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1 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Prescribing Skills Assessment Prescribing Question Item Authoring Tool This file contains a guide to authoring question items as well as example question items Please turn to the next page Slide compilation © 2011 The British Pharmacological Society & Medical Schools Council. All rights reserved.

2 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Information Given to Candidates This is a Prescribing Skills Assessment created by the Medical Schools Council and British Pharmacological Society with the aim of assessing knowledge, skills and judgement related to prescribing medicines. This assessment is designed for medical students who are in the final months of their undergraduate studies and are due to graduate shortly. We are asking you to identify yourself on the next page so that we can look for correlations between results of this test and the local assessment process. There will be 12 stations testing various aspects of prescribing, reviewing and advising about medicines as a Foundation doctor, mapped against the learning outcomes identified by the General Medical Council in Tomorrows Doctors (2009). You will have 1 hour to complete the whole assessment. The weighting of each station is summarised on the next page and the marks allocated to individual question items within it will be clearly marked. This assessment will not carry negative marks. The invigilator will indicate the time when 15, 30, and 45 minutes have passed. You are allowed the use of a BNF and a calculator at any time. Commonly used abbreviations are provided on the page after next. Candidates should be allowed 5 minutes to go through this information This page shows you the information provided to the candidates prior to the start of the pilot assessments.

3 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool StationDescriptionMarksComments 1Prescribing 1101 question item of 10 marks 2Prescribing 2101 question item of 10 marks 3Prescription Review 182 question items of 4 marks each 4Planning Management82 question items of 4 marks each 5Communicating Information63 question items of 2 marks each 6Drug Calculation Skills84 question items of 2 marks each 7Prescribing 3101 question item of 10 marks 8Prescribing 4101 question item of 10 marks 9Prescription Review 282 question items of 4 marks each 10Adverse Drug Reactions84 question items of 2 marks each 11Drug Monitoring84 question items of 2 marks each 12Data Interpretation63 question items of 2 marks each TOTAL MARKS100 This page shows you the overall structure of the one hour assessment with the weighting of the individual stations. This document has been written to help you create question items for the Prescribing Stations. Prescribing Skills Assessment – Format

4 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Abbreviations Prescribing abbreviations daily once each day (usually in the morning) nightly once each day at bedtime 12-hrly twice each day (morning and evening) 8-hrly three times each day 6-hrly four times each day 4-hrly six times each day as required as often as necessary IMintramuscular IVintravenous ORALby mouth SL sublingual SCsubcutaneous Examination findings BPblood pressure (mmHg) HR heart rate (per minute) HSheart sounds JVPjugular venous pressure (centimetres) RRrespiratory rate (per minute) O 2 sat arterial oxygen saturation (%) Investigations Hb haemoglobin WCC white cell count PT prothrombin time aPTT activated partial thromboplastin time Na + serum sodium K + serum potassium U serum urea Cr serum creatinine eGFR estimated glomerular filtration rate Bili serum total bilirubin ALT serum alanine aminotransferase Alk phos serum alkaline phosphatase ECG electrocardiogram CXR chest X-ray AXR abdominal X-ray US ultrasound scan Units mmol/L millimoles per litre µmol/L micromoles per litre g/L grams per litre Others PMH past medical history DH drug history FH family history SH social history BNF British National Formulary GP general practitioner KCl potassium chloride COPD chronic obstructive pulmonary disease This page is provided to the candidates before the assessment and highlights acceptable abbreviations that you may use when authoring questions

5 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool PRESCRIBING Reasoning and judgement: Deciding on the most appropriate prescription (drug, dose, route and frequency) to write, based on the clinical circumstances and supplementary information. Measurable action: Writing a safe, effective and legal prescription for a single medicine, using the documentation provided to tackle a specific indication highlighted by the question. This question type will present a clinical scenario followed by a request to prescribe a single appropriate medicine or fluid. It will be distinguished from other station types by the specific requirement to write a prescription on one of a variety of prescription charts. Typical scenarios will involve the treatment of acute conditions (e.g. acute asthma attack, acute heart failure), chronic conditions (e.g. depression, reflux oesophagitis) and important symptoms such as pain. The candidate will have to exercise judgement when deciding between different drugs, different formulations, different routes, different doses, and different dose intervals. Typical medicines that will be prescribed will include those that are high-risk (e.g. anticoagulants, opioids, insulin), those that are in common use (e.g. antibiotics), and intravenous fluids. It is expected that prescriptions will meet appropriate standards: they must be legible, unambiguous and complete (approved name written in upper case, appropriate form and route, correct dose appropriately written without abbreviations, necessary details and instructions, signed). The purpose will be to demonstrate the ability to write a safe and effective prescription [TD 17(c)][SPWG 3], to manage acute medical emergencies [TD 16(b)], and to plan appropriate drug therapy for common indications [TD 8(e) and 17(b)][SPWG 2]. TD = Tomorrows Doctors (General Medical Council, 2009)SPWG = Safe Prescribing Working Group (Medical Schools Council, 2008) This page contains information about the nature and purpose of Prescribing Station question items as described in the assessment blueprint document

