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A 78 year old man is admitted to a metropolitan hospital with delirium secondary to a urinary tract infection. He lives alone, attends one community pharmacy and was discharged from another hospital six months ago. The ward pharmacist is asked to obtain a best possible medication history before the medical team prescribes. Which approach is most likely to produce an accurate history?
Select the answer:Select the answer
1 correct answer
A.
Transcribe the medicines listed on the emergency department referral letter, as this is the most recent clinical document
B.
Copy the medicines from the discharge summary issued six months ago and ask the patient to confirm the list
C.
Interview the patient and his daughter using structured prompts, then verify the list against at least one independent source such as a recent dispensing history or the GP medicines list, and reconcile any discrepancies
D.
Ask the ward nurse to list the medicines found in the patient's bedside locker and record these as the current regimen
Explanation: A best possible medication history is defined by method rather than by document. It requires a structured patient or carer interview combined with verification against at least one other independent source, because every single source is known to be incomplete. Referral letters and admission notes are frequently transcribed from an earlier list and propagate existing errors. A discharge summary six months old cannot reflect subsequent changes made in primary care, and asking a delirious patient to confirm it invites acquiescence bias. Medicines brought from home may be out of date, may belong to another person, or may omit items stored elsewhere, so a locker inventory alone is unreliable. Cross checking dispensing records, the GP list or a shared electronic record against what the patient describes actually taking exposes the two most common defects in a history, namely omissions of non-prescription, complementary, inhaled, topical, injectable and when required medicines, and discrepancies between prescribed and actual dose or frequency. Where the patient cannot give a reliable account, a carer interview conducted with the patient's permission becomes essential. Every discrepancy found should be documented and resolved with the prescriber rather than silently corrected, since reconciliation at admission prevents errors carrying through the entire episode of care and into discharge.
Right Answer: C
Quiz
Question 2/102/10
Implement Medication Management Strategy
Implement Medication Management Strategy
Implement Medication Management Strategy
A 54 year old man with type 2 diabetes attends your community pharmacy with a new prescription. His clinic notes show an average home blood pressure of 152/94 mmHg, a urine albumin to creatinine ratio of 18 mg/mmol and an eGFR of 68 mL/min/1.73m2. He takes metformin 1 g twice daily only. Which antihypertensive is the most appropriate first choice for him?
Select the answer:Select the answer
1 correct answer
A.
Amlodipine 5 mg once daily
B.
Indapamide 1.5 mg controlled release once daily
C.
Perindopril 4 mg once daily
D.
Metoprolol tartrate 50 mg twice daily
Explanation: In a person with diabetes and established albuminuria, blockade of the renin angiotensin system is the preferred starting point because it does more than lower systemic pressure. Angiotensin converting enzyme inhibitors reduce efferent arteriolar tone, lowering intraglomerular pressure, and this translates into a measurable fall in albuminuria and slower decline in glomerular filtration rate independent of the blood pressure effect. An angiotensin receptor blocker is an equivalent alternative if cough develops. Dihydropyridine calcium channel blockers and thiazide like diuretics are legitimate first line agents for uncomplicated hypertension and will be needed later as combination partners, but neither offers the specific renoprotection that albuminuria demands, and calcium channel blockers may even increase protein excretion when used alone. Beta blockers are reserved for compelling indications such as heart failure, previous myocardial infarction or rate control, and they can mask hypoglycaemia awareness and worsen glycaemic control, so they are not a routine first choice in diabetes. Practical counselling includes checking electrolytes and creatinine one to two weeks after starting, warning that a small early rise in creatinine is expected and acceptable, advising a sick day plan to withhold the drug during dehydrating illness, and reinforcing that dry cough or angioedema should be reported promptly.
Right Answer: C
Quiz
Question 3/103/10
Monitor and Evaluate Medication Management
Monitor and Evaluate Medication Management
Monitor and Evaluate Medication Management
A 68 year old man with a hospital acquired chest infection is prescribed gentamicin 5 mg/kg IV once daily, given at 2000 hours as a 30 minute infusion. The resident asks the ward pharmacist when the trough concentration should be collected before the third dose. What is the most appropriate sampling advice?
Select the answer:Select the answer
1 correct answer
A.
Thirty minutes after the second infusion finishes, so that the highest concentration is captured
B.
Two hours after the second infusion starts, because this is when distribution is complete
C.
Within the hour immediately preceding the next scheduled dose, so the result reflects elimination between doses
D.
