Central Nervous System Questions
1. A 76-year-old woman is brought to the emergency department after developing sudden right-sided weakness and difficulty speaking 70 minutes ago. She has a history of hypertension, atrial fibrillation and type 2 diabetes. Her capillary blood glucose is 5.8 mmol/L. She is alert and her symptoms are ongoing.
Which ONE of the following is the most appropriate next step?
A. Administer aspirin 300 mg immediately.
B. Arrange urgent brain imaging and specialist stroke assessment.
C. Start apixaban immediately.
D. Arrange review by the stroke clinic within 72 hours.
E. Wait to see whether symptoms resolve spontaneously.
2. A 69-year-old man with Parkinson's disease is admitted with community-acquired pneumonia. During medicines reconciliation, you notice that his co-careldopa has been prescribed twice daily instead of his usual five-times-daily regimen.
Which ONE of the following is the pharmacist's most appropriate intervention?
A. Suggest withholding co-careldopa until the infection has resolved.
B. Recommend switching to modified-release co-careldopa once daily.
C. Continue the prescription because dose frequency is unlikely to affect symptoms over a few days.
D. Recommend amending the prescription so doses are given at the patient's usual times.
E. Replace co-careldopa with ropinirole.
3. A 34-year-old woman started lamotrigine three weeks ago for epilepsy. She now reports a widespread rash involving her trunk, mouth ulcers and a temperature of 38.3°C.
Which ONE of the following is the most appropriate advice?
A. Continue treatment and review in one week.
B. Reduce the dose by half.
C. Stop lamotrigine immediately and arrange urgent medical assessment.
D. Treat the rash with antihistamines only.
E. Restart lamotrigine once the rash settles.
4. A 45-year-old man taking sertraline for depression is prescribed tramadol following a dental procedure. Two days later, he develops agitation, sweating, tremor and hyperreflexia.
Which ONE of the following is the most likely diagnosis?
A. Neuroleptic malignant syndrome.
B. Acute dystonia.
C. Opioid withdrawal.
D. Serotonin syndrome.
E. Bell's palsy.
5. An 81-year-old woman with Alzheimer's disease becomes acutely confused over the past 24 hours. She is usually independent but is now drowsy and disorientated. Her daughter reports that she has developed dysuria and urinary frequency.
Which ONE of the following is the most likely explanation?
A. Progression of Alzheimer's disease.
B. Delirium secondary to infection.
C. New-onset Parkinson's disease.
D. Depression.
E. Normal ageing.
6. A 58-year-old man taking morphine modified-release tablets for cancer pain develops increasing drowsiness. His respiratory rate is 7 breaths/minute and his pupils are pinpoint.
Which ONE of the following is the most appropriate immediate management?
A. Reduce the next morphine dose by half.
B. Administer metoclopramide.
C. Continue routine observations.
D. Give oral naloxone.
E. Administer naloxone and urgently assess the patient.
7. A 49-year-old woman has diabetic peripheral neuropathy. Amitriptyline was stopped because of severe dry mouth and constipation despite dose reduction.
Which ONE of the following is the most appropriate alternative treatment?
A. Duloxetine.
B. Co-codamol.
C. Naproxen.
D. Flucloxacillin.
E. Hyoscine butylbromide.
8. A 29-year-old woman with epilepsy asks whether she should stop taking levetiracetam because she has been seizure-free for three years. She has not yet discussed this with her neurologist.
Which ONE of the following is the most appropriate advice?
A. Stop treatment immediately.
B. Take the medicine only if she experiences warning symptoms.
C. Continue treatment and discuss any withdrawal with her specialist.
D. Halve the dose for one week, then stop.
E. Replace levetiracetam with diazepam.
9. A 52-year-old woman presents with severe unilateral facial pain lasting a few seconds at a time. The pain is triggered by brushing her teeth and washing her face. Neurological examination is otherwise normal.
Which ONE of the following is the most appropriate first-line treatment?
A. Amitriptyline.
B. Sumatriptan.
C. Carbamazepine.
D. Ibuprofen.
E. Morphine modified-release.
10. A 73-year-old man taking donepezil attends his annual medication review. His wife reports that he has experienced two unexplained falls over the last month. His pulse is 46 beats/minute.
