💉 Patient Care, Self-Care, Immunization and Public Health

1. What does a structured self-care history cover before a product is recommended?

1. Only the symptom that prompted the visit.
2. The patient's preferred brand and budget.
3. The patient's occupation and address.
4. Symptom, duration and other medicines.

Whatever mnemonic is used, the same elements recur, and the two that most often change the recommendation are the other medicines and the pregnancy or breastfeeding status. Source: CPhA Therapeutic Choices, patient assessment for self-care.

2. Which single question most often reveals that a self-care request is not appropriate for self-care?

1. Which brand did you use before?
2. How long has this been going on?
3. Would you prefer a tablet or a liquid?
4. Is there a product on sale this week?

Duration beyond the interval expected for a self-limiting condition is one of the commonest referral triggers, alongside severity, recurrence and the presence of red flags. Source: CPhA Therapeutic Choices, patient assessment for self-care.

3. Why does the pharmacist ask about natural health products during a self-care consultation?

1. Because they must be recorded for provincial billing purposes at the end of every consultation
2. Because several interact with prescription therapy.
3. Because their sale is restricted to pharmacies and the record has to show where they came from
4. Because they cannot be taken at the same time of day as any conventional oral medicine

St John's wort, ginkgo, garlic, ginseng and high-dose fish oil all have documented interactions, and patients frequently do not consider them medicines, so they are asked about explicitly rather than left to volunteer. Source: CPhA Therapeutic Choices, natural health products.

4. A patient describes symptoms that could be self-limiting or could be serious. What is the safe approach?

1. Treat.
2. Refer.
3. Monitor.
4. Advise.

Uncertainty about whether a presentation is benign is itself the indication for referral; a trial of treatment delays diagnosis and the pharmacist carries the risk of that delay. Source: CPhA Therapeutic Choices, limits of self-care.

5. Which analgesic is generally first choice for mild to moderate pain in an adult without contraindications?

1. A strong opioid taken regularly.
2. Acetaminophen.
3. A topical corticosteroid.
4. An oral antihistamine.

Acetaminophen has the widest margin of safety for short-term use, with an NSAID added or substituted where inflammation dominates and there is no gastrointestinal, renal or cardiovascular contraindication. Source: CPhA Therapeutic Choices, self-care of pain.

6. Which patient needs a lower daily maximum of acetaminophen?

1. A patient with liver disease, chronic alcohol use, malnutrition or low body weight.
2. A patient who has taken it before without any adverse effect at all
3. A patient who prefers the liquid formulation to the tablet formulation
4. A patient who also takes a proton pump inhibitor for reflux symptoms

Reduced glutathione reserves and induced metabolism lower the threshold for hepatotoxicity, so a reduced ceiling is used and every source of acetaminophen is counted, including combination cold and pain products. Source: Health Canada acetaminophen labelling standard.

7. A patient with hypertension and chronic kidney disease asks for an anti-inflammatory for back pain.

1. Supply an NSAID at the usual dose.
2. Suggest acetaminophen and non-drug measures, and discuss any need for an NSAID with the prescriber.
3. Supply a topical NSAID without any assessment.
4. Supply a combination product with codeine.

Systemic NSAIDs raise blood pressure, reduce renal perfusion and interact with the renin-angiotensin blockers and diuretics such patients usually take; a topical NSAID has much lower systemic exposure but is still assessed. Source: CPhA Therapeutic Choices, NSAIDs in special populations.

8. What is the advantage of a topical NSAID for localised joint pain?

1. A higher plasma concentration than oral.
2. Much lower systemic exposure.
3. No absorption through the skin at all.
4. Free combination with an oral NSAID.

Topical diclofenac achieves local concentrations with a small fraction of the systemic exposure, which suits older adults and patients with gastrointestinal risk; systemic absorption is real, so combining it with an oral NSAID is avoided. Source: CPhA Therapeutic Choices, osteoarthritis.

9. Which headache presentation requires urgent assessment rather than an analgesic?

1. A sudden, severe headache peaking within a minute or two.
2. A band-like headache after a long day at a computer screen
3. A headache that recurs each month before menstruation
4. A headache that eases after caffeine and rest

A thunderclap headache suggests subarachnoid haemorrhage, and other red flags include fever with neck stiffness, new headache after fifty, neurological signs, and headache worse on waking or with exertion. Source: CPhA Therapeutic Choices, headache assessment.