At any convenient time during the dosing interval, because the result is interpreted against a single reference range
Explanation: With extended interval aminoglycoside dosing the concentration that matters for safety is the lowest point of the interval, because accumulation rather than peak exposure drives nephrotoxicity and ototoxicity. A trough must therefore be drawn as close as possible to the moment the next dose is due, conventionally within the hour before it, and the exact collection time and the exact time of the preceding dose must both be documented so that the result can be interpreted. A sample taken shortly after the infusion finishes measures the peak, which is determined mainly by dose and volume of distribution and is rarely required when a weight based once daily regimen is used. A sample taken during the distribution phase, roughly the first hour or two after the infusion, is uninterpretable because the drug has not yet equilibrated with peripheral tissue. Taking a level at a random time is the commonest practical error, because a single number without a time stamp cannot be compared with any target and may prompt either false reassurance or an unnecessarily withheld dose. Trough monitoring is supported by baseline and at least twice weekly renal function, daily fluid balance, and enquiry about tinnitus, vertigo or hearing change, with audiometry considered when therapy extends beyond a few days.
Right Answer: C
Quiz
Question 4/104/10
Compound Medicines
Compound Medicines
Compound Medicines
A prescriber orders 120 g of salicylic acid 3% w/w in white soft paraffin for a 52 year old man with plantar hyperkeratosis. The pharmacist will prepare the ointment on an ointment tile. What quantity of salicylic acid is required for the batch?
Select the answer:Select the answer
1 correct answer
A.
0.36 g
B.
3.6 g
C.
12 g
D.
36 g
Explanation: Percentage weight in weight expresses grams of active ingredient in every 100 g of finished product, so a 3% w/w ointment contains 3 g of salicylic acid in 100 g. The batch is 120 g, so the quantity required is 120 multiplied by 3 divided by 100, which equals 3.6 g. The balance of the formula is white soft paraffin 116.4 g, giving a total mass of 120 g. Two errors account for the common wrong answers. Shifting the decimal point one place, as though the strength were 0.3%, gives 0.36 g and would produce a subtherapeutic keratolytic. Treating the 3 as a number of grams per 10 g, or multiplying 120 by 0.3 rather than 0.03, gives 36 g, a tenfold overdose that would be both physically impossible to incorporate smoothly and potentially caustic to intact skin. When compounding a semisolid, the active ingredient should be weighed on a balance capable of that quantity with acceptable accuracy, then levigated with a small amount of base or a suitable levigating liquid before geometric dilution into the remainder, so the finished ointment is uniform and free of gritty aggregates.
Right Answer: B
Quiz
Question 5/105/10
Promote Health and Well-being
Promote Health and Well-being
Promote Health and Well-being
A 44 year old woman asks for something stronger than paracetamol for a headache. She describes a headache that came on abruptly while she was gardening about ninety minutes ago and reached maximum intensity within seconds. She says it is the worst headache of her life and she vomited once. She has no history of migraine and takes only a combined oral contraceptive. What is the most appropriate action?
Select the answer:Select the answer
1 correct answer
A.
Supply ibuprofen 400 mg and advise her to see her general practitioner if the headache persists beyond forty eight hours
B.
Supply a paracetamol and codeine combination and advise her to rest in a darkened room
C.
Arrange immediate emergency assessment by calling an ambulance, as this presentation suggests a subarachnoid haemorrhage
D.
Supply sumatriptan under the pharmacist only arrangements for migraine and review in one week
Explanation: A headache that is abrupt in onset and reaches peak intensity within seconds to a minute is described as thunderclap and is the classic presentation of subarachnoid haemorrhage until proven otherwise. Associated vomiting, neck stiffness, altered consciousness, seizure, focal neurological signs or collapse increase concern further, but their absence does not exclude the diagnosis, because a sentinel bleed can present with headache alone. The critical feature is the speed of onset rather than the severity, so a careful history that establishes how quickly the pain peaked is the single most useful piece of information a pharmacist can obtain. Definitive assessment requires urgent computed tomography, ideally within six hours of onset, followed by lumbar puncture if imaging is negative, so any delay caused by a trial of analgesia is potentially fatal. Supplying an analgesic risks masking the presentation and delaying diagnosis. Pharmacist supply of sumatriptan is restricted to people with an established diagnosis of migraine made by a medical practitioner and is inappropriate for a first ever severe headache. Other red flags that require prompt medical referral include new headache after age fifty, headache with fever and rash, headache worse on lying down or with coughing, progressive headache over weeks, and headache after head trauma.
