1.

In developing countries, Tanzania in particular there is a complex interaction of infectious

diseases (IDs) and non-communicable diseases (NCD). The trend of NCDs has increased in
recent years threatening health of individuals across all age groups as well as stretching the
already strained resources in fighting both diseases simultaneously. NCDs and IDs share
common features, such as long-term care needs and overlapping high-risk populations.
Moreover, there are notable direct interactions between NCDs and IDs, such as the
association between certain IDs and cancers, as well as evidence of increased susceptibility
to IDs in individuals with NCDs. As per its relation, treatment of these co-morbidities is as
well complex.
i. What are any three (3) opportunities of pharmacist in preventing NCDs? (3
Marks)
Pharmacists can contribute by screening and monitoring NCDs;
a. Counseling on lifestyle
b. Providing medication therapy management services
c. Promoting public health and
d. Providing other pharmaceutical services.
ii. What are any three (3) challenges pharmacists encounter in implementing NCDs
prevention strategies?
a. Inadequate training of pharmacists in NCD prevention and management
b. The cost of pharmaceutical services to patients and government and
c. The existing health care service delivery mode
iii. How is a pregnant woman (gestation age of 10 weeks) with severe symptoms of
gestational diabetes diagnosed with asymptomatic malaria treated?. (2 Marks)
Ans. Gestational diabetes use insulin (1Mark) and Malaria- Quinine (1 Mark)
tablets 10mg/kg 8 hourly
iv. What is the danger of using same dose of methadone to HIV positive clients on
efavirenz based antiretral viral (ART) to HIV negative? (2 Marks)
Ans. Efavirenz induces CYP3A4, an enzyme belonging to the cytochrome P450
complex (1 Mark). This lead to 80% decrease of methadone plasma
concentration which consequently cause the patient to experience withdrawal
symptoms such as tiredness, headache, cold sweats and shivering (1 Mark)
2. Insulin injection is usually indicated for type 1 diabetes, while oral hypoglycemia agents
indicated for type 2 diabetes. According to your experience in hospitals during internship,
what are the five (5) conditions that may necessitate a patient with type 2 diabetes mellitus
to be prescribed insulin injections? (5 Marks)
Ans. Insulin injections are indicated in T2DM in the following conditions:
 Initial presentation with fasting blood glucose more than 15 mmol/l
 Presentation in hyperglycaemic emergency
 Peri-operative period especially major or emergency surgery
 Other medical conditions requiring tight glycaemic control
 Organ failure: Renal, liver, heart etc
  Diabetes in pregnancy not well controlled with diet or oral drugs
 Latent autoimmune diabetes of adults (LADA)
 Contraindications to oral drugs
 Failure to meet glycaemic targets with oral drugs.
3. You are a pharmacist in a health centre in Kalebezo, a 25 year old girl diagnosed with
systemic bacterial infection responsive to ciprofloxacin with mild anemia presents to your
pharmacy with the prescription: Rx ferrous sulfate 200g (PO) tid 3/12, cipro®500mg bt 5/7,
panadol® 1000mg p.r.n .
i. Interpret the prescription
Ans. Supply (Rx) 200g of ferrous sulfate to be taken orally (PO) for three
months (3/12), take 500 mg cipro® at bed time (bt) for five days a week (5/7)
and 1000mg of panadol® where necessary (p.r.n).
ii. Comment on the prescription
a. The prescription has very high dose of ferrous sulfate 200g instead of 200mg, this
may lead to iron toxicity
b. It contain brand names cipro® and panadol® instead of generic names
ciplofloxacin and paracetamol respectively
c. Ciprofloxacin should be taken twice daily insteady of once at bed time
d. Ferrous sulfate interacts negatively with ciplofloxacin; ferrous sulfate reduce
absorption of ciplofloxacin by forming a unabsorbable iron-ciprofloxacin complex
iii. What is the short term and long term consequences if the medicines are dispensed
as per prescription?
a. Short term
 The patient will not be treated, since the ciprofloxacin dose is sub-therapeutic and
ciprofloxacin interacts with ferrous sulfate rendering it ineffective
 Patients condition will worsen due to iron overdose; (Iron toxicity can be classified as
corrosive or cellular. Ingested iron can have an extremely corrosive effect on the
gastrointestinal (GI) mucosa, which can manifest as nausea, vomiting, abdominal
pain, hematemesis, and diarrhea; patients may become hypovolemic because of
significant fluid and blood loss)
b. Long term
 Patient may die of iron toxicity or infection if not managed properly
 Emergence of bacteria resistant to ciprofloxacin as a result of sub-therapeutic level