10. What is medication overuse headache?

1. A headache caused by a single large dose of an analgesic taken on one occasion only
2. A headache maintained by frequent use of acute headache medication.
3. A headache that occurs only in patients taking preventive therapy for migraine attacks
4. A headache produced by the preservative used in an intranasal migraine preparation

Regular use of analgesics or triptans on more than about ten to fifteen days a month perpetuates the headache, and the treatment is withdrawal with support and, where appropriate, a preventive; recognising the pattern is the pharmacist's contribution. Source: CPhA Therapeutic Choices, headache management.

11. What advice accompanies a triptan supplied for migraine?

1. Take it only once the headache has lasted a day.
2. Take it every day to prevent attacks.
3. Take it early and keep within the daily limit.
4. Take it together with an ergot preparation.

Triptans work best taken early, are contraindicated in ischaemic heart disease and uncontrolled hypertension, must not be combined with ergots, and frequent use signals a need for preventive therapy. Source: CPhA Therapeutic Choices, migraine.

12. What is the most honest thing to tell a patient about non-prescription cough and cold products?

1. They are equally suitable for everyone.
2. They shorten the illness by several days.
3. They prevent secondary bacterial infection.
4. The benefit is modest at best.

The illness is self-limiting and these products relieve symptoms modestly at best; the pharmacist's contribution is avoiding a decongestant in uncontrolled hypertension, a sedating antihistamine in an older adult and duplicate acetaminophen. Source: CPhA Therapeutic Choices, common cold.

13. Which patient should avoid an oral decongestant?

1. A patient who has previously taken an antihistamine
2. A patient with mild seasonal allergic rhinitis
3. A patient with uncontrolled hypertension or ischaemic heart disease.
4. A patient who wears contact lenses during the day

Sympathomimetic decongestants raise blood pressure and heart rate and can precipitate urinary retention and angle-closure glaucoma; saline irrigation or a short course of a topical decongestant is preferred. Source: CPhA Therapeutic Choices, common cold.

14. Which feature of a sore throat suggests referral rather than self-care?

1. Soreness accompanied by a runny nose
2. Mild soreness that is worse in the morning
3. Difficulty swallowing or drooling.
4. Soreness lasting two days after a cold

Airway compromise, unilateral severe pain, high fever with rash, or symptoms persisting beyond about a week require assessment; most sore throats are viral and resolve with analgesia and fluids. Source: CPhA Therapeutic Choices, sore throat self-care.

15. What is the role of saline nasal irrigation in an upper respiratory infection?

1. It replaces the need for fluids and rest entirely
2. It kills the virus responsible for the infection
3. It prevents the infection from spreading to others
4. It clears secretions and moistens the mucosa without any systemic effect.

Irrigation is safe in pregnancy, in children and in patients with cardiovascular disease, which makes it a useful first suggestion when a decongestant is unsuitable; it has no antiviral action. Source: CPhA Therapeutic Choices, common cold.

16. Which combination is the most frequent cause of unintentional acetaminophen overdose?

1. A cough syrup taken with a throat lozenge
2. A cold remedy taken with a hot drink at bedtime
3. An antihistamine taken with a nasal spray
4. A cold remedy and an analgesic containing it.

Acetaminophen is present in many multi-symptom products under names patients do not recognise, so every ingredient list is read and the daily total is calculated across all sources. Source: Health Canada acetaminophen labelling standard.

17. Which antihistamine class is preferred for allergic rhinitis in an adult who drives?

1. A first-generation antihistamine in the morning.
2. A second-generation antihistamine.
3. A first-generation antihistamine at night.
4. A first plus a second generation antihistamine.

Cetirizine, loratadine, desloratadine, fexofenadine and bilastine cause much less sedation and psychomotor impairment; first-generation agents impair driving into the following day even when taken at night. Source: CPhA Therapeutic Choices, allergic rhinitis.

18. How long does an intranasal corticosteroid take to reach full effect?

1. Within five minutes of the first spray.
2. Several days to two weeks of regular use.
3. Only after a full month of use.
4. Only on days when symptoms are present.