6 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool The following pages are templates for creating Prescribing Station question items. Good Prescribing question items should: be based on a clinical scenario that might be faced by and actions that might reasonably be expected of a Foundation doctor avoid using over-elaborate clinical scenarios containing excessive amounts of information state clearly the symptom or problem to be addressed by the prescription within the Prescribing Request box require only one prescription to be written. You have the option to create items that involve prescriptions written into a variety of prescription forms, including hospital once-only, regular medicines, fluid prescription charts and general practice (FP10) forms. It is rarely possible to create clinical scenarios that have only one correct answer. We would like you to identify those answers that you believe to be optimal and those that are suboptimal but worthy of credit. This can be done on the Answer page that follows the question template.

7 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Please use the British National Formulary, to which the candidates will have access throughout, as the ultimate arbiter of dose ranges, routes, indications, contra- indications, etc.

8 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Prescribing Item Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility] On examination Temperature xx°C, HR xx/min and regular, BP xxx/xx mmHg, JVP xxxxxx, RR xx/min, O 2 sat xx% on air, HS xxxxxx, chest sounds xxxxxxx. Other important observations are ……. Investigations Na + xxx mmol/L (137–144), K + xxx mmol/L (3.5–4.9), U xxx mmol/L (2.5–7.0), Cr xxx µmol/L (60–110), eGFR etc. ECG shows ……… CXR shows ……… [Authors should provide sufficient information from the clinical examination and investigations to enable the candidate to make a sound judgement about the need for and choice of treatment] Prescribing request Write a prescription for ONE drug that will help to [treat/alleviate/prevent] [symptom or problem]. (use the hospital once-only medicines prescription chart provided) Please paste any picture or other illustration that supports the clinical case into this box PWS000 ID This question item is worth 10 marks You may use the BNF at any time ONCE ONLY MEDICINES Date Tim e Medicine (Approved name)DoseRoutePrescriber – sign + print Tim e given Given by

9 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS000 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Drug choice ScoreFeedback/justification B. Dose and route ScoreFeedback/justification Prescribing Item It is impossible to write Prescribing items with only one creditworthy answer! Use this page to indicate optimal answers (10/10) but also to anticipate and score as many suboptimal answers using the scoring system below.

10 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool To create further question items simply copy and paste the blank templates and answer pages The following pages contain templates for creating Prescribing Station question items that use other prescription charts and forms, such as regular medicines, fluid prescription charts and general practice (FP10) forms

11 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility] On examination Temperature xx°C, HR xx/min and regular, BP xxx/xx mmHg, JVP xxxxxx, RR xx/min, O 2 sat xx% on air, HS xxxxxx, chest sounds xxxxxxx. Other important observations are ……. Investigations Na + xxx mmol/L (137–144), K + xxx mmol/L (3.5–4.9), U xxx mmol/L (2.5–7.0), Cr xxx µmol/L (60–110), eGFR etc. ECG shows ……… CXR shows ……… [Authors should provide sufficient information from the clinical examination and investigations to enable the candidate to make a sound judgement about the need for and choice of treatment] Prescribing request Write a prescription for ONE drug that will help to [treat/alleviate/prevent] [symptom or problem]. (use the hospital regular medicines prescription chart provided) Please paste any picture or other illustration that supports the clinical case into this box PWS000 ID This question item is worth 10 marks Date Time Drug (Approved name) 6 8 DoseRoute 12 Prescriber – sign + printStart date NotesPharmacy 22 You may use the BNF at any time Prescribing Item

12 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS000 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Drug choice ScoreFeedback/justification B. Dose, route, freq. ScoreFeedback/justification Prescribing Item It is impossible to write Prescribing items with only one creditworthy answer! Use this page to indicate optimal answers (10/10) but also to anticipate and score as many suboptimal answers using the scoring system below.