4. You are a pharmacist at Misonga health center, two groups of TB patients presents to your
facility; newly diagnosed TB case and diagnosed with TB one year ago and did not
complete the TB regimen. The physician asks for your recommendation on initiating the
anti-TB for these patients. What will be your recommendations on the anti-TB drugs for
these two groups of TB patients?
 Newly TB patient: initiatin phase; Rifampicin + Isoniazid + Pyrazinamide and
Ethambutol in fixed dose (RHZE) for 2 months. Continuation phase; Rifampicin +
Isoniazid (RH) for 4 months
Defaulter’s TB patients: initiation phase Streptomycin+ Rifampicin + Isoniazid +
Pyrazinamide and Ethambutol for 2months then RHZE for 1months. Continuation
phase; Rifampicin + Isoniazid+ Ethambutol (RHE) for 5 months

5. Mwajuma, a 51-year-old woman, has a recent history of abnormal uterine bleeding and
vaginal discharge. Endometrial biopsy is positive for squamous cell carcinoma. Invasive
disease is not evident. The diagnosis is carcinoma in situ, and a vaginal hysterectomy is
scheduled. As a pharmacist in surgical team, antimicrobial regimen with what characteristics
would you propose to be a good surgical prophylaxis for Mwajuma?

The selection of a prophylactic regimen should incorporate such factors as;

 the agent's microbiologic activity against the most likely potential pathogens
encountered during the surgical procedure
 long half-life or prolonged duration of action
 less inherent toxicity( less toxic)
 less potential to promote the emergence of resistant strains of bacteria,
 cost effective (cheap)

6. Hilonga was diagnosed HIV+ and his genetic samples sent to MUHAS genetic laboratory
for evaluation. Results from Hilonga’s genotype analysis suggest that a regimen containing
tenofovir, 3TC, ABC, and darunavir–ritonavir may be useful. After thorough discussions
with Hilonga, and careful evaluation of potential drug–drug interactions, this regimen is
initiated. Within 2 weeks, Hilonga's T-cell counts increased from 55 to 127 cells/mm 3;
however, he now complains of progressive visual loss in his right eye. Physical examination
shows macular edema and retinal inflammation consistent with Cytomegalovirus infection.
Is this a treatment failure? Should Hilonga's antiretroviral regimen be discontinued or
changed?

In this case, Hilonga presents with signs and symptoms of immune reactivation-
associated (CMV retinitis, including new onset of visual complaints and inflammation
consistent with CMV retinitis on physical examination, in the face of increased T-cell
counts (from 55–127 cells/mm3). Because the new opportunistic infection is a result of
immune reconstitution and not clinical failure, the regimen does not need to be
discontinued or changed. Appropriate treatment for CMV, however, should be
implemented.
7. Joha, a 24-year-old woman, presented with a 5-day history of watery stools, bloody mucus,
and fever. She initially was treated with ampicillin, to which she did not respond. She is 22
weeks pregnant, and her medical history includes rheumatic fever at age 5 and heart
murmurs. Her temperature is 38.2°C and her abdomen is soft but non-tender; she complains
of severe cramps. Fresh stool is positive for occult blood, and the wet mount demonstrates
trophozoites with ingested RBC. A trichrome stain shows E. histolytica trophozoites.
Bacterial culture is negative for pathogenic bacteria. An abdominal computed tomography
(CT) scan is negative for abdominal or liver amebiasis, and an antiamebic antibody test is
negative. A diagnosis of intestinal amebiasis is made. How would you treat Joha.? If Joha
subsequently develops amebic colitis, how would you treat her, and what are some toxicities
of concern with the selected regimens?

Joha needs to receive a luminal amebicide to treat her intestinal amebiasis. Because she
is 22 weeks pregnant and has an underlying cardiovascular problem, the therapeutic
options are limited. Metronidazole, iodoquinol, and emetine are not preferred regimens
for Joha because of their potential adverse effects to mother or fetus. A drug with
minimal systemic effects would be optimal so as not to jeopardize her fetus.
Paromomycin, a nonabsorbable aminoglycoside, is effective and has been used in
pregnant patients.
The most common side effect of paromomycin is GI upset, manifested as increased
frequency of stools.
Amoebic colitis: Used concomitantly with a luminal amebicide, metronidazole or
tinidazole remain the drugs of choice for all patients with severe amebic colitis, hepatic
abscess, and extraintestinal amebiasis. Although metronidazole is considered safe in
Jona, who now is in her third trimester, it should be avoided if possible during the first
trimester of pregnancy.

The most common side effects include metallic taste, nausea, diarrhea, furry tongue, and
glossitis
Either iodoquinol or diloxanide furoate should be added to her metronidazole or
tinidazole regimen. If iodoquinol is selected, the side effects associated with usual dosages
include nausea and vomiting, abdominal discomfort, diarrhea, headache, and
occasionally enlargement of the thyroid gland.
If diloxanide furoate is selected instead of iodoquinol, this agent is essentially free of side
effects with the exception of some minor GI symptoms such as flatulence (belching and
abdominal distention) and stomach cramps

8. You are a district pharmacist, and MSD has tasked you to supervise distribution and monitor
availability of health commodities (eg. Medicines and medical devices) in your district.
Because you want to monitor products at all times in the pipeline, you tell your superior that
you need three types of logistics records to track the products. Each record type has a
 distinct form and use. Briefly explain the types of logistic types you need. Explain the
essential data needed for logistics management.

