Set 1: For each patient, select the most appropriate immediate action.
A. Reassure because symptoms are expected after opioid dose increases
B. Urgent assessment for opioid toxicity and consider naloxone with supportive care
C. Supply loperamide and oral rehydration salts only
D. Urgent hospital assessment for paracetamol overdose and acetylcysteine consideration
E. Advise the patient to wait until symptoms develop
F. Give activated charcoal at home
G. Increase morphine dose to overcome sedation
H. Treat as uncomplicated migraine
1. A 28-year-old woman took 24 × 500 mg paracetamol tablets 5 hours ago after an argument with her partner. She feels nauseated but has no abdominal pain. She now regrets taking them.
Which option is most appropriate?
2. A 72-year-old man with cancer pain is difficult to rouse after his morphine modified-release dose was increased yesterday. His respiratory rate is 6/min and his pupils are pinpoint.
Which option is most appropriate?
Set 2: For each patient, select the most appropriate pharmacist action.
A. Urgent lithium level, renal function and electrolytes, with specialist advice
B. Increase lithium dose because diarrhoea reduces absorption
C. Reassure because coarse tremor is expected in stable therapy
D. Check digoxin level, renal function, electrolytes and ECG urgently
E. Stop all monitoring if symptoms are mild
F. Give loperamide and continue lithium unchanged
G. Double the next digoxin dose
H. Treat as viral gastroenteritis only
3. A 69-year-old woman taking lithium develops vomiting and diarrhoea during a hot weekend. She now has coarse tremor, ataxia, slurred speech and confusion. She also takes ramipril and bendroflumethiazide.
Which option is most appropriate?
4. An 82-year-old woman taking digoxin develops nausea, confusion, yellow-green visual disturbance and a pulse of 46 bpm. Her renal function has worsened after dehydration.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate action.
A. Reassure because mouth ulcers show methotrexate is working
B. Increase methotrexate dose to compensate for missed folic acid
C. Urgent review for possible methotrexate toxicity and bone marrow suppression
D. Supply another week of colchicine and review later
E. Stop colchicine and arrange urgent assessment for possible colchicine toxicity
F. Add clarithromycin to improve colchicine effect
G. Treat bruising as normal ageing
H. Continue both medicines because interaction risk is theoretical only
5. A 61-year-old man with rheumatoid arthritis takes methotrexate 15 mg once weekly. He accidentally took 15 mg daily for 5 days and now has mouth ulcers, sore throat and bruising.
Which option is most appropriate?
6. A 74-year-old woman with CKD stage 4 is given colchicine for gout. She is also taking clarithromycin for pneumonia. Two days later she develops severe diarrhoea, vomiting, muscle weakness and abdominal pain.
Which option is most appropriate?
Set 4: For each patient, select the most likely toxicity or action.
A. Neuroleptic malignant syndrome requiring urgent assessment
B. Serotonin syndrome requiring urgent assessment
C. Anticholinergic toxicity managed with reassurance only
D. Opioid withdrawal
E. Simple anxiety due to new medicine
F. Continue serotonergic medicines and increase tramadol
G. Treat with loperamide only
H. Restart antipsychotic at a higher dose immediately
7. A 44-year-old woman taking sertraline is prescribed tramadol for back pain. Two days later she develops agitation, sweating, diarrhoea, tremor, hyperreflexia and muscle twitching.
Which option is most appropriate?
8. A 38-year-old man taking haloperidol develops high fever, severe muscle rigidity, confusion, sweating and unstable blood pressure. His creatine kinase is markedly raised.
Which option is most appropriate?
Set 5: For each patient, select the most appropriate action.
A. Treat as uncomplicated gastritis
B. Give glucose and monitor because sulfonylurea hypoglycaemia may recur
C. Urgent assessment for tricyclic antidepressant overdose with ECG and supportive care
D. Reassure because tinnitus means the drug is leaving the body
E. Urgent assessment for salicylate poisoning
F. Supply antacid only
G. Give extra gliclazide to stabilise glucose
H. Encourage sleep at home after overdose
9. A 35-year-old woman is found after taking an unknown quantity of amitriptyline. She is drowsy, has dry mouth, dilated pupils, tachycardia and a broad-complex rhythm on ECG.
Which option is most appropriate?
10. An 80-year-old man taking gliclazide is found confused, sweaty and shaky after missing meals during an infection. Capillary glucose is 2.1 mmol/L. His symptoms improve after glucose but recur 45 minutes later.
Which option is most appropriate?
Answers and Rationale
1. D
This is a deliberate paracetamol overdose above usual safe limits. Symptoms may be minimal early, but hepatotoxicity can still develop. She needs urgent hospital assessment, paracetamol level interpretation and possible acetylcysteine.
2. B
Reduced consciousness, respiratory rate 6/min and pinpoint pupils after morphine dose increase suggest opioid toxicity. Urgent assessment, airway/breathing support and naloxone may be needed.
3. A
Vomiting, diarrhoea, dehydration, coarse tremor, ataxia, slurred speech and confusion suggest lithium toxicity. ACE inhibitor and thiazide use further increase toxicity risk, so urgent lithium level, renal function, electrolytes and specialist advice are needed.
4. D
Nausea, confusion, visual disturbance and bradycardia suggest digoxin toxicity. Dehydration and worsening renal function increase risk. Digoxin level, ECG, electrolytes and renal function are needed urgently.
5. C
Daily methotrexate dosing is a serious medication error. Mouth ulcers, sore throat and bruising suggest mucositis and possible bone marrow suppression, requiring urgent review and blood tests.
6. E
Colchicine toxicity risk is increased by severe renal impairment and macrolide interactions. Severe gastrointestinal symptoms, muscle weakness and abdominal pain are concerning and need urgent assessment.
7. B
Sertraline plus tramadol increases serotonergic activity. Agitation, sweating, diarrhoea, tremor, hyperreflexia and muscle twitching are consistent with serotonin syndrome and require urgent assessment.
8. A
Fever, severe rigidity, autonomic instability, confusion and raised creatine kinase suggest neuroleptic malignant syndrome. This is a medical emergency.
9. C
Amitriptyline overdose can cause anticholinergic features, CNS depression and dangerous cardiac conduction abnormalities. Broad-complex ECG changes require urgent assessment and supportive care.
10. B
Sulfonylurea-induced hypoglycaemia can recur after initial glucose correction, especially in older adults with poor intake or infection. Ongoing monitoring and further treatment are required.
Here are 10 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.