Set 1: For each patient, select the most appropriate antidepressant-related option.
A. Citalopram
B. Mirtazapine
C. Amitriptyline
D. Venlafaxine
E. St John’s wort
F. Sertraline
G. Phenelzine
H. Fluoxetine
1. A 67-year-old man develops moderate depression 3 months after an MI. He takes aspirin, bisoprolol, ramipril, atorvastatin and clopidogrel. He has no history of mania, seizures or antidepressant intolerance. His ECG shows no QT prolongation.
Which option is most appropriate to consider first?
2. A 46-year-old woman has moderate depression with marked insomnia, poor appetite and 6 kg unintentional weight loss. She previously stopped an SSRI due to troublesome sexual dysfunction. She is not suicidal and has no history of bipolar disorder.
Which option is most appropriate to consider?
Set 2: For each patient, select the most appropriate management option.
A. Start fluoxetine immediately after stopping phenelzine
B. Reassure that withdrawal symptoms cannot occur with SSRIs
C. Add St John’s wort to improve response
D. Treat as serotonin syndrome and arrange urgent assessment
E. Stop antidepressant abruptly without follow-up
F. Add tramadol for mood symptoms
G. Increase all serotonergic medicines simultaneously
H. Taper gradually with shared decision-making and monitoring
3. A 38-year-old man has taken paroxetine for 18 months. He feels well and wants to stop treatment. He previously experienced dizziness and “electric shock” sensations when he missed doses.
Which option is most appropriate?
4. A 52-year-old woman taking sertraline is prescribed tramadol for back pain. Two days later she develops agitation, sweating, diarrhoea, tremor and muscle twitching.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate option.
A. Stop all antiseizure medicines immediately
B. Continue sodium valproate unchanged and advise pregnancy testing only if a period is missed
C. Discuss possible reproductive risks for men taking valproate and signpost for specialist review before conception planning
D. Replace antiseizure treatment with folic acid only
E. Start combined hormonal contraception as the only action
F. Reassure that antiseizure medicines are always safe in pregnancy
G. Urgently refer for specialist review because valproate has strict reproductive safety requirements
H. Supply emergency contraception monthly as routine contraception
5. A 25-year-old woman takes sodium valproate for generalised epilepsy. She is sexually active, not using reliable contraception and says she may want pregnancy within the next year. She has not seen neurology for 18 months.
Which option is most appropriate?
6. A 31-year-old man takes sodium valproate for epilepsy. He and his partner are planning a pregnancy. He asks whether recent safety advice applies to men as well as women.
Which option is most appropriate?
Set 4: For each patient, select the most appropriate pharmacist intervention.
A. Counsel that lamotrigine rash with fever or mucosal symptoms needs urgent review
B. Advise stopping antiseizure medicine after 3 seizure-free months
C. Recommend taking phenytoin with enteral feed continuously to improve absorption
D. Reassure that missed doses do not matter if seizures are controlled
E. Discuss enzyme induction and need for reliable contraception or specialist contraceptive advice
F. Recommend St John’s wort for seizure prevention
G. Advise driving immediately after any seizure
H. Replace all antiseizure medicines with benzodiazepines long term
7. A 28-year-old woman taking carbamazepine for epilepsy asks for combined oral contraception. She has no other medical conditions and does not want pregnancy.
Which option is most appropriate?
8. A 19-year-old man started lamotrigine 4 weeks ago. He now reports a painful widespread rash, fever and mouth ulcers.
Which option is most appropriate?
Set 5: For each patient, select the most appropriate option.
A. Give metoclopramide for nausea
B. Stop levodopa abruptly during hospital admission
C. Give haloperidol for agitation as first-line
D. Replace levodopa with prochlorperazine
E. Omit Parkinson’s medicines if the patient is nil by mouth without seeking advice
F. Review dopamine agonist therapy urgently because impulse-control disorder may be medicine-related
G. Double levodopa to prevent all falls
H. Maintain timely Parkinson’s medicine administration and avoid abrupt withdrawal
9. A 72-year-old man with Parkinson’s disease is admitted with pneumonia. His co-careldopa is prescribed “when convenient” rather than at his usual times. He becomes rigid, confused and unable to swallow safely.