Regular daily use is what produces the benefit, and patients who use it only on bad days conclude it does not work; starting before the season and continuing through it is the counselling point. Source: CPhA Therapeutic Choices, allergic rhinitis.

19. A patient reports itchy watery eyes with sneezing every spring. Which measure comes first?

1. Avoidance, plus an intranasal corticosteroid.
2. A systemic corticosteroid course each spring.
3. A topical ocular antibiotic for the season.
4. An oral decongestant taken continuously.

Avoidance measures and a regular intranasal corticosteroid are the most effective combination, with an ocular antihistamine added for eye symptoms; systemic steroids and antibiotics have no place in ordinary seasonal allergy. Source: CPhA Therapeutic Choices, allergic rhinitis.

20. Which reported reaction to a medicine is a true anaphylaxis rather than an intolerance?

1. A metallic taste for the day after the dose
2. Nausea occurring an hour after the first dose
3. Rapid onset of urticaria with breathing difficulty or hypotension.
4. Loose stools during a course of an antibiotic

Anaphylaxis involves two or more systems with rapid onset, typically skin plus respiratory or cardiovascular compromise, and the distinction matters because labelling an intolerance as an allergy removes an entire drug class unnecessarily. Source: CPhA Therapeutic Choices, allergy assessment.

21. Which red eye requires referral rather than a non-prescription product?

1. Bilateral itching with a watery discharge in spring
2. Red eye with pain, photophobia or lost vision.
3. Mild redness after a long day at a screen
4. Redness after swimming that clears overnight

Pain, visual change, photophobia, a fixed pupil, contact lens wear or trauma all point away from simple conjunctivitis toward keratitis, uveitis or angle-closure glaucoma, and delay costs vision. Source: CPhA Therapeutic Choices, ophthalmic self-care.

22. Which technique reduces systemic absorption of an eye drop?

1. Rubbing the closed eyelid to spread the drop across the eye
2. Blinking rapidly a dozen times after instilling the drop
3. Instilling two drops rather than one at each administration
4. Closing the eye and pressing on the inner corner for a minute.

Punctal occlusion limits drainage into the nasolacrimal duct, which matters for a timolol drop in a patient with asthma or bradycardia; rubbing and extra drops increase waste and irritation. Source: CPhA Therapeutic Choices, ophthalmic administration technique.

23. How long may an opened multi-dose eye drop bottle normally be used?

1. 28 days.
2. Until expiry.
3. Six months.
4. Indefinitely.

A preserved multi-dose bottle is discarded about four weeks after opening because of contamination risk, and preservative-free single-use units are discarded immediately after use. Source: Canadian ophthalmic product monographs.

24. Why are preservative-free tears preferred for a patient using drops many times a day?

1. Preservative-free drops last longer once opened
2. Preserved drops are absorbed more slowly by the eye
3. Benzalkonium chloride is toxic to the ocular surface with frequent exposure.
4. Preserved drops cannot be used with contact lenses

Preservative toxicity worsens the very dryness being treated, so frequent users and patients on multiple ocular medicines are moved to single-use units. Source: CPhA Therapeutic Choices, dry eye.

25. Which ear presentation should not be treated with a non-prescription product?

1. A sensation of blockage after swimming that clears with time
2. Ear pain with discharge, fever, or a suspected perforation.
3. Mild itch in the outer ear with no pain or discharge
4. A single episode of mild wax build-up in one ear

Discharge suggests perforation or otitis externa needing assessment, and cerumenolytics are contraindicated when the drum may be perforated or when there are grommets. Source: CPhA Therapeutic Choices, ear care.

26. What is the advice on cotton swabs for ear wax?

1. Do not use them in the ear canal.
2. Use them gently once a week.
3. Use them after a cerumenolytic.
4. Use them in preference to irrigation.

Swabs push wax deeper, cause impaction and can perforate the drum; wax normally migrates outward on its own, and a softening agent is used when removal is genuinely needed. Source: CPhA Therapeutic Choices, ear care.

27. Which advice reduces the risk of dental caries in a patient with a dry mouth from medication?

1. Frequent sugary drinks to relieve the dryness
2. Fluoride, water, sugar-free gum and dental review.
3. Avoiding toothpaste because it irritates dry tissue
4. Rinsing with an alcohol-based mouthwash daily

Xerostomia from anticholinergics, diuretics and many other drugs removes the protective effect of saliva, so fluoride, saliva substitutes, hydration and dental follow-up matter; sugary drinks and alcohol rinses make it worse. Source: CPhA Therapeutic Choices, xerostomia.