A pharmacist is beginning a medication review interview with a 66 year old woman who takes perindopril, amlodipine and rosuvastatin. The pharmacist wants to learn how she actually takes her antihypertensives day to day rather than how she has been told to take them. Which question is most likely to achieve this?
Select the answer:Select the answer
1 correct answer
A.
Tell me how you take your blood pressure tablets on a typical day
B.
Do you take your blood pressure tablet every morning with breakfast
C.
You are taking both of the blood pressure tablets in the morning, aren't you
D.
Have you missed any blood pressure tablets in the past week
Explanation: Open questions invite the patient to describe their own experience in their own words and cannot be answered with a single word, so they generate the richest and least distorted information at the start of an interview. Beginning with an invitation to describe a typical day lets the patient reveal timing, missed doses, splitting of tablets, use of a dose administration aid and any self initiated changes, none of which would surface from a question that only requires confirmation. Closed questions have a legitimate place later in the consultation for pinning down specific detail, but used early they narrow the field prematurely and encourage acquiescence, where a patient agrees with the interviewer to avoid appearing non adherent. Leading questions that embed the expected answer are worse still, because they signal what the pharmacist wants to hear and make disclosure of non adherence socially difficult. A question about missed doses in the past week is closed and also invites recall bias and a socially desirable answer of none. Best practice is a funnel structure, starting broad and open, following with focused probes, then confirming understanding, all delivered without judgement so the patient feels safe to describe what really happens.
Right Answer: A
Quiz
Question 7/107/10
Implement Medication Management Strategy
Implement Medication Management Strategy
Implement Medication Management Strategy
A 62 year old man has been taking indapamide 2.5 mg daily for hypertension for three years. Over the past nine months he has had four acute gout flares affecting his first metatarsophalangeal joints, and his serum urate is 0.53 mmol/L. His blood pressure is well controlled at 128/78 mmHg. Which change to his antihypertensive therapy should the pharmacist recommend?
Select the answer:Select the answer
1 correct answer
A.
Cease indapamide and start amlodipine 5 mg daily
B.
Cease indapamide and start hydrochlorothiazide 25 mg daily
C.
Continue indapamide and add prednisolone 5 mg daily long term
D.
Halve the indapamide dose and add atenolol 50 mg daily
Explanation: Thiazide and thiazide like diuretics reduce renal urate excretion by competing with urate at the organic anion transporters in the proximal tubule and by causing mild volume contraction, both of which raise serum urate and precipitate gout flares. When flares become recurrent, the sensible medication management step is to remove the offending agent and replace it with an antihypertensive from a class that is urate neutral or urate lowering. Dihydropyridine calcium channel blockers are urate neutral and are an evidence based first line option, so substitution maintains blood pressure control without perpetuating the trigger. Losartan is another rational choice because it has a mild uricosuric effect. Swapping one thiazide for another does not solve the problem, since the class effect on urate is shared and hydrochlorothiazide at this dose carries the same risk. Long term low dose corticosteroid is not an appropriate strategy for recurrent gout because of the metabolic, bone and infection risks, and it does not address the cause. Beta blockers such as atenolol are also associated with higher urate levels, so adding one compounds the problem, whereas losartan is an angiotensin receptor blocker with a mild uricosuric effect and is a reasonable alternative. Urate lowering therapy with allopurinol, started at a low dose and titrated to a target urate below 0.36 mmol/L, should be discussed separately.
Right Answer: A
Quiz
Question 8/108/10
Monitor and Evaluate Medication Management
Monitor and Evaluate Medication Management
Monitor and Evaluate Medication Management
A 54 year old woman is receiving vancomycin 1 g IV every 12 hours for a methicillin resistant Staphylococcus aureus bacteraemia. Population modelling from her measured concentrations estimates her vancomycin clearance to be 4 L/h. Assuming the target 24 hour area under the concentration time curve is 400 to 600 mg.h/L, what is her estimated AUC24 and the appropriate action?
Select the answer:Select the answer
1 correct answer
A.
500 mg.h/L, which is within target, so continue the current regimen
B.
250 mg.h/L, which is below target, so increase the dose
C.
125 mg.h/L, which is well below target, so double the dose and shorten the interval
D.