Which option is most appropriate?
10. A 61-year-old man with Parkinson’s disease recently started ropinirole. His wife reports new compulsive gambling, increased spending and hypersexual behaviour.
Which option is most appropriate?
Set 6: For each patient, select the most appropriate medicine-related option.
A. Memantine
B. Diazepam for routine confusion
C. Amitriptyline for memory impairment
D. Donepezil
E. Stop all dementia medicines once symptoms progress
F. Haloperidol long term for all behavioural symptoms
G. Chlorphenamine for cognition
H. No review of anticholinergic burden needed
11. A 78-year-old woman is newly diagnosed with mild-to-moderate Alzheimer’s disease. She has no bradycardia, syncope, active peptic ulcer disease or severe asthma/COPD. The memory clinic asks about a suitable cognitive enhancer.
Which option is most appropriate?
12. An 82-year-old man with moderate Alzheimer’s disease cannot tolerate donepezil due to persistent nausea and bradycardia. His cognition and function continue to decline.
Which option is most appropriate to consider?
Set 7: For each patient, select the most appropriate pharmacist action.
A. Continue clozapine and ignore fever
B. Increase haloperidol dose
C. Arrange urgent assessment for possible neuroleptic malignant syndrome
D. Treat antipsychotic-induced parkinsonism with more antipsychotic
E. Check full blood count urgently and follow clozapine monitoring procedure
F. Ignore QT risk if the patient is young
G. Add metoclopramide for extrapyramidal symptoms
H. Stop all antipsychotics permanently without specialist input
13. A 45-year-old man taking haloperidol develops fever, severe muscle rigidity, confusion, sweating and unstable blood pressure. Creatine kinase is raised.
Which option is most appropriate?
14. A 36-year-old woman taking clozapine phones the pharmacy with sore throat, fever and flu-like symptoms. She missed her last scheduled blood test.
Which option is most appropriate?
Set 8: For each patient, select the most appropriate option.
A. Emergency assessment for possible subarachnoid haemorrhage
B. Oral sumatriptan with an NSAID or paracetamol if suitable
C. Amitriptyline or propranolol as possible migraine prophylaxis after assessment
D. Reassure and supply opioid analgesia for all headaches
E. Start combined hormonal contraception for migraine with aura
F. Give ergotamine as first-line for all patients
G. Treat as medication-overuse headache and review analgesic/triptan use
H. Delay assessment of neurological symptoms until routine review
15. A 29-year-old woman has episodic migraine without aura. She has nausea and photophobia. Paracetamol alone is not effective. She has no cardiovascular disease, is not pregnant and has no contraindication to NSAIDs or triptans.
Which option is most appropriate for acute treatment?
16. A 41-year-old man has daily headache. He has been taking codeine/paracetamol most days for 4 months and using sumatriptan 15 days per month.
Which option is most appropriate?
Set 9: For each patient, select the most appropriate management option.
A. Continue indefinitely without review
B. Review opioid and pregabalin therapy, assess harms and dependence risk, and plan safer management rather than supplying early automatically
C. Stop abruptly because dependence-forming medicines should not be tapered
D. Add alcohol to reduce withdrawal symptoms
E. Review benefits, harms and dependence risk, then plan gradual zopiclone reduction if appropriate
F. Increase dose whenever tolerance develops
G. Replace all long-term opioids with benzodiazepines
H. Supply extra early without review when tablets run out early repeatedly
17. A 74-year-old woman has taken zopiclone 7.5 mg nightly for 18 months. She reports poor balance, daytime drowsiness and two recent falls. She is worried she will not sleep if it is stopped.
Which option is most appropriate?
18. A 58-year-old man with chronic non-cancer back pain takes morphine modified-release and pregabalin. He requests early supplies repeatedly and reports increasing sedation. He is still in significant pain.
Which option is most appropriate?
Set 10: For each patient, select the most appropriate option.