13 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility] On examination Temperature xx°C, HR xx/min and regular, BP xxx/xx mmHg, JVP xxxxxx, RR xx/min, O 2 sat xx% on air, HS xxxxxx, chest sounds xxxxxxx. Other important observations are ……. Investigations Na + xxx mmol/L (137–144), K + xxx mmol/L (3.5–4.9), U xxx mmol/L (2.5–7.0), Cr xxx µmol/L (60–110), eGFR etc. ECG shows ……… CXR shows ……… [Authors should provide sufficient information from the clinical examination and investigations to enable the candidate to make a sound judgement about the need for and choice of treatment] Prescribing request Write a prescription for ONE drug that will help to [treat/alleviate/prevent] [symptom or problem]. (use the general practice prescription form provided) Please paste any picture or other illustration that supports the clinical case into this box PWS000 ID This question item is worth 10 marks Pharmacy Stamp Please dont stamp over age box Age 0yr 0mths D.o.B. 00/00/0000 Title, Forename, Surname & Address Patient Name Address Line 1 Address Line 2 Town Postcode Number of days treatment N.B. Ensure dose is stated Endorsements Drug name Dose Frequency Signature of Prescriber Signature Date 00/00/0000 For Dispenser No. of Prescns. on form Xxxxx Health Authority Dr Address Town Postcode Tel: FP10NC0105 You may use the BNF at any time Prescribing Item

14 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS000 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Drug choice ScoreFeedback/justification B. Dose, route, freq. ScoreFeedback/justification Prescribing Item It is impossible to write Prescribing items with only one creditworthy answer! Use this page to indicate optimal answers (10/10) but also to anticipate and score as many suboptimal answers using the scoring system below.

15 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Case presentation A [age]-year-old [man/woman/child] presents to [location and situation] complaining of [symptom] etc. PMH. She/he has suffered from …. [describe any past medical history relevant to the scenario]. DH. She/he normally takes …. [list any current prescriptions]. SH. [include any relevant social history] [Authors should try to adhere to this general layout but there is room for flexibility] On examination Temperature xx°C, HR xx/min and regular, BP xxx/xx mmHg, JVP xxxxxx, RR xx/min, O 2 sat xx% on air, HS xxxxxx, chest sounds xxxxxxx. Other important observations are ……. Investigations Na + xxx mmol/L (137–144), K + xxx mmol/L (3.5–4.9), U xxx mmol/L (2.5–7.0), Cr xxx µmol/L (60–110), eGFR etc. ECG shows ……… CXR shows ……… Prescribing request Write a prescription for ONE intravenous fluid that would be most appropriate for the patient at this point. (use the hospital fluid prescription chart provided) Please paste any picture or other illustration that supports the clinical case into this box PWS000 ID This question item is worth 10 marks INFUSION THERAPY Date Start time Infusion solutionMedicine added Prescribers signature Given by Type/strengthVolumeRouteRateDurationApproved nameDose You may use the BNF at any time Prescribing Item

16 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS000 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Fluid choice ScoreFeedback/justification B. Volume and duration ScoreFeedback/justification Prescribing Item It is impossible to write Prescribing items with only one creditworthy answer! Use this page to indicate optimal answers (10/10) but also to anticipate and score as many suboptimal answers using the scoring system below.

17 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool The following pages contain examples of Prescribing Station question items written using the previous templates

18 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Case presentation A 74-year-old man presents to the medical assessment unit complaining of shortness of breath at rest and swollen legs. These symptoms have been gradually increasing over the last 2 weeks. He has been having difficulty sleeping and sat up in a chair all of last night, calling his doctor this morning. PMH. He has ischaemic heart disease and hypertension, both of which are normally well controlled. DH. He normally takes ramipril 10 mg orally daily, isosorbide mononitrate 60 mg orally daily, simvastatin 40 mg orally nightly, and aspirin 75 mg orally daily. An intravenous infusion of glyceryl trinitrate has just been started. On examination HR 105/min and regular, BP 110/70 mmHg, JVP elevated at 6 cm, RR 30/min, O 2 sat 93% on air. HS third heart sound. Examination of the chest reveals dullness to percussion both bases and fine inspiratory crackles in both lower and mid zones. Bilateral swollen legs with pitting oedema to knees. Investigations Na mmol/L (137–144), K mmol/L (3.5–4.9), U 7.0 mmol/L (2.5–7.0), Cr 120 µmol/L (60–110). ECG shows sinus tachycardia. The CXR is illustrated (right). Prescribing request Write a prescription for ONE drug that will help to relieve his fluid overload and breathlessness. (use the hospital once-only medicines prescription chart provided) PWS001 ID This question item is worth 10 marks You may use the BNF at any time ONCE ONLY MEDICINES Date Tim e Medicine (Approved name)DoseRoutePrescriber – sign + print Tim e given Given by Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Prescribing Item