Which ONE of the following is the most appropriate action?
A. Continue donepezil unchanged because bradycardia is unrelated.
B. Stop donepezil permanently without further assessment.
C. Increase the donepezil dose.
D. Review the patient promptly because donepezil may be contributing to symptomatic bradycardia.
E. Replace donepezil with sertraline.
11. A 67-year-old woman with Parkinson's disease attends clinic complaining that her tremor and rigidity return approximately 45 minutes before each scheduled dose of co-careldopa. She reports good symptom control for the first few hours after taking each dose and has no troublesome involuntary movements.
Which ONE of the following is the most appropriate management?
A. Stop co-careldopa and commence haloperidol.
B. Advise taking all daily doses together in the morning.
C. Review for end-of-dose wearing-off and discuss optimisation of dopaminergic therapy.
D. Replace co-careldopa with modified-release morphine.
E. Continue current treatment without review.
12. A 73-year-old man with Alzheimer's disease is brought to the emergency department because of sudden confusion, visual hallucinations and agitation that developed over 12 hours. His daughter reports that he has been complaining of dysuria for two days. His temperature is 38.4°C.
Which ONE of the following is the most likely explanation?
A. Progression of Alzheimer's disease.
B. Delirium precipitated by a urinary tract infection.
C. Lewy body dementia.
D. Major depressive disorder.
E. Donepezil toxicity.
13. A 56-year-old woman is admitted following a tonic-clonic seizure. During medicines reconciliation, you discover that she stopped taking her levetiracetam three days ago because she had run out of tablets.
Which ONE of the following is the pharmacist's most appropriate intervention?
A. Explain that abrupt withdrawal of antiseizure medicines increases seizure risk and discuss restarting treatment promptly.
B. Advise waiting until her neurology clinic appointment before restarting treatment.
C. Recommend replacing levetiracetam with diazepam permanently.
D. Advise taking double her usual dose for the next week.
E. Reassure her that missing several days of treatment is unlikely to be important.
14. A 48-year-old man with diabetic peripheral neuropathy has taken duloxetine for eight weeks. His pain has improved, but he reports feeling nauseated during the first week of treatment. The nausea has now resolved.
Which ONE of the following is the most appropriate advice?
A. Stop duloxetine because nausea occurred.
B. Continue treatment as the adverse effect has resolved and the medicine is providing benefit.
C. Reduce the dose despite good pain control.
D. Replace duloxetine with ibuprofen.
E. Take duloxetine only when pain is severe.
15. A 79-year-old man with Parkinson's disease develops nausea after commencing oral antibiotics. The medical team asks which antiemetic would be most appropriate.
Which ONE of the following is the best option?
A. Metoclopramide.
B. Prochlorperazine.
C. Domperidone.
D. Haloperidol.
E. Chlorpromazine.
16. A 42-year-old woman presents with recurrent unilateral throbbing headaches associated with photophobia, nausea and occasional visual zig-zag lines lasting 20 minutes before the headache begins. She experiences two attacks each month.
Which ONE of the following is the most likely diagnosis?
A. Cluster headache.
B. Tension-type headache.
C. Trigeminal neuralgia.
D. Migraine with aura.
E. Giant cell arteritis.
17. A 69-year-old man receiving modified-release oxycodone for chronic cancer pain reports increasing drowsiness over the last 24 hours. His respiratory rate is 8 breaths/minute and oxygen saturation is 91% on room air.
Which ONE of the following is the most appropriate immediate action?
A. Omit the next dose only.
B. Encourage mobilisation.
C. Prescribe a stimulant laxative.
D. Continue treatment and reassess tomorrow.
E. Suspect opioid toxicity and arrange urgent assessment with consideration of naloxone.
18. A 35-year-old woman taking sertraline for depression attends a medication review after eight weeks. She reports that her mood has improved significantly and asks whether she can stop treatment now.
Which ONE of the following is the most appropriate advice?
