressants that have a tertiary

amine structure. Imipramine is a dibenzazepine with a structure that is very

similar to the phenothiazines, whereas amitriptyline is a dibenzocyclohepta-

diene that has a structure which resembles thioxanthenes. Amitriptyline is more

sedative than imipramine. Tolerance to this effect tends to develop with long-

term treatment. Elderly patients may be particularly sensitive to the side-effects

of tricyclic antidepressants and reduced doses are recommended. MC is

taking a dose of 20 mg at night, probably to induce sleep and reduce anxiety.

The dose is appropriate for the age group. Use of amitriptyline in MC requires

review as its use may result in cardiotoxicity and it may alter blood-glucose

concentrations, which may include hypoglycaemia unawareness. It may also

cause confusion, which is a problem in MC as she also has dementia.

A71 D

MC has presented with early parkinsonian features. Bradykinesia which is

general slowness of movement, is the main symptom for parkinsonism, which,

during the initial phases of the disease, may occur as the only symptom or in

combination with tremor at rest that disappears with activity and muscular

rigidity. Postural instability is a late feature of the condition and increases the

tendency to fall. As the disease progresses, patients develop reduced blink

frequency, monotonous and impaired speech, greasy skin leading to sebor-

rhoea, urinary incontinence and constipation.

110 Test 2: Answers

A72 B

Amitriptyline, being a tricyclic antidepressant, may cause movement disorders

and dyskinesias. Parkinsonian symptoms in MC may be precipitated by the

administration of amitriptyline. The involvement of a physiotherapist in MC’s

healthcare team could help her to follow exercises that would delay onset of

muscle rigidity and allow her to carry out normal daily activities at home with

minimal support.

Questions 73–75

Eczema is a chronic inﬂammatory skin condition. Atopic eczema occurs mostly

in children and it is characterised by pruritus, itchy papules, inﬂamed and

licheniﬁed skin especially on ﬂexures such as elbows and knees. It is associ-

ated with a family history of asthma and hayfever and it may be exacerbated

by allergens. The area may become infected because of pruritus, leading to

a ﬂare-up of the condition and a bacterial infection. Common causative

bacteria include staphylococci and streptococci.

A73 B

BC may have an exacerbation of atopic eczema or impetigo, which is a

common occurrence in patients with atopic eczema, as the area becomes

infected because of the scratching that is associated with intense itching.

Atopic eczema is a chronic condition that may be exacerbated by exposure

to allergens such as clothing ﬁbres, by changes in environment such as

exposure to sun, hot temperatures or cold temperatures. Impetigo is a skin

infection characterised by pruritic vesicles and golden-coloured crusts. It is

caused by Gram-positive cocci and is a contagious condition. Ringworm

infection is a fungal infection and when it occurs on non-hairy areas (tinea

corporis) it is characterised by discoid, erythematous scaly plaques.

Test 2: Answers 111