19 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS001 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Drug choice ScoreFeedback/justification B. Dose and route ScoreFeedback/justification 1 Furosemide4This is a powerful loop diuretic and is one of the drugs most likely to achieve a significant diuresis. 40–100 mg IV4This dose and route would be likely to achieve a significant diuresis (doses > 50 mg should be given by slow IV infusion) 2 <40 mg IV2This dose may produce a suboptimal diuresis 3 >100 mg IV2This is an unnecessarily high dose of furosemide that risks causing adverse effects in a diuretic naïve patient 4 20 mg oral1This dose is unlikely to be effective 5 40–100 mg oral2Any oral route will be less effective than IV 6 >100 mg oral1This dose is excessive and the route would be less likely to achieve a significant diuresis 7 Bumetanide41–2 mg IV4This dose and route would be likely to achieve a significant diuresis 8 <1 mg IV2This dose runs a significant danger of producing a suboptimal diuresis 9 >2 mg IV2This is an unnecessarily high dose of bumetanide that risks causing adverse effects in a diuretic naïve patient mg oral2Any oral route will be less effective than IV 11 oral dose outside this range1This dose and route are inappropriate 12 Torasemide2This is a powerful loop diuretic but is available only via the oral route 5 – 40 mg oral2This is the correct dose of torasemide but a parenteral loop diuretic should have been chosen 13 Any thiazide diuretic1This is a thiazide diuretic, which will not have sufficient efficacy to achieve a significant diuresis Correct dose and route1This is the correct dose but a parenteral loop diuretic should have been chosen 14 Any other diuretic0This kind of diuretic will not have sufficient efficacy to achieve a significant diuresis 15 Nitrates0The patient is already being given a nitrate 16 Morphine/diamorphine2May redistribute fluid but will not improve fluid overload2.5–10 mg/2.5–5 mg2Higher doses would be hazardous (0 marks) Prescribing Item

20 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Case presentation A 60-year-old man is admitted to the acute medical admission unit with a 2-month history of intermittent epigastric pain radiating to the back, which typically occurs 2 or 3 hours after meals and at night. His weight has remained stable and he has not been vomiting. He has recently been suffering from pain in his left knee. PMH. None. DH. No regular medicines but he has been taking over-the-counter pain killers on a daily basis. SH. He is a non- smoker and drinks alcohol in moderation (10 units/week). On examination He appears well but has some epigastric tenderness on abdominal examination. Investigations Hb and MCV normal. Serum biochemistry normal. Endoscopy reveals a small duodenal ulcer but no evidence of bleeding. Tests for H pylori infection are all negative. Prescribing request Write a prescription for ONE drug that will promote the healing of the duodenal ulcer. (use the hospital regular medicines prescription chart provided) PWS002 ID This question item is worth 10 marks Date Time Drug (Approved name) 6 8 DoseRoute 12 Prescriber – sign + printStart date NotesPharmacy 22 You may use the BNF at any time Prescribing Item