A. Continue treatment for an appropriate maintenance period before considering gradual withdrawal.
B. Stop treatment immediately because symptoms have improved.
C. Take sertraline only when she feels low.
D. Alternate days for one week before stopping.
E. Replace sertraline with diazepam.
19. An 81-year-old woman with dementia is prescribed oxybutynin for urinary urgency by another clinic. Two weeks later, her family report worsening confusion and increased daytime sleepiness.
Which ONE of the following is the pharmacist's most appropriate recommendation?
A. Increase the oxybutynin dose.
B. Continue treatment because cognitive decline is expected.
C. Recommend a medication review because anticholinergic medicines can worsen cognition.
D. Stop donepezil instead.
E. Add promethazine at night.
20. A 61-year-old man taking carbamazepine for focal epilepsy is prescribed clarithromycin for community-acquired pneumonia.
Which ONE of the following is the most appropriate concern?
A. Clarithromycin may increase carbamazepine concentrations, increasing the risk of toxicity.
B. Carbamazepine prevents clarithromycin absorption.
C. The combination causes predictable severe hypoglycaemia.
D. Carbamazepine becomes ineffective immediately.
E. There is no clinically relevant interaction.
21. A 58-year-old woman with epilepsy takes lamotrigine 200 mg twice daily. She has recently started taking a combined oral contraceptive prescribed by her GP. At her next review, she reports two breakthrough focal seizures after being seizure-free for over two years.
Which ONE of the following is the most likely explanation?
A. The contraceptive has increased lamotrigine concentrations.
B. Lamotrigine commonly becomes ineffective after two years.
C. Combined hormonal contraception may reduce lamotrigine concentrations, increasing seizure risk.
D. The seizures are most likely due to placebo effect.
E. The contraceptive should improve seizure control.
22. A 71-year-old man with Parkinson's disease is admitted with bowel obstruction and is made nil by mouth. He normally takes co-careldopa five times daily. Four hours after missing his medicines, he becomes increasingly rigid and struggles to communicate.
Which ONE of the following is the pharmacist's most appropriate recommendation?
A. Restart oral co-careldopa once bowel function returns.
B. Hold all Parkinson's medicines until he can swallow again.
C. Reduce the co-careldopa dose by half.
D. Urgently discuss an alternative non-oral dopaminergic regimen with the Parkinson's specialist team.
E. Prescribe haloperidol to reduce agitation.
23. A 76-year-old woman with vascular dementia has become increasingly agitated over the past week. Examination reveals suprapubic tenderness and a temperature of 38.1°C.
Which ONE of the following is the most appropriate initial management?
A. Start long-term haloperidol.
B. Assess and treat the likely underlying infection before considering sedative medicines.
C. Increase her dementia medicine.
D. Prescribe diazepam regularly.
E. Stop all long-term medicines.
24. A 63-year-old man receives modified-release morphine for metastatic cancer pain. He asks why he has also been prescribed senna.
Which ONE of the following is the best explanation?
A. Senna reduces opioid-induced nausea.
B. Senna prevents respiratory depression.
C. Senna improves pain relief.
D. Opioids commonly cause constipation, and stimulant laxatives help prevent or treat this.
E. Senna reduces opioid tolerance.
25. A 39-year-old woman taking sertraline telephones the pharmacy because she has started taking St John's wort that she purchased online. She feels well and has no adverse effects.
Which ONE of the following is the most appropriate advice?
A. Continue both medicines because no interaction has occurred.
B. Increase the sertraline dose.
C. Take the products six hours apart.
D. Stop sertraline immediately.
E. Advise her to stop St John's wort and seek review because the combination increases the risk of clinically significant interactions.
26. A 46-year-old man presents with severe unilateral headache around his right eye associated with lacrimation and nasal congestion. Each attack lasts approximately 40 minutes and occurs twice daily for several weeks.
Which ONE of the following is the most likely diagnosis?
A. Cluster headache.
B. Migraine with aura.
C. Medication-overuse headache.
D. Tension-type headache.
E. Trigeminal neuralgia.
27. A 67-year-old woman with diabetic peripheral neuropathy has been taking pregabalin for three months. She reports increasing ankle swelling and dizziness that are affecting her mobility.
