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Tackling extended matching questions in the GPhC registration exam

Are you familiar with the structure of extended matching questions? Why not try our five worked examples

This is another instalment in our pre-registration examination series. The General Pharmaceutical Council (GPhC) registration exam has 30 extended matching questions (EMQ). EMQs are a variant of single best answer questions with, in the case of the GPhC, eight options. According to the Bloom’s Taxonomy learning framework, EMQs test higher order learning – ie knowledge application, evaluation and analysis leading to reasoning and clinical judgement. Simple recall of isolated facts (remembering) will not yield the best results with EMQ questions.

The time allocated for each question is approximately 1.25 minutes, which is meant to teach you how to make decisions under pressure. It is important to read the question carefully and understand what is being asked, then go about synthesizing the knowledge you have in figuring out the answer.

Below, we show you five worked examples demonstrating how to evaluate and analyse a scenario, applying the necessary knowledge and putting the pieces together to arrive at the best answer. Please feel free to use the method that works best for you.

Question 1: A 26-year-old woman who is four months pregnant presents at the GP with a two-day history of a sore throat. She has a Centor score of four and a positive throat swab result for Streptococcus pyogenes. The patient medication record shows that she developed wheezing, breathlessness and a swollen tongue and lips after taking flucloxacillin two years ago.

For the patient described, select the single most appropriate management option from the list below. Each option may be used once, more than once or not at all.

Management of sore throats

A: Amoxicillin

B: Call an ambulance

C: Clarithromycin

D: Co-amoxiclav

E: Doxycycline

F: Erythromycin

G: Pain relief only, eg paracetamol and reassurance

H: Phenoxymethylpenicillin

Click here for the comments, working out and answer

Answer: F: Erythromycin

Explanation and rationale:

This question is assessing your knowledge of diagnosing sore throats, application of guidelines in relation to choosing an appropriate management option (eg advice or reassurance, drug treatment or supportive measures, or referral) and appropriate selection of the drug based on the guidelines and patient history (eg age, pregnancy, prior reaction to flucloxacillin). The woman’s medical history, presenting symptoms and Centor score, along with a positive throat swab, suggest a diagnosis of bacterial sore throat. The first-line treatment according to National Institute for health and Care Excellence (Nice) and Public Health England guidelines is phenoxymethylpenicillin. However, the woman’s history suggests penicillin allergy – as demonstrated by the wheezing, swollen tongue and lips after taking flucloxacillin (a penicillin) two years ago. The next drug option in patients with penicillin allergy is clarithromycin, but this is not preferred for pregnant women. That leaves us with erythromycin as the best option.

References: Nice (2020) Summary of antimicrobial prescribing guidance – managing common infections; Nice  (2018) NG84 Sore throat (acute): antimicrobial prescribing.

 

Question 2: A 68-year-old woman presents at the GP with a five-day history of constipation. Her stools are hard and lumpy. Her regular medications are: amlodipine 10mg 1OD; atorvastatin 20mg 1OD; beclometasone 100mcg CFC inhaler; 2puffs BD; buprenorphine patch 10mcg/hr, 1 patch applied once weekly; morphine sulphate oral solution 10mg/5mL; 2.5mL QDS prn; salbutamol 100mcg; 1-2puffs QDS. She has tried lifestyle measures which have not helped.

For the patient described, select the single most appropriate management option below. Each option may be used once, more than once or not at all.

Drug(s) for managing constipation

A: Bisacodyl

B: Docusate

C: Ispaghula husk

D: Lactulose + senna

E: Macrogol

F: Methylcellulose + sodium picosulfate

G: Methylnaltrexone bromide

H: Naloxegol

Click here for the comments, working out and answer

Answer: D: Lactulose + senna

Explanation and rationale: In order to answer this question correctly, you need to have sufficient knowledge about the causes of constipation and how to manage it based on guidelines – eg, British National formulary (BNF), Nice, etc. Additionally, knowledge of common adverse effects of drugs is handy. You also need to know the examples of different classes of laxative; eg bulk-forming (ispaghula, sterculia, methylcellulose), stimulant (bisacodyl, senna, sodium picosulfate) and osmotic (lactulose, macrogol). You should then apply this knowledge in the context of the information provided in the scenario. The diagnosis of constipation has already been provided and you are asked to choose the most appropriate drug treatment option. Do not jump into recommending a first-line treatment option according to guidelines (a bulk-forming laxative) without first putting everything into context. Look at the patient history and medications carefully and identify pertinent information relevant to this scenario. This woman is taking opioids (buprenorphine and morphine) so is likely to be suffering from opioid induced constipation. Now, it’s time to apply your knowledge of guidelines. How do you treat opioid-induced constipation? Nice (2020) guidelines recommend an osmotic laxative and a stimulant laxative as first-line (or docusate sodium as an alternative to soften stools) and to avoid bulk-forming laxatives. Naloxegol and methylnaltrexone bromide can be used for opioid-induced constipation if other laxatives fail to provide an adequate response. Finally, use your knowledge of laxative classes to select an answer that features the recommended classes. In this scenario, it is D: lactulose (osmotic) + senna (stimulant).

Reference: Nice Clinical Knowledge Summaries (2020). Constipation in adults.