28. A patient describes a white coating in the mouth after starting an inhaled corticosteroid.

1. Likely oral candidiasis: treat and reinforce rinsing and spacer use.
2. A normal effect of the inhaler that needs no action
3. An allergic reaction requiring the inhaler to be stopped
4. A sign that the inhaler dose is too low to be effective

Local immunosuppression allows candida to grow, and the answer is treatment plus prevention through mouth rinsing, spacer use and technique review rather than stopping the controller therapy. Source: CPhA Therapeutic Choices, oral candidiasis.

29. Which mouth ulcer needs referral?

1. A crop of small painful ulcers that recur two or three times each year
2. A small ulcer that appeared after biting the inside of the cheek two days ago
3. An ulcer lasting more than about three weeks.
4. An ulcer that has become less painful over the past three or four days

A persistent, indurated or painless ulcer raises the possibility of malignancy, and so do ulcers with systemic symptoms; recurrent minor aphthous ulcers are managed symptomatically. Source: CPhA Therapeutic Choices, oral lesions.

30. Which patient with heartburn should be referred rather than treated with a non-prescription product?

1. A patient who has had symptoms for two weeks
2. A patient whose symptoms occur after a large late meal
3. A patient whose symptoms began during pregnancy
4. Difficulty swallowing, weight loss or anaemia.

Dysphagia, odynophagia, weight loss, bleeding, anaemia, persistent vomiting and new symptoms in an older patient are alarm features; pregnancy-related heartburn is managed with lifestyle measures and appropriate products. Source: CPhA Therapeutic Choices, gastro-oesophageal reflux.

31. Which product suits infrequent heartburn occurring after meals?

1. A systemic corticosteroid taken during flare periods
2. A proton pump inhibitor taken continuously for a year
3. An antacid or an alginate taken when symptoms occur.
4. An oral antibiotic taken for a fortnight at each episode

Occasional symptoms respond to an as-needed antacid or alginate with lifestyle advice, an H2 antagonist gives a longer effect, and a short course of a proton pump inhibitor is reserved for frequent symptoms with review. Source: CPhA Therapeutic Choices, gastro-oesophageal reflux.

32. What is the first-line advice for simple constipation?

1. Start a stimulant laxative every night.
2. More fibre and fluid, plus activity.
3. Take a saline enema twice each week.
4. Reduce fluid intake to firm the stool.

Lifestyle change plus a bulk-forming agent with adequate fluid is first line, with an osmotic agent such as polyethylene glycol next; a bulk-forming agent without fluid can cause obstruction. Source: CPhA Therapeutic Choices, constipation.

33. Which change in bowel habit requires referral?

1. A persistent change with bleeding, weight loss or a family history of bowel cancer.
2. A single day of harder stools after a long journey
3. Softer stools while taking a course of an antibiotic
4. Constipation that settles after fibre is increased

Rectal bleeding, unexplained weight loss, a persistent change lasting weeks, anaemia or a family history are the alarm features, and provincial screening programmes are also discussed with eligible patients. Source: CPhA Therapeutic Choices, constipation and lower gastrointestinal symptoms.

34. When is loperamide inappropriate for acute diarrhoea?

1. In an adult with watery stools after a change of diet
2. With bloody stools, high fever or invasive infection.
3. In an adult travelling who has mild watery stools
4. In an adult with a single loose stool after a meal

Slowing transit in invasive or toxin-mediated infection prolongs illness and risks complications, so bloody diarrhoea, high fever and severe abdominal pain are referred; loperamide is also avoided in young children. Source: CPhA Therapeutic Choices, acute diarrhoea.

35. What is the priority in an adult with acute diarrhoea?

1. Complete fasting.
2. An antimotility agent.
3. An antibiotic.
4. Rehydration.

Fluid and electrolyte replacement prevents the complications, and oral rehydration solution is preferred to water or soft drinks; most acute diarrhoea is viral and antibiotics are not indicated. Source: CPhA Therapeutic Choices, acute diarrhoea.