Which ONE of the following is the most appropriate action?
A. Double the pregabalin dose.
B. Continue treatment without review because these effects are expected.
C. Recommend a clinical review to reassess the balance between benefit and adverse effects.
D. Stop pregabalin abruptly.
E. Add a benzodiazepine to improve tolerance.
28. A 74-year-old man with Parkinson's disease develops vivid visual hallucinations after his dopamine agonist dose was increased two weeks ago. His motor symptoms remain well controlled.
Which ONE of the following is the most appropriate initial management?
A. Increase the dopamine agonist dose further.
B. Review Parkinson's medication with the specialist team as hallucinations may be treatment-related.
C. Stop all Parkinson's medicines immediately.
D. Start metoclopramide.
E. Reassure him that no review is required.
29. A 52-year-old woman is prescribed amitriptyline for post-herpetic neuralgia. She has a history of recurrent falls and chronic angle-closure glaucoma.
Which ONE of the following should be considered before treatment is continued?
A. Amitriptyline may worsen anticholinergic adverse effects and increase falls risk.
B. Amitriptyline has no effect on falls risk.
C. Amitriptyline is contraindicated because of post-herpetic neuralgia.
D. Amitriptyline should always be taken in the morning.
E. Amitriptyline reduces intraocular pressure.
30. A 68-year-old man presents to the emergency department after his wife noticed sudden left-sided weakness that completely resolved within 30 minutes. He is now neurologically normal.
Which ONE of the following is the most appropriate next step?
A. Reassure him because symptoms have resolved.
B. Arrange routine outpatient review within six months.
C. Discharge with advice to return if symptoms recur.
D. Treat as a suspected transient ischaemic attack and arrange urgent specialist assessment.
E. Diagnose migraine without further investigation.
31. A 66-year-old man with focal epilepsy has been seizure-free for four years while taking carbamazepine. He attends the pharmacy after being prescribed clarithromycin for a lower respiratory tract infection.
Which ONE of the following is the most appropriate pharmacist action?
A. Advise that no interaction is expected.
B. Recommend taking carbamazepine and clarithromycin at different times of the day.
C. Contact the prescriber because clarithromycin may increase carbamazepine concentrations and toxicity.
D. Advise the patient to stop carbamazepine until the antibiotic course is complete.
E. Reduce the clarithromycin dose by half without consulting the prescriber.
32. A 75-year-old woman with Alzheimer's disease is reviewed six months after starting donepezil. Her husband reports that she remains independent with dressing and washing but has noticed gradual worsening of her memory. She has experienced no significant adverse effects.
Which ONE of the following is the most appropriate management?
A. Stop donepezil because her memory has deteriorated.
B. Continue donepezil after assessing overall clinical benefit and tolerability.
C. Double the dose immediately regardless of current dose.
D. Replace donepezil with haloperidol.
E. Stop treatment because dementia medicines should only be used for six months.
33. A 44-year-old woman presents with low mood, poor sleep and loss of interest in activities. She reports thoughts that "life isn't worth living" but denies any immediate plans to harm herself.
Which ONE of the following should be prioritised before deciding on treatment?
A. Assessment of suicide risk and appropriate safety planning.
B. Measurement of body mass index only.
C. Liver function tests.
D. Serum vitamin B12 concentration.
E. Visual acuity testing.
34. A 59-year-old man receiving long-term morphine modified-release tablets reports worsening diffuse pain despite several recent dose increases. He describes the pain as different from his original cancer pain.
Which ONE of the following should be considered?
A. Opioid-induced constipation.
B. Medication-overuse headache.
C. Progression of Parkinson's disease.
D. Opioid-induced hyperalgesia.
E. Trigeminal neuralgia.
35. A 70-year-old woman with Parkinson's disease develops severe nausea after chemotherapy.
Which ONE of the following antiemetics is generally the most appropriate choice?
A. Haloperidol.
B. Prochlorperazine.
C. Metoclopramide.
D. Chlorpromazine.
E. Ondansetron.
36. A 27-year-old man is brought to the emergency department after a tonic-clonic seizure lasting eight minutes. Intravenous access has not yet been obtained.