21 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS002 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Drug choice ScoreFeedback/justification B. Dose, route, frequency ScoreFeedback/justification 1Omeprazole4A proton pump inhibitor is the optimal choice for the treatment of a benign duodenal ulcer 20 mg oral once daily4This is the optimal dosage and should be given for 4 weeks in the first instance 210 mg or 40 mg oral once daily3This dosage is too low/too high. 3Lansoprazole4A proton pump inhibitor is the optimal choice for the treatment of a benign duodenal ulcer 30 mg daily oral once daily4This is the optimal dosage and should be given for 4 weeks in the first instance 415 mg oral once daily3This dosage is too low. 5Esomeprazole3A proton pump inhibitor is the optimal choice but esomeprazole is much more expensive than others and is not indicated for benign duodenal ulcer 10 or 20 mg oral once daily3This is the correct dosage 6Pantoprazole4A proton pump inhibitor is the optimal choice for the treatment of a benign duodenal ulcer 40–80 mg oral once daily4This is the optimal dosage and should be given for 2 weeks in the first instance 7Rabeprazole sodium3A proton pump inhibitor is the optimal choice but rabeprazole is much more expensive than others 20 mg oral once daily3This is the optimal dosage and should be given for 4 weeks in the first instance 8Any of the above by the intravenous route in the correct dose 2The intravenous route is unnecessary in this clinical situation 9Ranitidine, cimetidine, famotidine, nizatidine 3An H 2 -antagonist is a good choice for the treatment of a benign duodenal ulcer but is less effective than a proton pump inhibitor 300 mg oral at night or 150 mg oral twice daily3This is the optimal dosage and should be given for 4 weeks in the first instance 10An inappropriate but prescribable dose2This is not the optimal dosage of this drug for the indication 11Misoprostol1A prostaglandin analogue that can be used to treat and prevent duodenal ulcers but is less effective and more expensive than other drugs 400 micrograms oral twice daily 200 micrograms oral four times daily 1This is the optimal dosage and should be given for 4 weeks in the first instance 12Antacid preparations1Antacids are effective for relieving symptoms but not for healing duodenal ulcers at conventional doses. Appropriate high antacid dose1 13DeNol/Sucralfate1These preparations are indicated for treating duodenal ulcers but are rarely used and unlikely to be immediately available from a hospital pharmacy Appropriate doses1 Prescribing Item

22 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Case presentation A 68-year-old woman is reviewed in a primary care cardiovascular clinic with hypercholesterolaemia. After a careful explanation she is keen to have drug treatment to lower her cholesterol. PMH. Hypertension. DH. Bendroflumethiazide 2.5 mg orally daily, lisinopril 20 mg orally daily, amlodipine 5 mg orally daily. FH. Nil relevant. SH. She eats a sensible diet and is a non-smoker. On examination She has an early corneal arcus in both eyes. BP 130/70 mmHg. Investigations Normal FBC, renal, liver and thyroid function tests. Normal fasting plasma glucose and HbA 1c. Serum cholesterol 7.5 mmol/L ( 1.55), fasting serum triglycerides 1.90 mmol/L (0.45–1.69). Normal ECG. Her 10-year cardiovascular risk is estimated to be 23%. Prescribing request Write a prescription for ONE drug that will reduce her serum cholesterol and risk of cardiovascular events. (use the general practice prescription form provided) PWS003 ID This question item is worth 10 marks Pharmacy Stamp Please dont stamp over age box Age 0yr 0mths D.o.B. 00/00/0000 Title, Forename, Surname & Address Patient Name Address Line 1 Address Line 2 Town Postcode Number of days treatment N.B. Ensure dose is stated Endorsements Drug Name Dose Frequency Signature of Prescriber Signature Date 00/00/0000 For Dispenser No. of Prescns. on form Xxxxx Health Authority Dr Address Town Postcode Tel: FP10NC0105 You may use the BNF at any time Prescribing Item

23 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS003 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Drug choice ScoreFeedback/justification B. Dose, route, frequency ScoreFeedback/justification 1Simvastatin4A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk 20 mg or 40 mg oral once daily (10 mg too low, 80 mg too high = 2 marks) 4This is an appropriate starting dosage and is normally prescribed nightly. 2Atorvastatin3A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but atorvastatin, although more efficacious, is less cost-effective 10 mg oral once daily 20 – 80 mg oral once daily 3232 This is an appropriate starting dosage This starting dosage is unnecessarily high 3Rosuvastatin3A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but rosuvastatin, although more efficacious, is less cost-effective 5–10 mg oral once daily 20 – 80mg oral once daily 3232 This is an appropriate starting dosage This starting dosage is unnecessarily high 4Pravastatin sodium2A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but pravastatin is less efficacious and more expensive 10–40 mg oral once daily2This is an appropriate starting dosage 5Fluvastatin2A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but fluvastatin is less efficacious and more expensive 20–40 mg oral once daily 80 mg oral once daily 2121 This is an appropriate starting dosage This starting dosage is unnecessarily high 6Simvastatin with ezetimibe 2A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk but use of a combination product is not indicated 40 mg/10 mg oral once daily2This is an appropriate starting dosage 7Ezetimibe1A cholesterol absorption inhibitor that is much less efficacious and more expensive than simvastatin 10 mg oral once daily1This is an appropriate starting dosage 8Fibric acid derivatives2Fibric acid derivatives are less efficacious and more expensive than simvastatin Appropriate dose2This is an appropriate starting dosage 9Bile acid sequestrants2A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk and sequestrants are less efficacious and more expensive Appropriate dose2This is an appropriate starting dosage 10Nicotinic acid derivatives 1A statin is the optimal treatment for lowering LDL cholesterol and cardiovascular risk and nicotinic acid derivatives are less efficacious and more expensive Appropriate dose1This is an appropriate starting dosage 11Omega-3 fatty acids1These lower cholesterol but are not indicatedAppropriate dose1This is an appropriate starting dosage Prescribing Item