 

Question 3: Safe custody requirements apply, prescription handwriting requirements apply, the pharmacist does NOT need to confirm the identity of the patient collecting.

For the scenario described, select the single most appropriate controlled drug from the options below. Each option may be used once, more than once or not at all.

Legal requirements for controlled drugs

A: Buprenorphine

B: Clenbuterol

C: Diazepam

D: Fentanyl

E: Flunitrazepam

F: Midazolam

G: Pentazocine

H: Phenobarbitone

Click here for the comments, working out and answer

Answer: A: Buprenorphine

Explanation and rationale: To answer this question correctly, you need a full understanding of the legal requirements for schedule 2, 3, 4 and 5 controlled drugs and the appropriate exemptions as outlined in your recent Medicines, Ethics and Practice (Royal Pharmaceutical Society, 2019). For each schedule, you also need to know examples of common drugs in the schedule,along with the exemptions. Safe custody requirements apply means that the drug is in either schedule 2 or 3 (unless exempt). Identity of the patient collecting DOES NOT need to be confirmed means it is likely to be a schedule 3. Prescription writing requirements apply imply that it is most likely to be a schedule 2 or 3. Applying all the criteria should lead you to a drug in schedule 3. Be careful to consider some exemptions for schedule 3 controlled drugs. You then need to know which drug on the list is a schedule 3 and select your answer. Final answer: A, buprenorphine.

Reference: Royal Pharmaceutical Society (2019) Medicines, ethics, and practice.

 

Question 4: A dentist that you have a good working relationship with is on the phone to get your recommendation for treating a 40-year-old man who has attended the dental practice complaining of moderate dental pain. The man also suffers from angina pectoris and takes atenolol 100mg and glyceryl trinitrate 400mcg spray.

For the patient described, select the single most appropriate management option below. Each option may be used once, more than once or not at all.

Drug indications for non-steroidal anti-inflammatory drugs (NSAIDs)

A: Celecoxib

B: Diclofenac

C: Etodolac

D: Ibuprofen

E: Indometacin

F: Ketoprofen

G: Mefenamic acid

H: Naproxen

Click here for the comments, working out and answer

Answer: D: Ibuprofen

Explanation and rationale: You should be up to date with the BNF and Nice guidelines regarding managing moderate dental pain. You should then apply these guidelines in the context of this patient,who has moderate dental pain and suffers from angina, which is managed with atenolol and glyceryl trinitrate spray. Additionally, you should be aware of the safety profile of the various NSAIDs in patients suffering from different medical conditions. According to the BNF, ibuprofen and diclofenac can be used for dental pain. The man suffers from ischaemic heart disease (angina) so diclofenac is contraindicated. Select ibuprofen as the best option.

Reference: BNF (2020) Analgesics.

 

Question 5: A 70-year-old man is taking citalopram and ibuprofen long term.

For the patient described, select the single most likely drug interaction from the options below. Each option may be used once, more than once or not at all.

Drug interactions

A: Increased risk of bleeding

B: Increased risk of gastric irritation

C: Increased risk of hyperkalaemia

D: Increased risk of hypomagnesaemia

E: Increased risk of nephrotoxicity

F: Increased risk of renal failure

G: Increased risk of seizures

H: No significant drug interaction

Click here for the comments, working out and answer

Answer: A: Increased risk of bleeding

Explanation and rationale: A thorough knowledge of the common drug interactions in relation to NSAIDs and selective serotonin reuptake inhibitors (SSRIs) is vital. A knowledge of drug classes and common examples of drugs in each class means that you can learn drug interactions between classes and apply to individual drugs in each class. For example, if you know a drug interaction exists between ibuprofen (a NSAID) and citalopram (an SSRI), you could extrapolate it to naproxen (a NSAID) and fluoxetine (an SSRI). However, note that there are some exceptions to these extrapolations. In the scenario above, ibuprofen (a NSAID) co-administered with citalopram (an SSRI) increases the risk of bleeding. Look at the answer options and select the correct one.

Reference: BNF (2020) Drug interactions: NSAIDS.

 

So, in conclusion, with EMQs it is important to have an underpinning knowledge of the topic area, and be prepared to apply this knowledge in a given scenario. It is therefore important to studiously revise using the relevant textbooks and standard treatment guidelines so that you know the theory and practice of the subject. We do hope these scenarios will help you in orienting you and understanding how to approach these types of questions.

Authors:

Luso Kumwenda: MSc Community Pharmacy (Cardiff), B Pharm Hons (Zimbabwe), independent prescriber, MRPharms, mentor at UK Black Pharmacist Association and the Royal Pharmaceutical Society

Professor David R. Katerere: PhD Pharmaceutical Science (Strathclyde), Tshwane University of Technology, platform research chair – Pharmaceutical and Biotech Advancement and Development in Africa (PbADA)

Acknowledgements: The questions were kindly provided by: Focus Pre-Reg Revision

Disclaimer: The questions and explanations presented here are for educational purposes only and do not replace your training, knowledge and application of professional judgement as a pharmacist or pre-reg or prov-reg pharmacist. The views in this article are our own and do not represent the views of any organisations we are associated with.

 

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