Which ONE of the following is the most appropriate initial treatment according to standard emergency practice?
A. Oral carbamazepine.
B. Buccal or intramuscular emergency benzodiazepine according to local protocol.
C. Oral diazepam.
D. Intramuscular haloperidol.
E. Intravenous phenytoin before seizure control.
37. A 48-year-old woman with multiple sclerosis reports increasing muscle stiffness that is interfering with walking and transferring from a chair. There is no evidence of an acute relapse.
Which ONE of the following medicines may be considered to improve her symptoms?
A. Donepezil.
B. Sumatriptan.
C. Baclofen.
D. Levetiracetam.
E. Naloxone.
38. A 63-year-old man taking pregabalin for neuropathic pain has chronic kidney disease with an eGFR of 22 mL/min/1.73 m². He reports increasing drowsiness and difficulty concentrating.
Which ONE of the following is the most appropriate pharmacist recommendation?
A. Increase the pregabalin dose.
B. Continue unchanged because renal function does not affect pregabalin.
C. Add a stimulant medicine.
D. Review the dose because pregabalin accumulates in renal impairment.
E. Stop all analgesics permanently.
39. A 34-year-old woman taking sertraline for depression reports that she feels much better after three months of treatment. She asks whether she should stop the medicine by taking it on alternate days for one week.
Which ONE of the following is the most appropriate advice?
A. Stop immediately because symptoms have resolved.
B. Continue treatment for an appropriate duration and plan a gradual withdrawal with her prescriber when suitable.
C. Alternate-day dosing is the preferred method of stopping all SSRIs.
D. Replace sertraline with diazepam before stopping.
E. Continue indefinitely without future review.
40. A 73-year-old man presents with sudden-onset confusion, fever, neck stiffness and photophobia.
Which ONE of the following is the most appropriate management?
A. Recommend paracetamol and fluids before GP review.
B. Arrange a routine outpatient neurology appointment.
C. Treat as an emergency and arrange immediate hospital assessment.
D. Supply sumatriptan.
E. Advise rest at home and review in 48 hours.
41. A 65-year-old man with Parkinson's disease attends his annual review. His wife reports that over the past month he has developed compulsive online gambling and excessive spending. His symptoms began shortly after the dose of his dopamine agonist was increased.
Which ONE of the following is the most appropriate management?
A. Reassure the patient that this is unrelated to treatment.
B. Start sertraline for gambling behaviour.
C. Stop all Parkinson's medicines immediately.
D. Refer for cognitive behavioural therapy only.
E. Arrange an urgent medication review as dopamine agonists can cause impulse control disorders.
42. A 57-year-old woman presents to her GP with burning pain affecting the lateral aspect of her thigh for the past eight months. Amitriptyline improved the pain but caused intolerable dry mouth and urinary retention. Duloxetine was ineffective despite an adequate trial.
Which ONE of the following is the most appropriate next treatment option?
A. Naproxen.
B. Co-codamol.
C. Omeprazole.
D. Flucloxacillin.
E. Pregabalin.
43. A 71-year-old man with epilepsy has been admitted with vomiting and diarrhoea. He has been unable to keep his antiseizure medication down for the last 24 hours. He remains alert and has not had a seizure.
Which ONE of the following is the pharmacist's most appropriate recommendation?
A. Wait until he has a seizure before restarting treatment.
B. Omit all antiseizure medicines until discharge.
C. Double the next oral dose.
D. Urgently discuss an alternative route or management plan with the treating team to maintain seizure control.
E. Stop treatment permanently.
44. A 79-year-old woman with Alzheimer's disease is reviewed in clinic. Her daughter reports that her memory has gradually deteriorated despite treatment, but she remains calmer, requires less supervision and continues to recognise close family members.
Which ONE of the following is the most appropriate interpretation?