A. Urgent assessment for opioid toxicity and consider naloxone with supportive care
B. Give flumazenil routinely for all sedative overdoses
C. Reassure because tremor is expected with lithium
D. Increase morphine dose if respiratory rate is low
E. Give loperamide for lithium toxicity
F. Stop lithium permanently without specialist advice
G. Ignore renal function when prescribing lithium
H. Urgent lithium level, renal function and electrolytes
19. A 66-year-old man taking morphine modified-release is found difficult to rouse. His respiratory rate is 6 breaths/minute and pupils are pinpoint. His dose was increased yesterday.
Which option is most appropriate?
20. A 70-year-old woman taking lithium develops vomiting and diarrhoea during a viral illness. She now has coarse tremor, ataxia, slurred speech and confusion. She also takes ramipril.
Which option is most appropriate?
Central Nervous System Questions
Answers and Rationale
1. F
Sertraline is commonly preferred after MI because it has a relatively favourable cardiovascular profile compared with many alternatives. Tricyclics are more problematic in cardiac disease, and St John’s wort has significant interaction concerns.
2. B
Mirtazapine can be useful where depression is associated with insomnia, poor appetite and weight loss. It may also be considered if SSRI-related sexual dysfunction has been troublesome.
3. H
Paroxetine is associated with withdrawal symptoms, especially if stopped abruptly. Antidepressants should usually be reduced gradually with shared decision-making and monitoring.
4. D
Sertraline plus tramadol increases serotonergic activity. Agitation, sweating, diarrhoea, tremor and muscle twitching are concerning for serotonin syndrome and require urgent assessment.
5. G
Valproate has major pregnancy safety risks and strict reproductive safety requirements. A woman of childbearing potential without reliable contraception should receive urgent specialist review.
6. C
UK safety advice includes reproductive risk counselling for males taking valproate who may father children. Specialist review is needed before conception planning.
7. E
Carbamazepine is an enzyme inducer and can reduce the effectiveness of combined hormonal contraception. Reliable contraception, often non-hormonal or specialist-advised, should be discussed.
8. A
Lamotrigine can cause serious skin reactions, including Stevens–Johnson syndrome. Rash with fever or mouth ulcers requires urgent medical assessment.
9. H
Parkinson’s medicines are time-critical. Delayed or omitted dopaminergic medicines can cause severe rigidity, swallowing deterioration and neuroleptic malignant-like syndromes.
10. F
Dopamine agonists such as ropinirole can cause impulse-control disorders, including gambling, compulsive spending and hypersexuality. Dopaminergic therapy should be reviewed urgently.
11. D
Donepezil is an acetylcholinesterase inhibitor used for mild-to-moderate Alzheimer’s disease when suitable. Bradycardia, syncope and gastrointestinal adverse effects should be considered.
12. A
Memantine can be considered in moderate Alzheimer’s disease when acetylcholinesterase inhibitors are not tolerated, and in severe disease depending on clinical circumstances.
13. C
Fever, severe rigidity, autonomic instability, confusion and raised creatine kinase suggest neuroleptic malignant syndrome. This is a medical emergency.
14. E
Clozapine can cause neutropenia and agranulocytosis. Fever and sore throat, especially with missed blood monitoring, require urgent full blood count review and action according to clozapine monitoring procedures.
15. B
For acute migraine, a triptan with either an NSAID or paracetamol is commonly used when suitable. An antiemetic may also be needed if nausea or vomiting is significant.
16. G
Frequent use of opioids, paracetamol and triptans can cause medication-overuse headache. Management requires reviewing analgesic and triptan use and planning withdrawal or reduction appropriately.
17. E
Long-term zopiclone can cause dependence, sedation, cognitive impairment and falls. Benefits and harms should be reviewed, and gradual reduction planned if appropriate.
18. B
Repeated early supplies, sedation and poor pain control suggest possible tolerance, dependence, harm or inappropriate therapy. Treatment should be reviewed rather than automatically escalated or supplied early.
19. A
Pinpoint pupils, severe drowsiness and respiratory depression after opioid dose increase suggest opioid toxicity. Urgent assessment, supportive care and naloxone may be required.
20. H
Vomiting, diarrhoea, dehydration and ACE inhibitor use can increase lithium toxicity risk. Coarse tremor, ataxia, slurred speech and confusion require urgent lithium level, renal function and electrolyte assessment.
Here are 20 extended matching questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.