24 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Prescribing Item Case presentation A 62-year-old woman is admitted to hospital with a 3-day history of increasing breathlessness, wheeze, and dry cough. PMH. Chronic obstructive pulmonary disease with several admissions for exacerbations, and angina pectoris. DH. Salbutamol inhaler 200 micrograms as required, tiotropium inhaler 18 micrograms daily, fluticasone propionate 250 micrograms with salmeterol 50 micrograms inhaler (Seretide 250 Accuhaler®) 12-hrly. Treatment with oral prednisolone has already been started by the GP. On examination She appears distressed, and is centrally cyanosed and coughing. Temperature 37.1°C, HR 112/min, BP 116/72 mmHg, RR 30/min, O 2 sat 90% on air. PEFR 120 L/min. She is using her accessory muscles to breathe. Auscultation of the chest reveals widespread wheezes bilaterally. Investigations Hb 146 g/L (115–165), WCC 9.8 × 10 9 /L (4.0–11.0). Na mmol/L (137–144), K mmol/L (3.5–4.9), U 7.2 mmol/L (2.5–7.0), Cr 85 µmol/L (60-110). CXR shows hyperexpanded lungs. Prescribing request Please write a prescription for ONE drug that will provide rapid relief of her bronchospasm. (use the hospital once-only medicines prescription chart provided) PWS004 ID This question item is worth 10 marks You may use the BNF at any time ONCE ONLY MEDICINES Date Tim e Medicine (Approved name)DoseRoutePrescriber – sign + print Tim e given Given by

25 Prescribing Skills Assessment – Prescribing Question Item Authoring Tool Marking guide for A and B. Candidates should be given 4 marks for an optimal answer that cant be improved. They should get 3 marks for an answer that is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit. PWS004 ID This question item is worth 10 marks You may use the BNF at any time Answer Page C. Timing. Candidates will also be given 1 mark for correctly dating (and timing) the prescription D. Signature. Candidates will also be given 1 mark for signing the prescription A. Drug choice ScoreFeedback/justification B. Dose and route ScoreFeedback/justification 1Salbutamol4Commonest drug for this situation2.5 – 5 mg nebulised4Probably the most effective route 2100– 200 micrograms inhaled2Already on it/less easy to administer/less effective 3Dosages outside these ranges2Dosages would be hazardous 4Other routes with right dosage0Other routes more hazardous or less effective 5Terbutaline4Equivalent to salbutamol in efficacy5 – 10 mg nebulised4Probably the most effective route 6500 micrograms inhaled2May be less easy to administer/less effective 7Dosages outside these ranges2Dosages would be hazardous 8Other routes with right dosage0Other routes more hazardous or less effective 9Ipratropium bromide3Anticholinergic drug equally effective in COPD but the patient is already on tiotropium 250– 500 micrograms3This is the correct dose range for the nebuliser 10Dosage outside this range1Hazardous or ineffective 1120 – 40 microgram inhaled1Already taking an inhaled anticholinergic drug 12Duovent4Compound preparation via nebuliser that has equivalent efficacy to either alone. Correct nebulised dose4The most effective route of administration 13Combivent4Compound preparation via nebuliser that has equivalent efficacy to either alone. Correct nebulised dose4The most effective route of administration 14Oral theophyllines1Effect too delayed to be usefulCorrect oral dosage1 15Aminophylline2This would pose greater than necessary hazards as a firstline treatment An appropriate intravenous loading dosage (250–500 mg) 2This dose implies a body weight of 50–100 kg although weight not given (other doses get zero) 16Tiotropium0The patient is already taking tiotropium 17Adrenaline0Would be unacceptably hazardous in this situation 18Salmeterol, indacaterol, formoterol, bambuterol 0Patient is already taking a long-acting beta-2 agonist Prescribing Item


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