A. Donepezil has failed because memory has worsened.
B. Dementia medicines should always be stopped after one year.
C. Overall clinical benefit should be considered rather than memory alone.
D. Immediate dose doubling is indicated.
E. Alzheimer's disease has been cured.
45. A 32-year-old woman taking sertraline attends the emergency department with agitation, confusion, tremor, inducible clonus, hyperreflexia and a temperature of 39.1°C after taking an overdose of another medicine.
Which ONE of the following additional medicines would most strongly support the diagnosis of serotonin syndrome?
A. Ibuprofen.
B. Amoxicillin.
C. Salbutamol.
D. Amlodipine.
E. Tramadol.
46. An 82-year-old man with Parkinson's disease develops increasing difficulty swallowing tablets following aspiration pneumonia. He remains alert and requires ongoing dopaminergic treatment.
Which ONE of the following is the most appropriate pharmacist action?
A. Stop Parkinson's treatment until swallowing improves.
B. Crush all modified-release tablets.
C. Halve all Parkinson's doses.
D. Change immediately to oral haloperidol.
E. Work with the Parkinson's specialist team to identify an appropriate alternative formulation or route.
47. A 54-year-old man taking oxycodone modified-release tablets reports increasing constipation despite taking senna regularly. He is opening his bowels once every five days and is becoming uncomfortable.
Which ONE of the following is the most appropriate next step?
A. Stop oxycodone immediately.
B. Increase oxycodone to improve bowel function.
C. Review constipation management and consider adding an osmotic laxative.
D. Replace senna with loperamide.
E. No change is required because constipation is expected.
48. A 43-year-old woman presents with a sudden severe headache during exercise. She describes it as the worst headache she has ever experienced. She vomited once shortly afterwards but has no previous history of migraine.
Which ONE of the following is the most appropriate management?
A. Recommend ibuprofen and review tomorrow.
B. Diagnose migraine and prescribe sumatriptan.
C. Arrange a routine outpatient neurology appointment.
D. Advise hydration and rest at home.
E. Arrange immediate emergency assessment for a possible subarachnoid haemorrhage.
49. A 76-year-old woman with depression started mirtazapine four weeks ago. Her mood has improved, but she reports feeling sleepy during the day.
Which ONE of the following is the most appropriate initial advice?
A. Stop treatment immediately.
B. Take the medicine in the morning.
C. Double the dose.
D. Review when she takes the medicine, advise taking it at night if appropriate, and reassess if sedation persists.
E. Replace it with diazepam.
50. A 68-year-old man with atrial fibrillation develops sudden right arm weakness and expressive dysphasia lasting 20 minutes. By the time he arrives at hospital, all symptoms have resolved completely.
Which ONE of the following is the most appropriate diagnosis?
A. Bell's palsy.
B. Migraine with aura.
C. Delirium.
D. Focal seizure.
E. Transient ischaemic attack.
Answers and Rationale
1. B
The patient has ongoing focal neurological deficits consistent with an acute stroke. Immediate brain imaging is required to distinguish between ischaemic and haemorrhagic stroke before deciding on reperfusion therapy. Aspirin is generally started only after intracranial haemorrhage has been excluded in patients who are not receiving thrombolysis.
2. D
Patients with Parkinson's disease should receive their dopaminergic medicines at their usual scheduled times whenever possible. Delayed or omitted doses can result in significant worsening of motor symptoms and, in severe cases, Parkinsonism-hyperpyrexia syndrome.
3. C
A widespread rash with mucosal involvement and fever shortly after starting lamotrigine raises concern for Stevens–Johnson syndrome or toxic epidermal necrolysis. Lamotrigine should be stopped immediately and the patient referred for urgent medical assessment.
4. D
The combination of sertraline and tramadol increases serotonergic activity. Agitation, hyperreflexia, tremor and autonomic features are characteristic of serotonin syndrome and require urgent assessment.
5. B
An acute deterioration in cognition developing over hours or days in a patient with dementia is most likely delirium. Urinary tract infections are a common precipitating cause in older adults and should be investigated and treated promptly.
6. E
The combination of respiratory depression, reduced consciousness and pinpoint pupils is highly suggestive of opioid toxicity. Naloxone should be administered promptly alongside appropriate airway, breathing and supportive management.
