Set 1: For each patient, select the most appropriate immediate action.
A. Start oral co-codamol and review in 2 weeks
B. Reassure because back pain is common in cancer
C. Urgent assessment for possible metastatic spinal cord compression
D. Start oral iron and routine GP review
E. Supply loperamide and fluids only
F. Delay assessment until the next oncology clinic
G. Stop all cancer medicines permanently
H. Immediate hospital assessment for possible neutropenic sepsis
1. A 62-year-old woman received chemotherapy for breast cancer 8 days ago. She has a temperature of 38.1°C, rigors and feels generally unwell. She has no cough, dysuria or obvious source of infection.
Which option is most appropriate?
2. A 69-year-old man with metastatic prostate cancer has new severe thoracic back pain worse when lying flat. He now reports unsteadiness on stairs and numbness around his trunk.
Which option is most appropriate?
Set 2: For each patient, select the most appropriate pharmacist action.
A. Withhold oral chemotherapy and arrange urgent oncology review for possible severe toxicity
B. Increase capecitabine dose because diarrhoea suggests poor absorption
C. Supply loperamide only and continue chemotherapy unchanged
D. Reassure because chemotherapy extravasation is harmless
E. Apply heat to all extravasation injuries without checking the drug
F. Stop all antiemetics permanently
G. Stop the infusion and follow local extravasation protocol urgently
H. Flush the cannula forcefully to dilute the drug
3. A patient receiving IV chemotherapy reports burning pain at the cannula site. The nurse notices swelling and redness around the cannula while the infusion is still running.
Which option is most appropriate?
4. A 57-year-old woman taking capecitabine develops profuse diarrhoea, painful red peeling palms and soles, mouth ulcers and reduced oral intake. She has continued taking tablets because she thought symptoms were expected.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate action.
A. Start long-term loperamide without review
B. Withhold immune checkpoint inhibitor and arrange urgent assessment for possible immune-mediated colitis
C. Reassure because immunotherapy cannot affect the lungs
D. Urgent assessment for possible immune-mediated pneumonitis
E. Treat all symptoms as viral infection only
F. Start oral fluconazole
G. Continue immunotherapy and ignore new endocrine symptoms
H. Give live vaccine to boost immune response
5. A 64-year-old man receiving pembrolizumab develops new shortness of breath and dry cough. He has no previous lung disease. Oxygen saturation is 92% on air and symptoms are worsening.
Which option is most appropriate?
6. A 51-year-old woman receiving nivolumab has diarrhoea 8 times daily with abdominal pain and blood in the stool. She feels weak and dizzy.
Which option is most appropriate?
Set 4: For each patient, select the most appropriate option.
A. Start oral calcium tablets
B. Treat as uncomplicated dyspepsia
C. Reassure because facial swelling is expected with cancer
D. Urgent assessment for suspected tumour lysis syndrome
E. Urgent assessment for suspected malignant hypercalcaemia
F. Urgent assessment for possible superior vena cava obstruction
G. Start loperamide
H. Start oral iron only
7. A 44-year-old man with high-grade lymphoma starts chemotherapy. Two days later he develops nausea, muscle cramps and reduced urine output. Blood tests show high potassium, high phosphate, high urate and rising creatinine.
Which option is most appropriate?
8. A 72-year-old woman with metastatic breast cancer becomes increasingly drowsy and constipated. She has thirst, polyuria and confusion. Corrected calcium is 3.25 mmol/L.
Which option is most appropriate?
Set 5: For each patient, select the most appropriate medicine-related action.
A. Provide immediate-release opioid for breakthrough pain and review total opioid requirements
B. Stop modified-release morphine and provide paracetamol only
C. Increase opioid dose without checking sedation or renal function
D. Use codeine for all severe cancer pain
E. Avoid laxatives because opioids cause diarrhoea
F. Apply two fentanyl patches after heat exposure
G. Give naloxone routinely for mild nausea
H. Urgent assessment for opioid toxicity and consider naloxone/supportive care
9. A 63-year-old man with metastatic lung cancer takes modified-release morphine twice daily. His background pain is controlled, but he has severe short-lived pain on movement several times daily. He has no excessive sedation.