Types of records
• Stock keeping records: Holds information about products in storage
• Transaction records: Holds information about products being moved
• Consumption records: Holds information about products being consumed or used

Essential data:

 stock on hand: These quantities of usable stock are available at any, or all, levels
of the system. Do not count unusable items, but consider them losses to the system.
 Consumption: The quantity of a particular item dispensed to users or used by service
providers during a specific time period.
 losses and adjustments: Losses are the quantity of stock removed from the pipeline
for any reason other than consumption by clients (e.g., losses, expiration, theft,
damage, etc.) or for use when services are provided. Adjustments include quantities
transferred between facilities or levels. Adjustments may also include administrative
changes, such as a mathematical correction after a physical count when a different
amount from the quantity listed on the stock cards was discovered. Remember:
Adjustments can be either positive or negative changes to stock.

9. You are a newly employed pharmacist at Tandahimba district and the regional medical
doctor (RMO) has entrusted you to ensure no medicines expires in stores. Expiration of
medicines made the former pharmacist demoted from his position. As a vibrant pharmacist,
what will you do to avoid expiration of medicines in warehouses in your region?

How to avoid product expiry

Assessing stock status to anticipate if products will expire in storage in order to take
action before this occurs, for example, if a regional manager calculates that one facility
has more stock on hand than they will be able to dispense before the expiry date, and the
manager knows another facility is running low on stock, then they can arrange a transfer
to avoid stock expiring in storage at the first facility. Similarly, if the central medical store
assesses that it has more stock on hand than it will be able to dispense nationally, it can
arrange a transfer to another country in order to avoid expiry.

10. You are a pharmacist in charge in Katavi hospital, one patient presents to the clinician with
complain of not getting any relief from the drug you dispensed for treatment of malaria. The
clinician contacts you to give an overview of the possibilities of unusual lack of efficacy of
that antimalaria. As the drug expert in that health facility, what do you think are the possible
reasons for unusual failure in efficacy?
 Possible reasons for lack of efficacy include:
 Did not retain the medication because of vomiting or severe diarrhea
 Lack of adherence to treatment schedule
 Inadequate dose
 Poor quality medication
 Counterfeit medication
 Incorrect diagnosis
 Interactions reducing blood levels; and
 Drug resistance

11. Medication errors can occur when prescribing, repacking, dispensing, or administering a
product. What medication errors have you experienced? What are the common causes of
medication errors you faced during internship? Where should medication errors reported?

Common causes of medication errors include;

 poor communication
 patient misunderstanding, and
 Ambiguities in product names or directions for use.
 Errors, or hazardous conditions including administering the wrong drug, strength, or
dose of medications
 confusion over look-alike/sound-alike medicines
 incorrect route of administration
 calculation or preparation errors
 misuse of medical equipment and
 Errors in prescribing, transcribing, dispensing.

Medication errors should be reported to TFDA using the ADR reporting form

12. You have been appointed to be a pharmacovigilance focal person in Namtumbo hospital,
and your main task is to supervise reporting and to report adverse reactions from the use of
pharmaceuticals, herbal, biological products and medical devices. As a pharmacist with
broad knowledge on the named products, what things will you be reporting?
ANS.

Report all suspected reactions to pharmaceutical products, herbal medicines, biologicals (e.g.
vaccines, blood products etc), medical devices (e.g. dental and medical supplies, contrast
media etc) and cosmetics. The following should be reported;-
 All ADRs as a result of prescription and non-prescription;
 All suspected adverse drug reactions regardless of whether or not the product was used
in accordance with the product information provided by the company marketing the
product;
 Unexpected reactions, regardless of their nature or severity, whether or not consistent
with product information or labeling;
 An observed increase in frequency of a given reaction;
  A serious reaction, whether expected or not;
 All suspected ADRs associated with drug-drug, drug-food or drug-food supplement
interactions;
 ADRs in special field of interest such as drug abuse and drug use in pregnancy and
during lactation;
 ADRs occurring from overdose or medication errors;
 Unusual lack of efficacy or when suspected quality defects are observed.
 Product quality problems include colour change, separating of composition, caking,
change of odour, questionable stability, suspected contamination, poor packaging and
labeling, mislabeling, incomplete pack, defective and expired product.

13. What is medication error? Which information should be reported when reporting medication
errors?

Medication error defn; Any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of the health care
professional, patient, or consumer.

Medication errors reporters are encouraged to submit associated materials such as

product photographs, containers, labels, prescription order scans, etc, that would support
the information being submitted. TFDA guarantees CONFIDENTIALITY of information
received and respects reporters' wishes as to the level of detail included in the report.