7. A
Duloxetine is a recommended first-line treatment option for diabetic peripheral neuropathic pain. It is an appropriate alternative when amitriptyline has been discontinued because of intolerable antimuscarinic adverse effects.
8. C
Antiseizure medicines should not be discontinued without specialist advice. Decisions regarding withdrawal should consider seizure type, duration of seizure freedom, recurrence risk and individual patient factors, with gradual dose reduction where appropriate.
9. C
The patient's symptoms are characteristic of trigeminal neuralgia. Carbamazepine is generally considered the first-line pharmacological treatment unless contraindicated or poorly tolerated.
10. D
Acetylcholinesterase inhibitors such as donepezil can cause bradycardia, syncope and falls. This patient requires prompt clinical review to assess whether donepezil is contributing to the symptoms and whether treatment should be modified.
11. C
The patient has a classic wearing-off phenomenon. Symptoms return before the next levodopa dose but improve after the dose is taken, suggesting that optimisation of dopaminergic therapy is required rather than stopping treatment.
12. B
A sudden deterioration over hours with signs of infection strongly suggests delirium rather than progression of dementia. Older adults with dementia are particularly susceptible to delirium triggered by infections such as urinary tract infections.
13. A
Abrupt discontinuation of antiseizure medicines increases the risk of seizure recurrence. The patient should be assessed and treatment restarted appropriately, with support to prevent future missed supplies.
14. B
Transient nausea is a common early adverse effect of duloxetine. As the nausea has resolved and the medicine is providing benefit for neuropathic pain, continuing treatment is the most appropriate option.
15. C
Domperidone is generally preferred when an antiemetic is required in Parkinson's disease because it has minimal central dopamine-blocking effects. Dopamine antagonists such as metoclopramide, prochlorperazine and haloperidol can worsen Parkinsonian symptoms.
16. D
Visual aura followed by unilateral throbbing headache with nausea and photophobia is characteristic of migraine with aura. The history is less consistent with cluster headache, trigeminal neuralgia or giant cell arteritis.
17. E
Reduced respiratory rate, drowsiness and hypoxia suggest opioid toxicity. This requires urgent assessment, supportive care and consideration of naloxone where clinically indicated.
18. A
After remission, antidepressants are usually continued for a maintenance period to reduce relapse risk. When it is appropriate to stop, treatment should usually be withdrawn gradually rather than stopped abruptly.
19. C
Oxybutynin has significant anticholinergic activity, which can worsen cognition and precipitate confusion in older adults with dementia. A medication review is appropriate to assess risks, benefits and alternatives.
20. A
Clarithromycin can inhibit carbamazepine metabolism and increase carbamazepine concentrations. This may increase the risk of toxicity, including dizziness, diplopia, ataxia and confusion.
21. C
Combined hormonal contraceptives can reduce lamotrigine plasma concentrations, increasing the risk of breakthrough seizures. Patients should be reviewed when hormonal contraception is started, stopped or changed.
22. D
Patients with Parkinson's disease should not have dopaminergic therapy interrupted unnecessarily. If oral administration is not possible, urgent specialist review is needed to consider suitable non-oral alternatives and prevent severe deterioration.
23. B
Acute agitation in a patient with dementia should prompt assessment for reversible causes such as infection, pain or constipation. Treating the underlying cause is the priority before considering sedative medication.
24. D
Constipation is a predictable adverse effect of opioids. A stimulant laxative such as senna is commonly prescribed to prevent or manage opioid-induced constipation.
25. E
St John's wort has significant pharmacodynamic and pharmacokinetic interactions, including an increased risk of serotonergic toxicity when combined with SSRIs. The patient should be advised to stop St John's wort and seek review.
26. A
Severe unilateral orbital headache with ipsilateral autonomic features occurring in clusters is characteristic of cluster headache. The repeated short attacks over several weeks support this diagnosis.
27. C
Pregabalin commonly causes dizziness and peripheral oedema. If adverse effects affect mobility or quality of life, the patient should be reviewed to determine whether dose adjustment or an alternative treatment is appropriate.