Which option is most appropriate?
10. A 70-year-old woman with advanced cancer is found difficult to rouse after her morphine dose was increased. Her respiratory rate is 6/min and pupils are pinpoint.
Which option is most appropriate?
Set 6: For each patient, select the most appropriate safety action.
A. Stop all endocrine therapy permanently
B. Add combined hormonal contraception for hot flushes
C. Urgent assessment for possible venous thromboembolism
D. Reassure because calf swelling is expected with tamoxifen
E. Start oral iron only
F. Review bone protection and fracture risk with aromatase inhibitor therapy
G. Use oestrogen-only HRT without specialist input
H. Give live vaccine to reduce recurrence risk
11. A 55-year-old woman taking tamoxifen for breast cancer develops unilateral calf swelling, pain and shortness of breath. She has no history of asthma.
Which option is most appropriate?
12. A 67-year-old woman starts letrozole after breast cancer surgery. She has a previous fragility fracture and low vitamin D. She asks whether bone health matters.
Which option is most appropriate?
Set 7: For each patient, select the most appropriate pharmacist advice.
A. Give live vaccine during high-dose immunosuppression without checking
B. Withhold biologic and arrange urgent review for possible serious infection
C. Reassure because biologics do not increase infection risk
D. Review vaccination status before immunosuppression and avoid live vaccines during significant immunosuppression unless specialist advice supports use
E. Start antibiotics for every patient on a biologic
F. Increase biologic dose during fever
G. Stop all immunosuppressants permanently without specialist review
H. Use intranasal live influenza vaccine routinely
13. A 48-year-old woman is due to start adalimumab for severe inflammatory bowel disease. Her vaccination history is incomplete and she asks whether she can receive any vaccines later.
Which option is most appropriate?
14. A 59-year-old man taking rituximab and prednisolone develops fever, productive cough, pleuritic chest pain and oxygen saturation of 91% on air.
Which option is most appropriate?
Set 8: For each patient, select the most appropriate medicine-related intervention.
A. Reassure because tacrolimus has no interactions
B. Start clarithromycin without monitoring
C. Stop transplant medicines permanently during mild infection
D. Urgent specialist review before conception because mycophenolate is teratogenic
E. Review tacrolimus interaction risk, renal function and levels before supplying interacting medicines
F. Use NSAIDs freely with ciclosporin
G. Increase tacrolimus dose during diarrhoea without checking levels
H. Give live vaccine routinely after transplant without specialist advice
15. A kidney transplant recipient taking tacrolimus is prescribed clarithromycin for a chest infection. He has tremor and a recent rise in creatinine.
Which option is most appropriate?
16. A 32-year-old woman with a renal transplant takes mycophenolate mofetil and tacrolimus. She wants to start trying for pregnancy next month and has not spoken to her transplant team.
Which option is most appropriate?
Set 9: For each patient, select the most appropriate option.
A. Assess need for Pneumocystis jirovecii pneumonia prophylaxis according to regimen and local protocol
B. Reassure because corticosteroids prevent all infections
C. Urgent assessment for possible shingles complications in an immunosuppressed patient
D. Give live shingles vaccine immediately
E. Treat disseminated rash with topical hydrocortisone only
F. Stop all prophylaxis because resistance is inevitable
G. Use antibiotics only if neutrophils are normal
H. Avoid all non-live vaccines permanently
17. A 66-year-old man is starting high-dose prednisolone plus cyclophosphamide for vasculitis. The prescriber asks whether any infection prophylaxis should be considered.
Which option is most appropriate?
18. A 54-year-old woman taking azathioprine and prednisolone develops a painful vesicular rash affecting the forehead and tip of the nose with a red painful eye.
Which option is most appropriate?
Set 10: For each patient, select the most appropriate referral or assessment option.