1000 mg.h/L, which is above target, so halve the dose
Explanation: The relationship that underpins area under the curve guided vancomycin dosing is that at steady state the 24 hour area under the concentration time curve equals the total dose given in 24 hours divided by clearance. Here the patient receives 1 g twice daily, so the 24 hour dose is 2000 mg, and clearance is 4 L/h. Dividing 2000 mg by 4 L/h gives 500 mg.h/L. This sits comfortably inside the accepted efficacy and safety window of 400 to 600 mg.h/L for serious staphylococcal infection, so no dose change is indicated and monitoring simply continues. Values below 400 are associated with treatment failure and emergence of reduced susceptibility, while values above about 600 are associated with acute kidney injury without added benefit. The arithmetic errors that generate the alternative figures are using a single 1 g dose instead of the 24 hour total, which halves the answer, or inverting the division. Area under the curve targeting has largely replaced trough only targeting because troughs of 15 to 20 mg/L overshoot the intended exposure in many patients and increase nephrotoxicity. Whichever method is used, renal function should be checked at least twice weekly and more often with concurrent nephrotoxins.
Right Answer: A
Quiz
Question 9/109/10
Compound Medicines
Compound Medicines
Compound Medicines
A pharmacist must incorporate 250 mg of a finely divided potent powder uniformly into 100 g of an emulsifying ointment base. Which technique will best ensure a homogeneous final product?
Select the answer:Select the answer
1 correct answer
A.
Add the entire quantity of base to the powder in one portion and stir vigorously for five minutes
B.
Dissolve the powder in a few drops of purified water and then stir it through the finished base
C.
Mix the powder with an approximately equal quantity of base, then repeatedly double the amount of base added at each subsequent step until all of it is incorporated
D.
Spread the base on the tile, sprinkle the powder over the surface and fold it in as the final step of preparation
Explanation: Geometric dilution is the standard method for distributing a very small quantity of solid uniformly through a much larger mass. Starting with roughly equal parts of powder and base, and doubling the quantity of base at each successive step, keeps the ratio of the two phases close to one to one at every stage, which is the condition under which mixing by shear on a tile or in a mortar is most efficient. Adding the whole base at once creates an enormous disparity in bulk, so the small quantity of powder tends to remain as discrete aggregates or to be lost against the walls of the vessel, producing a product with dangerous variation in strength from dose to dose. Dissolving the powder in water introduces an aqueous phase that an anhydrous or emulsifying base may not accommodate, risking phase separation, altered rheology and a shortened beyond-use date because water supports microbial growth. Sprinkling and folding at the end gives no opportunity for particle size reduction or for progressive shear. Where the powder is coarse or crystalline it should first be triturated to reduce particle size, and levigation with a compatible liquid removes grittiness before geometric dilution begins.
Right Answer: C
Quiz
Question 10/1010/10
Promote Health and Well-being
Promote Health and Well-being
Promote Health and Well-being
A 61 year old man presents asking for a cough mixture. He describes a dry, tickly, non productive cough that has troubled him for about six weeks, is worse at night and is not associated with fever, wheeze, weight loss or sputum. His dispensing history shows perindopril was started two months ago and he also takes atorvastatin and metformin. What is the most appropriate response?
Select the answer:Select the answer
1 correct answer
A.
Explain that the cough is likely caused by his antihypertensive and refer him back to his prescriber to discuss substitution with an angiotensin receptor blocker
B.
Supply pholcodine linctus to suppress the cough at night and review in two weeks
C.
Supply a bromhexine containing mucolytic to loosen the secretions
D.
Advise that the cough is a symptom of uncontrolled diabetes and recommend a blood glucose check
Explanation: A dry, persistent, tickly cough is a well recognised class effect of angiotensin converting enzyme inhibitors, reported in up to ten to fifteen per cent of users and more common in women. It arises from accumulation of bradykinin and substance P in the airways because the enzyme that normally degrades them is inhibited, and it is not dose related. Onset ranges from within days of starting to several months later, and the temporal link to a recent prescription is the key diagnostic clue. The cough is not harmful but it is intensely irritating, disturbs sleep and is a common cause of covert non adherence, so it should never be simply suppressed with an antitussive. Resolution usually occurs within one to four weeks of cessation, although it may take longer. The appropriate management is referral to the prescriber, who can substitute an angiotensin receptor blocker, which acts downstream of the enzyme and does not raise bradykinin, so the cough almost always resolves while blood pressure control and renal protection are preserved. Mucolytics are illogical for a non productive cough. A cough persisting beyond three weeks always warrants review to exclude asthma, reflux, postnasal drip, heart failure and malignancy.
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Quiz name:CAOP: Competency Assessment for Overseas Pharmacist
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