28. B
Hallucinations are a recognised adverse effect of dopaminergic therapy, particularly dopamine agonists. The initial step is to review treatment with the Parkinson's specialist team rather than stopping medicines abruptly.
29. A
Amitriptyline has significant anticholinergic effects, which can worsen glaucoma, increase sedation and contribute to falls. These risks should be considered before treatment is continued.
30. D
Transient focal neurological symptoms consistent with a TIA require urgent specialist assessment because the risk of subsequent stroke is highest in the hours and days following the event.
31. C
Clarithromycin inhibits carbamazepine metabolism and may increase the risk of toxicity, including dizziness, diplopia and ataxia. The prescriber should be contacted to consider an alternative antibiotic or appropriate monitoring.
32. B
Treatment with donepezil should be continued if there is evidence of overall benefit and it remains well tolerated. Gradual cognitive decline is expected in Alzheimer's disease and does not automatically mean treatment has failed.
33. A
Assessment of suicide risk is an essential priority in any patient presenting with depression and suicidal thoughts. This should guide the urgency of intervention, follow-up and safety planning.
34. D
Increasing, diffuse pain despite escalating opioid doses may indicate opioid-induced hyperalgesia. This is where increasing opioid exposure paradoxically increases pain sensitivity.
35. E
Dopamine antagonists such as metoclopramide, prochlorperazine and haloperidol can worsen Parkinsonian symptoms. Ondansetron is generally an appropriate option because it does not block dopamine receptors.
36. B
A prolonged tonic-clonic seizure requires prompt treatment with an emergency benzodiazepine using an appropriate available route. Further emergency management can then follow according to local protocol.
37. C
Baclofen is commonly used to reduce muscle spasticity in multiple sclerosis when symptoms interfere with function and non-pharmacological measures alone are insufficient.
38. D
Pregabalin is primarily eliminated by the kidneys. Reduced renal function can lead to accumulation and increase the risk of adverse effects such as sedation, dizziness and impaired concentration.
39. B
Patients who respond to antidepressant therapy should usually continue treatment for an appropriate maintenance period to reduce relapse risk. Withdrawal should be gradual and planned with the prescriber.
40. C
Fever, neck stiffness, photophobia and acute confusion raise concern for meningitis or encephalitis. This is a medical emergency requiring immediate hospital assessment and treatment.
41. E
Dopamine agonists are associated with impulse control disorders, including pathological gambling, compulsive shopping and hypersexuality. Prompt medication review is required, and dose reduction or withdrawal may be necessary.
42. E
When first-line options such as amitriptyline and duloxetine are ineffective or not tolerated, pregabalin is an appropriate alternative for neuropathic pain, depending on the clinical context.
43. D
Interrupting antiseizure medication increases the risk of breakthrough seizures. If oral administration is not possible, the pharmacist should discuss alternative routes or temporary management strategies with the treating team.
44. C
Treatment decisions in dementia should be based on overall clinical function, quality of life, behaviour and tolerability, rather than memory scores alone.
45. E
The combination of sertraline and tramadol substantially increases serotonergic activity. In the presence of clonus, hyperreflexia, agitation and hyperthermia, serotonin syndrome is the most likely diagnosis.
46. E
Patients with Parkinson's disease should continue dopaminergic therapy whenever possible. If swallowing becomes difficult, specialist advice should be sought promptly to identify a suitable alternative formulation or route.
47. C
Persistent opioid-induced constipation despite a stimulant laxative should prompt review of bowel management. Adding an osmotic laxative is a common next step, alongside reassessing hydration, diet and opioid requirements.
48. E
A thunderclap headache, especially during exertion and associated with vomiting, should be treated as a possible subarachnoid haemorrhage until proven otherwise and requires immediate emergency assessment.
49. D
Mirtazapine commonly causes sedation, particularly early in treatment. Taking it at night may reduce the impact of daytime drowsiness, but persistent sedation should be reviewed.
50. E
Transient focal neurological symptoms that resolve completely are characteristic of a transient ischaemic attack. This requires urgent specialist assessment because of the high early risk of stroke.
Here are 50 multiple-choice questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.