When reporting errors, include the following:

 Describe the error or preventable adverse medicine reaction. What went wrong?
 Was this an actual medication error (reached the patient) or are you expressing
concern about a potential error or writing about an error that was discovered before it
reached the patient?
 Patient outcome.
 Type of health facility (hospital, dispensary, retail pharmacy, ADDO, drug outlets,
health centers, home-based services, etc).
 The generic name (INN or official name) of all products involved.
 The brand name of all products involved.
 The dosage form, concentration or strength, etc.
 How was the error discovered/intercepted?
 State your recommendations for error prevention.

14. Describe the management of a patient with complicated malaria who presents with severe
anemia, agitation and confusion.
ANS. Guide. See malaria treatment guideline
Rx of complicated malaria; inj. Quinine followed by quinine tablets (with glucose) or
inj. Artesunate followed by ALU for 3 days.
Severe anemia; administer packed RBC
 Confusion; Give IM diazepam

15. A 27-year old woman presents to your health facility with a history of streaky haemoptysis
and weight loss for the past two months. Clinical examination is reported as normal. Her
chest x-ray shows patchy right upper lobe consolidation and her sputum is positive for acid-
fast bacilli. After having obtained three sputum samples, she is started, while in hospital, on
a four-drug regimen, pyrazinamide (800mg/day), ethambutol (600mg/day), isoniazid
(300mg/day) and rifampicin (450mg/day). She is also prescribed pyridoxine 10mg daily.
She tolerates the therapy well, without evidence of hepatic dysfunction, and her systemic
symptoms improve. Three months later, when reviewed in the outpatient clinic, she has been
off pyrazinamide and ethambutol for just over one month, and she complains of daily
nausea and vomiting, and is found to be eight weeks pregnant. She was taking the low-dose
oestrogen contraceptive pill and is adamant that she has been meticulously compliant with
all of her anti-TB medications and the contraceptive pill.
Questions.
I. What therapeutic problem has occurred here and how can you explain the clinical
situation?

ANS. Ethambutol, isoniazid, rifampicin and pyrazinamide are all inducers of hepatic
CYP450 enzymes. Rifampicin is most potent. and affects many CYPs. Over a period of
several weeks her drug therapy induced several CYP450 isoenzymes, especially
CYP3A4, so that hepatic metabolism of oestrogen and progesterone was markedly
enhanced, reducing their systemic concentrations and efficacy as contraceptives.
Therefore, drug-induced hepatic CYP450 enzyme induction caused a failure of
contraceptive efficacy and so the patient was ‘unprotected’ and became pregnant. The
patient should continue on her anti-TB drug regimen, as there is no evidence that these
agents are harmful to the developing fetus, except for streptomycin, which should
never be given in pregnancy.

II. How could this outcome have been avoided?

ANS. This outcome could have been prevented by advising the patient to double her
usual dose of her oral contraceptives while taking anti-TB therapy, and to take
additional contraceptive precautions (e.g. barrier methods), or to abandon the pill
altogether and use alternative effective contraceptive measures (e.g. an intrauterine
contraceptive device) during her anti-TB drug treatment.

III. Why was pyridoxine prescribed?

 ANS. to reduce the likelihood of developing peripheral neuropathy secondary to INH.
B6 and INH compete for the same site in the neuronal cells, therefore supplement of
Vit.B6 is required to overcome the effect of INH on the neuronal cell.

16. You are a pharmacist at a TB (Tuberculosis) clinic, a diabetic type 2 patient presents with
pulmonary TB and the physician recommends switching oral hypoglycemia with insulin
injections and initiating anti-TB drugs. For you as a pharmacist, is change of anti-diabetic
drugs necessary? Why?

i. Tuberculosis affects both the liver and pancreas: oral anti-diabetic drugs are
contraindicated in hepatic disease, which is a common adverse effect of anti-
tuberculous therapy.
ii. Metformin produces weight loss, particularly in high doses, and it is also an
anorectic.
iii. Marked weight loss and higher insulin and caloric needs in tuberculosis are other
important indications for reviewing oral anti-diabetic therapy in diabetes mellitus.

17. Immune reconstitution inflammatory syndrome (IRIS) is a phenomenon associated with the
occurrence or worsening of opportunistic infections/malignancies which can occur early
after initiation of ART or at later (several months) during the course of ART. Which any
four clinical situations are associated with an increased risk for occurrence of IRIS? Which
drug should be provided to patients on ART with severe life threatening IRS?
a. Treatment naïve patients
b. Patients with advanced HIV disease with CD4 cell count < 50 cells/mm3
c. Patients with undiagnosed and untreated opportunistic conditions
d. Patients who have been introduced on ART before or shortly after initiation of
treatment of opportunistic infection/malignancy

Drug: Provide high doses of prednisolone 1mg/kg for 4 weeks then taper down the dose.

18. Rheumatic heart diseases is one of the chronic diseases leading to complications like heart
failure, valve failure and cardiomyopath. Proper management of Rheumatic fever may help
to solve these complications
a) What are the proper medications to treat the condition
b) What is the medicine of choice for preventing recurrent episode of rheumatic
fever
c) how will a patient with acute rheumatic fever present?