A. Reassure because bleeding is common with age
B. Urgent suspected-cancer referral for possible breast cancer
C. Treat with topical steroid and review in 6 months
D. Urgent suspected-cancer referral for possible melanoma
E. Start oral fluconazole
F. Treat as uncomplicated eczema
G. Supply oral iron only
H. Treat as viral wart
19. A 46-year-old woman notices a new hard irregular breast lump fixed to surrounding tissue. She also has new nipple inversion on the same side.
Which option is most appropriate?
20. A 38-year-old man has a pigmented skin lesion that has changed shape and colour over 3 months. It is asymmetric with an irregular border and occasional bleeding.
Which option is most appropriate?
Answers and Rationale
1. H
Fever and rigors within days of chemotherapy should be treated as possible neutropenic sepsis, even without a clear infection source. This requires immediate hospital assessment and urgent treatment.
2. C
Cancer with new severe back pain worse lying flat, sensory symptoms and gait disturbance suggests metastatic spinal cord compression. This is an emergency because neurological injury can become irreversible.
3. G
Pain, swelling and redness around an active chemotherapy infusion suggest extravasation. The infusion should be stopped and the local extravasation protocol followed urgently.
4. A
Severe diarrhoea, hand-foot syndrome, mucositis and reduced intake during capecitabine therapy suggest significant toxicity. Oral chemotherapy should be withheld and urgent oncology advice sought.
5. D
New cough, worsening breathlessness and hypoxia on pembrolizumab may indicate immune-mediated pneumonitis. This requires urgent assessment and treatment guidance from the oncology team.
6. B
Frequent bloody diarrhoea, abdominal pain and weakness during nivolumab therapy suggest immune-mediated colitis. Immunotherapy should be withheld and urgent specialist assessment arranged.
7. F
High-grade lymphoma soon after chemotherapy with hyperkalaemia, hyperphosphataemia, hyperuricaemia and AKI suggests tumour lysis syndrome. This is an oncology emergency.
8. E
Drowsiness, constipation, thirst, polyuria and confusion with markedly raised corrected calcium suggest malignant hypercalcaemia. Urgent assessment and treatment are required.
9. A
Controlled background cancer pain with predictable breakthrough episodes usually requires immediate-release opioid rescue dosing, with review of total opioid requirements and adverse effects.
10. H
Pinpoint pupils, reduced consciousness and respiratory rate of 6/min after morphine dose escalation suggest opioid toxicity. Urgent assessment, supportive care and naloxone may be needed.
11. C
Tamoxifen increases thromboembolism risk. Unilateral calf swelling plus shortness of breath is concerning for DVT with possible pulmonary embolism and requires urgent assessment.
12. G
Aromatase inhibitors can accelerate bone loss and increase fracture risk. Previous fragility fracture and low vitamin D make bone protection and fracture risk review important.
13. D
Vaccination status should be reviewed before significant immunosuppression where possible. Live vaccines are generally avoided during biologic therapy unless specialist advice supports use.
14. B
Rituximab and corticosteroids increase infection risk. Fever, productive cough, pleuritic pain and hypoxia suggest serious infection, so the biologic should be withheld and urgent review arranged.
15. E
Clarithromycin can markedly increase tacrolimus levels, increasing nephrotoxicity and neurotoxicity risk. Tremor and rising creatinine make level and renal review particularly urgent.
16. D
Mycophenolate is teratogenic and requires specialist pre-conception planning. Pregnancy should be avoided until the transplant team has reviewed immunosuppression and safety.
17. A
High-dose corticosteroid plus cyclophosphamide can increase Pneumocystis jirovecii pneumonia risk. Prophylaxis should be considered according to regimen, local policy and patient-specific risk.
18. C
Shingles affecting the ophthalmic branch, especially the tip of the nose and eye symptoms, is urgent. Immunosuppression increases complication risk and needs prompt assessment.
19. B
A hard irregular breast lump with nipple inversion is suspicious for breast cancer. Urgent suspected-cancer referral is appropriate.
20. D
A changing asymmetric pigmented lesion with irregular border, colour change and bleeding is suspicious for melanoma. Urgent suspected-cancer referral is required.
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.