Set 1: For each patient, select the most appropriate management option.
A. Start loperamide and review in 1 week
B. Urgent assessment for possible upper gastrointestinal malignancy
C. Long-term metoclopramide without review
D. Treat as uncomplicated constipation
E. Start oral fluconazole
F. Trial of proton pump inhibitor with lifestyle advice if no alarm features
G. Start oral iron only
H. Immediate antibiotics for H. pylori without testing
1. A 42-year-old man has burning retrosternal discomfort after meals and when lying flat. He has no dysphagia, weight loss, vomiting, haematemesis, melaena or anaemia. He has tried antacids occasionally with partial benefit.
Which option is most appropriate?
2. A 67-year-old woman reports progressive dysphagia to solids, unintentional weight loss and persistent upper abdominal discomfort. She has not had previous reflux symptoms.
Which option is most appropriate?
Set 2: For each patient, select the most appropriate action.
A. Start oral iron and routine review
B. Treat as irritable bowel syndrome
C. Supply ibuprofen with a proton pump inhibitor
D. Emergency assessment for possible acute upper gastrointestinal bleed
E. Start loperamide
F. Reassure if abdominal pain settles
G. Review NSAID use and gastroprotection because of high GI bleeding risk
H. Treat as uncomplicated reflux only
3. A 74-year-old man with osteoarthritis takes naproxen regularly. He has a previous peptic ulcer bleed and is also taking sertraline. He asks to buy more naproxen because it “works better than paracetamol”.
Which option is most appropriate?
4. A 61-year-old woman presents with coffee-ground vomiting, black tarry stools, dizziness and a blood pressure of 88/54 mmHg. She takes aspirin and apixaban.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate pharmacist action.
A. Stop all IBD medicines permanently
B. Treat as uncomplicated IBS
C. Urgent assessment for possible severe ulcerative colitis flare
D. Start loperamide without review
E. Increase NSAID use for abdominal pain
F. Start antibiotics for all Crohn’s symptoms
G. Reassure because blood in stool is expected in remission
H. Review mesalazine adherence and renal monitoring requirements
5. A 39-year-old man with ulcerative colitis takes mesalazine tablets. He admits missing doses because he feels well. He asks whether monitoring is still needed.
Which option is most appropriate?
6. A 28-year-old woman with ulcerative colitis has bloody diarrhoea 8 times daily, fever, tachycardia and abdominal tenderness. She looks dehydrated.
Which option is most appropriate?
Set 4: For each patient, select the most appropriate action.
A. Stop azathioprine and arrange urgent full blood count and clinical review
B. Increase azathioprine dose
C. Reassure because mouth ulcers show response
D. Start loperamide and continue treatment
E. Urgent review for possible methotrexate toxicity
F. Take methotrexate daily until symptoms settle
G. Add ibuprofen to reduce toxicity
H. No monitoring is needed once stable
7. A 35-year-old woman with Crohn’s disease has been taking methotrexate once weekly. She accidentally took it daily for 5 days and now has mouth ulcers, nausea and bruising.
Which option is most appropriate?
8. A 44-year-old man taking azathioprine for Crohn’s disease develops fever, sore throat and mouth ulcers. His last blood monitoring was missed.
Which option is most appropriate?
Set 5: For each patient, select the most appropriate option.
A. Treat as uncomplicated IBS without further assessment
B. Urgent assessment for possible colorectal cancer
C. Start long-term oral prednisolone
D. Start loperamide indefinitely
E. Avoid gluten before coeliac serology
F. Continue gluten intake until coeliac testing is completed
G. Start oral antibiotics for IBS
H. Start omeprazole only
9. A 32-year-old woman has bloating, abdominal discomfort relieved by defecation and alternating constipation and diarrhoea for 8 months. She has no rectal bleeding, weight loss, nocturnal symptoms, anaemia or family history of bowel cancer.
Which option is most appropriate?
10. A 26-year-old woman has chronic diarrhoea, bloating, fatigue and iron-deficiency anaemia. Her GP plans coeliac serology. She asks whether she should stop gluten immediately.
Which option is most appropriate?
Set 6: For each patient, select the most appropriate management option.
A. Increase dietary fibre only and delay review
B. Start loperamide
C. Treat opioid-induced constipation with a regular stimulant and/or osmotic laxative regimen if suitable
D. Reassure because vomiting is expected with constipation
E. Start oral iron
F. Start antibiotics
G. Treat as uncomplicated haemorrhoids
H. Urgent assessment for possible bowel obstruction
11. A 70-year-old woman with metastatic cancer has recently started modified-release morphine. She has not opened her bowels for 4 days and has abdominal discomfort. She has no vomiting or severe distension.
Which option is most appropriate?
12. A 59-year-old man has colicky abdominal pain, marked distension, vomiting and absolute constipation. He had previous abdominal surgery.
Which option is most appropriate?
Set 7: For each patient, select the most appropriate option.
A. Assess urgently for hepatic encephalopathy and precipitating causes
B. Start loperamide
C. Start high-dose paracetamol regularly
D. Reassure because confusion is expected in cirrhosis
E. Assess for decompensated cirrhosis and ascites management
F. Start NSAIDs for abdominal discomfort
G. Treat with oral iron only
H. Recommend alcohol to stimulate appetite
13. A 58-year-old man with known cirrhosis presents with increasing abdominal swelling, ankle oedema and shortness of breath when lying flat. He has gained 5 kg over 2 weeks.
Which option is most appropriate?
14. A 63-year-old woman with cirrhosis becomes increasingly drowsy and confused. Her partner says she is “not herself” and has had constipation for several days.
Which option is most appropriate?
Set 8: For each patient, select the most appropriate action.