Treatment of Acute Attack

1. A.
Benzathine penicillin (IM) as a single dose
Children under 5 years 0.3 MU
Children 5-10 years 0.6 MU
 Children above 10 years and adults 1.2.MU

OR
Phenoxymethylpenicillin (O) for 10 days
Children under 5 years 125mg every six hours
Children 5-10 years 250 mg every six hours
Children above 10 years and adults 500 mg every six hours
Or
Erythromycin (O) 500mg every six hours for 10 days (penicillin allergy).

B.
Specifi c situations always requiring prophylaxis at least to 30 years are
• High risk to Streptococcal infections
• Proved carditis in previous attacks
• Not more than 5 years since last attack.

ANTIBIOTIC CHILDREN<12 YEARS CHILDREN>12 YEARS

Benzathine penicillin 1.2.MU monthly 2.4 MU monthly
(IM) 125-250 mg twice daily 250 mg twice daily
Or
Phenoxymethylpenicillin
(PO)
Penicillin allergy
Erythromycin (PO) 125-250mg twice daily 250mg twice daily

C.

Its very important to ask more questions to determine if there are any other
symptoms and signs before giving sore throat remedy to a children of 5 -15 years
of age
 Fever
 Painful and tender joints — most often in the knees, ankles, elbows and wrists
 Pain in one joint that migrates to another joint
 Red, hot or swollen joints
 Small, painless bumps (nodules) beneath the skin
 Chest pain
 Fatigue
 Flat or slightly raised, painless rash with a ragged edge (erythema marginatum)
 Jerky, uncontrollable body movements (Sydenham chorea, or St. Vitus' dance) — most
often in the hands, feet and face
 Outbursts of unusual behavior, such as crying or inappropriate laughing, that
accompanies Sydenham chorea
  sore throat(major complain)

19. In an effort to prevent teratogenic effects, the FDA has established five categories
suggesting the potential of a drug for causing birth defects. Information regarding the
pregnancy category of a specific drug is found in reliable drug literature, such as the inserts
accompanying drugs and approved drug references. Name and explain the meaning of each
category

PREGNANCY CATEGORY A
Controlled studies show no risk to the fetus. Adequate well-controlled studies in pregnant women
have not demonstrated risk to the fetus.
PREGNANCY CATEGORY B
There is no evidence of risk in humans. Animal studies show risk, but human findings do not. If
no adequate human studies have been done, animal studies are negative.
PREGNANCY CATEGORY C
Risk cannot be ruled out. Human studies are lacking, and animal studies are either positive for
fetal risk or lacking. The drug may be used during pregnancy if the potential benefits of the drug
outweigh its possible risks.
PREGNANCY CATEGORY D
There is positive evidence of risk to the human fetus. Investigational or post marketing data show
risk to the fetus. However, potential benefits may outweigh the risk to the fetus. If needed in a
life-threatening situation or a serious disease, the drug may be acceptable if safer drugs cannot
be used or are ineffective.
PREGNANCY CATEGORY X
Use of the drug is contraindicated in pregnancy. Studies in animals or humans or investigational
or post marketing reports, have shown fetal risk that clearly outweighs any possible benefit to
the patient.

20. A 70-year-old woman who was previously very active but whose mobility has recently
been limited by osteoarthritis of the knees and hips sees her general practitioner because of a
recent change in bowel habit from once daily to once every three days. Her current
medication includes regular co-codamol (paracetamol with codein) for her osteoarthritis,
oxybutynin for urinary frequency, aluminium hydroxide prn for dyspepsia, and
bendroflumethiazide and verapamil for hypertension.Following bowel evacuation with a
phosphate enema, proctoscopy and colonoscopy are reported as normal.
Which of this patient’s medications may have contributedto her constipation?

 Co-codamol, which contains an opioid–codeine phosphate.(opiod intuced

constipation)
  Aluminium hydroxide ( Aluminium ions cause the relaxation of the
gastrointestinal smooth muscle, which can postpone gastric emptying and can
cause constipation)
 Bendroflumethiazide(side effect caused by dihydration)
 Verapamil(inhibition of colonic motor activity)
 Oxybutynin (an anticholinergic).

21. Improper prescription of drugs is a common cause of morbidity in elderly people.

Common-sense rules for prescribing do not apply only to the elderly, but are especially
important in this vulnerable group. What precautions should a pharmacist take to avoid and
minimize the problem?

Take a full drug history, which should include any adverse reactions and use of over-the-
counter drugs.
 Know the pharmacological action of the drug employed.
 Use the lowest effective dose.
 Use the fewest possible number of drugs the patient needs.
 Consider the potential for drug interactions and co-morbidity on drug response.
 Drugs should seldom be used to treat symptoms without first discovering the cause of the
symptoms (i.e. first diagnosis, then treatment).
 Drugs should not be withheld because of old age, but it should be remembered that there
is no cure for old age either.
 A drug should not be continued if it is no longer necessary.
 Do not use a drug if the symptoms it causes are worse than those it is intended to relieve.
 It is seldom sensible to treat the side effects of one drug by prescribing another.

22. How would you spot "drug seeking behavior"? What would you do if you spotted it?
Indicators of drug-seeking behaviors
 Typical requests and complaints
 Aggressively complaining about a need for a drug
 Asking for specific drugs by name
 Asking for brand names
 Requesting to have the dose increased
 Claiming multiple allergies to alternative drugs
 Anger or irritability when questioned closely about symptoms such as pain

Resistant behaviour

 Unwilling to consider other drugs or non-drug treatments

 Frequent unauthorised dose escalations after being told that it is inappropriate
 Unwilling to bring doctors prescription
 Refusing diagnostic workup or consultation

Manipulative or illegal behaviour

 Obtaining controlled drugs from family members (including stealing from older relatives)
  Forging prescriptions
 Pattern of lost or stolen prescriptions
 Obtaining controlled drugs from illicit sources

Other typical behaviors

 Being more concerned about the drug than a medical problem

 Deterioration at home or work or reduction of social activities because of adverse drug
effects

what to do when you face such cases

 outright refusal to prescribe

 Prescribing for a limited time (e.g. two to three days)
 Supervised daily dosing
 Prescribing a drug appropriate for the reported symptoms but different from the one
requested by the patient
 Seeking a second opinion from a colleague

23. A 73-year-old man has a long history of hypertension and of osteoarthritis. Three months
ago he had a myocardial infarction, since when he has been progressively oedematous and
dyspnoeic, initially only on exertion but more recently also on lying flat. He continues to
take co-amilozide(amiloride plus hydrochlorothiazide 5/50mg) for his hypertension and
naproxen for his osteoarthritis. The blood pressure is 164/94 mmHg and there are signs of
fluid overload with generalized oedema and markedly elevated jugular venous pressure.
Serum creatinine is 138 μmol/L and K_ is 5.0 mmol/L. Why would it be hazardous to
commence furosemide in addition to his present treatment? What alternative strategy could
be considered?

The patient may go into prerenal renal failure with the addition of the loop diuretic to the
two more distal diuretics he is already taking in the co-amilozide combination. The NSAID
he is taking makes this more likely, and also makes it more probable that his serum
potassium level(which is already high) will become dangerously elevated.It would be
appropriate to consider hospital admission, stopping naproxen (perhaps substituting
paracetamol for pain if necessary), stopping the co-amilozide and cautiously instituting an
ACE inhibitor (which could improve his prognosis from his heart failure followed by
introduction of furosemide with close monitoring of blood pressure, signs of fluid overload
and serum creatinine and potassium levels over the next few days.

24. What is the clinical significance of the following laboratory test

A. MCHC
B. lymphocytes
C. HbA1c
D. INR
E. thrombocytes
A. The mean corpuscular haemoglobin concentration (MCHC) is a red cell index that forms part
of haematology tests. It measures the average concentration of haemoglobin in
erythrocytes (red blood cells). It is decreased in different presentations of anaemia, including
iron deficiency anaemia and in thalassemia. In iron deficiency anaemia, the haematocrit value
(space occupied by packed erythrocytes) is decreased.

B. The measurement of total and differential white blood cell (WBC) count is a part of all routine
laboratory diagnostic evaluations. It is helpful in the evaluation of a patient with an infection,
although a high WBC count may also be found in other conditions such as neoplasma, allergy
and immunosuppression.

C. One type of WBCs is the lymphocytes, their primary function being to fight chronic bacterial
infection and acute viral infections. Lymphocytes can be further classified into B cells and T
cells. The mature B cells produce immunoglobulins. The T cells have cell-mediated immunity as
a major property, where they act directly to eliminate certain microorganisms and
regulate the activity of B cells in producing immunoglobulins. An increased number of
lymphocytes(lymphocytosis) occurs with viral infections, such as in patients with upper
respiratory tract infections,mumps and infectious mononucleosis.

D. Thrombocytes (platelets) are elements in blood, their main role being the maintenance of
vascular integrity. In idiopathic thrombocytopenia purpura there is a deficiency of platelets
leading to bruising and bleeding. Idiopathic thrombocytopenia purpura is associated with the
occurrence of antibodies to platelets.

E. Regularly monitor the INR of people using warfarin in order to balance the risk of excessive
bleeding (when the INR is too high, meaning that the blood is too thin) against the risk of
clotting or thrombosis (when the INR is too low or the blood is too thick). INR values over 4.5
increase the risk of major haemorrhage (bleeding), and an INR less than 2 increases the
risk of thromboembolism (formation of blood clots within the blood vessels) and
associated conditions such as heart attack and stroke.