A. Treat as uncomplicated dyspepsia
B. Urgent assessment for possible ascending cholangitis
C. Supply loperamide
D. Urgent assessment for possible acute pancreatitis
E. Start oral fluconazole
F. Reassure if pain radiates to the back
G. Start oral iron
H. Recommend high-fat meals to stimulate bile flow
15. A 46-year-old man has severe epigastric pain radiating to the back with repeated vomiting. He drinks heavily and looks unwell.
Which option is most appropriate?
16. A 72-year-old woman has right upper quadrant pain, fever, rigors and jaundice. She has a history of gallstones.
Which option is most appropriate?
Set 9: For each patient, select the most appropriate pharmacist contribution.
A. Urgent review for dehydration, electrolyte disturbance and high-output stoma management
B. Stop all oral fluids
C. Start bulk-forming laxative only
D. Treat as constipation
E. Ignore medicine absorption issues
F. Review medicine formulation and absorption suitability in ileostomy or short bowel context
G. Start oral iron for all high-output stomas
H. Use loperamide without assessing hydration status
17. A 38-year-old woman with a new ileostomy reports output over 2 litres daily, thirst, dizziness and reduced urine output. She has lost 3 kg in a week.
Which option is most appropriate?
18. A 51-year-old man with an ileostomy reports seeing intact modified-release tablets in his stoma bag. His symptoms are worsening despite adherence.
Which option is most appropriate?
Set 10: For each patient, select the most appropriate counselling or safety action.
A. Take alendronic acid with orange juice and lie down afterwards
B. Take pancreatin only at bedtime
C. Use metoclopramide long term without review
D. Separate calcium or iron from levothyroxine because absorption may be reduced
E. Take pancreatic enzyme replacement with meals and snacks
F. Take NSAIDs on an empty stomach for best effect
G. Continue metoclopramide indefinitely for chronic nausea
H. Stop levothyroxine while taking supplements
19. A 69-year-old woman takes levothyroxine every morning. She has started ferrous sulfate and calcium carbonate after being diagnosed with anaemia and osteoporosis. Her TSH is rising despite adherence.
Which option is most appropriate?
20. A 57-year-old man with chronic pancreatitis is prescribed pancreatic enzyme replacement. He says he takes all capsules at night because he forgets during the day.
Which option is most appropriate?
Gastrointestinal Questions
Answers and Rationale
1. F
Typical reflux symptoms without alarm features can be managed initially with lifestyle advice and a proton pump inhibitor trial. Dysphagia, weight loss, bleeding or persistent vomiting would change the urgency.
2. B
Progressive dysphagia and weight loss are alarm features for possible upper gastrointestinal malignancy. This requires urgent clinical assessment rather than empirical reflux treatment alone.
3. G
Regular NSAID use in a patient with previous ulcer bleeding and SSRI use increases GI bleeding risk. NSAID need, safer analgesia and gastroprotection should be reviewed.
4. D
Coffee-ground vomiting, melaena, hypotension and dizziness suggest acute upper GI bleeding. Anticoagulant and antiplatelet use increase bleeding risk, so emergency assessment is needed.
5. H
Mesalazine is used for maintenance of remission in ulcerative colitis and requires adherence support. Renal monitoring is also important because mesalazine can rarely affect kidney function.
6. C
Frequent bloody diarrhoea, fever, tachycardia, abdominal tenderness and dehydration suggest a severe ulcerative colitis flare. Urgent assessment is required.
7. E
Daily methotrexate dosing is a serious medication error. Mouth ulcers, nausea and bruising suggest possible toxicity and bone marrow suppression, requiring urgent review.
8. A
Azathioprine can cause bone marrow suppression. Fever, sore throat and mouth ulcers with missed monitoring require urgent blood tests and clinical review.
9. B
The scenario is consistent with IBS because symptoms are chronic and there are no alarm features such as bleeding, weight loss, nocturnal symptoms or anaemia. Diagnosis still requires appropriate clinical assessment.
10. F
Coeliac serology may be falsely negative if gluten has already been excluded. The patient should continue gluten until testing is completed, unless advised otherwise by a clinician.
11. C
Opioid-induced constipation is common and should be anticipated. A regular stimulant and/or osmotic laxative regimen is usually required, with review of bowel pattern and red flags.
12. H
Colicky pain, distension, vomiting and absolute constipation suggest bowel obstruction, especially with previous abdominal surgery. This requires urgent assessment.
13. E
Increasing abdominal swelling, oedema, orthopnoea and rapid weight gain in cirrhosis suggest ascites and decompensation. Clinical review is needed for assessment and safe diuretic/paracentesis planning.
14. A
Drowsiness and confusion in cirrhosis suggest hepatic encephalopathy. Constipation, infection, bleeding, dehydration or sedatives can precipitate it and need urgent assessment.
15. D
Severe epigastric pain radiating to the back with vomiting and alcohol history suggests acute pancreatitis. Urgent assessment is required.
16. B
Right upper quadrant pain, fever/rigors and jaundice suggest ascending cholangitis. This is a biliary infection emergency needing urgent assessment and antibiotics/source control.
17. A
High-output ileostomy can rapidly cause dehydration, electrolyte disturbance and acute kidney injury. Thirst, dizziness, reduced urine output and weight loss are concerning.
18. G
Modified-release preparations may pass through an ileostomy without adequate absorption. Formulation suitability should be reviewed, and alternatives considered.
19. D
Calcium and iron can bind levothyroxine and reduce absorption, causing rising TSH. Administration should be separated and thyroid function monitored.
20. E
Pancreatic enzyme replacement should be taken with meals and snacks so enzymes mix with food. Taking all capsules at bedtime will not adequately support digestion during the day.
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.