25. A 20-year-old female medical student attended her GP requesting a course of co-
trimoxazole for cystitis. She tells her GP that her last menstrual bleed was about six weeks
earlier. She did not think she was at risk of pregnancy as her periods had been irregular
since stopping the oral contraceptive one year previously due to fears about thrombosis, and
her boyfriend used a condom. Physical examination, which did not include a vaginal
examination, was normal. Urinalysis was positive for blood and a trace of protein. Why
should the GP not prescribe co-trimoxazole for this patient?
Until proven otherwise, it should be assumed that this woman is pregnant. Co-trimoxazole
(a combination of sulfamethoxazole and trimethoprim) has been superseded by
trimethoprim alone as a useful drug in lower urinary tract infection (UTI). The
sulfamethoxazole does not add significant antibacterial advantage in lower UTI, but does
have sulphonamide-associated side effects, including the rare but life-threatening Stevens–
Johnson syndrome. Both sulfamethoxazole and trimethoprim inhibit folate synthesis and are
theoretical teratogens. If pregnancy is confirmed (urinary frequency is an early symptom of
pregnancy in some women, due to a progesterone effect) and if the patient has a lower UTI
 confirmed by pyuria and bacteria on microscopy whilst awaiting culture and sensitivity
results, amoxicillin is the treatment of choice. Alternatives include an oral cephalosporin or
nitrofurantoin. Note that lower urinary tract infection in pregnancy can rapidly progress to
acute pyelonephritis.

26. A 24-year-old woman with epilepsy is well controlled on phenytoin. Months after starting
treatment, she complained of fatigue. Her haemoglobin was 8.0 g/dL and mean corpuscular
volume (MCV) was 103fL .
a)What additional investigations would you undertake?
b)What is the most likely diagnosis and how should you treat this patient?

a) During follow up, she should also be monitored for possible development of
osteomalacia (suggested by proximal myopathy with low serum phosphate and calcium
and raised alkaline phosphatase), as phenytoin also induces the metabolic inactivation of
vitamin D.

b) This patient has a macrocytic anaemia. Your investigations show her serum folate to
be low, with a normal B12. This confirms your suspicion of phenytoin-induced folate
deficiency. A dietary assessment reveals an adequate folate intake;there is no evidence of
other causes of malabsorption. Phenytoin commonly causes folate deficiency, impairing
the absorption of dietary folate by inducing gastro-intestinal enzymes involved in its
catabolism. Treatment should consist of daily oral folate supplementation, keeping her on
the phenytoin (as this has controlled her epilepsy), and further monitoring of her
haematological status for response.

27. Communication skills are one of important aspects for a community pharmacist when
accessing if the patient understood the directions or taking patient history. highlight
advantages and disadvantages of
a) open end questions
b) closed end questions

When taking patient history the pharmacist must use ‘funnel approach’ where the first
questions are open questions to encourage the customer to start providing information and
then using more closed questions to narrow down the detail. Only closed end question are
favored when trying to know if the patient understood the directions

Advantages of Open Questions

 They allow for an infinite array of answers.
 They allow pharmacist to understand the complaints and logic that has caused the
respondent to form their opinion.
  They allow pharmacist to more deeply understand the topic under discussion.
 The respondent can feel that they are receiving personal attention and that the
proposer is interested in their opinion.
 It gives a room for the pharmacist to get a broad picture of a customer requirements
Closed-ended question advantages:
 They are easy and quick to answer.
 There will be almost no answers that are difficult to understand.
 They are useful in funneling the conversation to get diagnosis after open end question
 The use of leading closed questions help to direct a conversation, for example, using
“can you live with this decision?” (closed) rather than, “does everyone agree with
this decision?” (open).
 The answers of different respondents are easier to compare
 The pharmacist can easily access the understanding of a customer
 Respondents are more likely to answer about sensitive topics
 There are fewer irrelevant or confused answers to questions
 Less articulate or less literate respondents are not at a disadvantage

28. A customer asks about an over the counter medication you have never heard of before. How
would you handle this situation
This hypothetical question allows the candidate to explain how they would react in a
situation where they don't know the answer. This question is important as it checks a
candidates problem-solving skills. What to look for in an answer:

 Ability to interact with patients

 Research ability
 Customer service

Explain to the patient that it was a drug you never heard of and check to see you carried
it in the store. If you didn't, let the patient know you will do some research on the drug
using references you carry out in pharmacy and if you can't find the answer promptly you
will call them to let them know what you found out and answer any questions they may
have.

29. A customer returns to the pharmacy with a bottle of prescription medication that is partially
used and says it doesn't work. How would you address the issue?
Patients don't always follow the instructions listed on their prescriptions. This question
will let you see how applicants handle a situation where the patient isn't following
directions and because of that, not seeing results. What to look:

 Interpersonal skills
 Patient communication
 First ask why they thought the medicine didn't work. check the type of medication they
were prescribed since certain meds require the entire amount is taken for them to work,
and if that were the case with their prescriptions, let them know they needed to take all
the medication to see results. If that wasn't the case, and the store policy allowed for a
refund, let them know your sorry the medicine didn't work for them and immediately
issue a refund."

30. You're out of stock on medication for a customer who is extremely difficult. How would
you explain the situation to the patient?

Pharmacists have to deal with all types of people. This question will let you know if they
are capable of handling the different personalities they will encounter on the job. What to
look for:

 Applicants ability to interact with difficult patients

 Ability to diffuse potentially volatile situations
 Problem solving

Mostly this kind of patients are royal customers ie. they often visit and buys from your
pharmacy. Instead of waiting for the patient to come into the pharmacy, call them and let
them know their medication is out of stock, you are ordering some more immediately and
that your sorry for any inconvenience this would bring. The goal with the phone call is to
get ahead of the situation and prevent an in-store confrontation."

Another approach is to buy or borrow from a nearby store in order to satisfy your
customer, make sure you explain that you're sorry for the inconvenience and respond as
quick as possible

31. A 73-year-old man develops severe shoulder pain and is diagnosed as having a frozen
shoulder, for which he is prescribed physiotherapy and given naproxen, 250 mg three times
a day, by his family practitioner. The practitioner knows him well and checks that he has
normal renal function for his age. When he attends for review about two weeks later, he is
complaining of tiredness and reduced urine frequency.Over the past few days he noted
painful but non-swollen joints and a maculopapular rash on his trunk and limbs. He is
afebrile and apart from the rash there are no other abnormal physical signs. Laboratory
studies show a normal full blood count; an absolute eosinophil count raised at 490/mm3. His
serum creatinine was 110 μmol/L at baseline and is now 350 μmol/L with a urea of 22.5
mmol/L; electrolytes and liver function tests are normal. Urinalysis shows 2-protein, urine
microscopy contains 100 leukocytes/hpf with 24% eosinophils.

a) If this is an adverse drug reaction, what type of reaction is

it and what is the diagnosis?
b)What is the best management plan and should this patient
ever receive naproxen again?
 a) The patient has developed an acute interstitial nephritis, probably secondary to the
recent introduction of naproxentreatment. This is a well-recognized syndrome, with the
clinical features that the patient displays in this case. It can be associated with many
NSAIDs (both non selective NSAIDs and COX-2 inhibitors), particularly in the elderly.
This is a type B adverse drug reaction whose pathophysiology is probably a combination
of type III and type IV hypersensitivity
reactions.

b) Discontinuation of the offending agent is vital and this is sometimes sufficient to

produce a return to baseline values of renal function and the disappearance of systemic
symptoms of fever and the rash. Recovery may possibly be accelerated and further renal
toxicity minimized by a short course (five to seven days) of high-dose oral
corticosteroids, while monitoring renal function. The offending agent
should not be used again in this patient unless the benefits of using it vastly outweigh the
risks associated with its use in a serious illness

32. Two of your technicians aren't getting along, and customers are starting to notice. How you
do handle the situation?
Pharmacists are often in a management role and need to be able to supervise their
technicians. A good pharmacist will be able to manage their employees and any conflicts
that arise. What to look for:

 Management ability
 Interpersonal Skills
 Conflict resolution

schedule a time to speak with both technicians before the pharmacy opened. Let each of
them explain their grievances to the other and then work towards a solution. Let them
know their behavior was unacceptable and in the future, if they had a problem with a co-
worker, to bring it to the pharmacist so we could work it out. Also tell them any further
public disruptions could potentially lead to disciplinary action."

33. What things do you need to assure yourself about before dispensing prescription medicines
to a customer?
 Right patient
-Ask the patient their first and last name
-Does the order match the patient?
 Right medication
-Does the medication label match the order?
-Be vigilant with look-alike and sound-alike medications
 Right dose
 -Does the strength and dosage match the order?
-Is it half, whole or multiple tablets?
 Right route
-Does the route match the order?
 Contraindications
-does the patient bear any contra indications

34. Proper Asthma management involves the use of both Reliever and Controller. Explain
Controller medications are daily inhalers that control the inflammation in the airways of
your lungs. This type of medication is generally the most effective for controlling asthma
long term, Since they can take longer to work than the reliever medications, they are not
to be used to quickly relieve symptoms, such as during an asthma attack. They are
available in inhaler(combined and single) and tablet dosage form. examples include
leukotriene receptor antagonist(montelucast), budesonide, salmeterol + fluticasone

These are usually only taken when needed for quick relief or for an asthma attack,
Reliever medications are sometimes called “rescue” medications or “quick relief”
medications, since they start working quickly (usually within a few minutes. These
medications are not useful for long-term control of asthma since they do not control the
inflammation in your lungs. Example is fast acting bronchodilator salbutamol

35. SOP is a written document that specifies what should be done, when, where and by whom.
State any five benefits of Document on SOPs in a community pharmacy

 help to assure the quality of the service

 help to ensure that good practice is achieved consistently
 enable pharmacists to delegate more readily and may possibly free the pharmacist’s
time for other activities
 help to avoid confusion over who does what and clarify roles within the pharmacy
 provide advice and guidance to locums and part-time staff
 provide useful training tools for new members of staff
 provide a contribution to the audit process.