8th Edition
This edition first published 2018
© 2018 John Wiley & Sons Ltd
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Wiley-Blackwell (7e, 2014)
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Library of Congress Cataloging-in-Publication Data
Names: Blenkinsopp, Alison, author. | Duerden, Martin, author. | Blenkinsopp, John, author.
Title: Symptoms in the pharmacy : a guide to the management of common illnesses / by
Alison Blenkinsopp, Martin Duerden, and John Blenkinsopp.
Description: Eighth edition. | Hoboken, NJ, USA : Wiley-Blackwell, [2018] |
Includes bibliographical references and index. |
Identifiers: LCCN 2017060730 (print) | LCCN 2017061257 (ebook) | ISBN 9781119317975 (pdf) |
ISBN 9781119318002 (epub) | ISBN 9781119317968 (pbk.)
Subjects: | MESH: Drug Therapy | Pharmaceutical Services | Diagnosis | Referral and
Consultation | Handbooks
Classification: LCC RS122.5 (ebook) | LCC RS122.5 (print) | NLM QV 735 | DDC
615.5/8–dc23
LC record available at https://lccn.loc.gov/2017060730
Cover Design: Wiley
Cover Image: ©Piotr Zajc/Shutterstock; ©Sentavio/Shutterstock
This is the eighth edition of our book and appears 28 years after the first. Dr Martin Duerden has joined us as co-author and we wish Dr Paul Paxton well in his retirement. Paul was instrumental in the original development of the ideas and format for the book and made a major contribution over the years. The update in this edition comes at an exciting time for pharmacists in the United Kingdom with increasing emphasis on their clinical role.
Among the changes in this new edition are
As for previous editions, we have received positive and constructive feedback and suggestions from pharmacists (undergraduate students, pre-registration trainees and practising pharmacists) as well as formal reviewers and have tried to act on your suggestions. We have continued to add more accounts by patients to our case studies. We thank all the pharmacists who sent us comments and we hope you like the new edition.
We once again thank Kathryn Coates and her network of mums, who provided advice on the sort of concerns and queries that they hope their pharmacists can answer.
Alison Blenkinsopp
Martin Duerden
John Blenkinsopp
Every working day, people come to the community pharmacy for advice about minor ailments and symptoms. Recent research found that the proportion of general practice and emergency department (ED) consultations for minor ailments potentially suitable for management in community pharmacy was around 13 and 5%, respectively. Encouraging self-care is a good thing, and with increasing pressure on doctors' and nurses' workload, it is likely that the community pharmacy will be even more widely used as a first port of call for minor illness. There are often local initiatives to encourage this. Members of the public present to pharmacists and their staff in a number of ways, which include
The pharmacist's role in responding to symptoms and overseeing the sale of over-the-counter (OTC) medicines is substantial and requires a mix of knowledge and skills in diseases and their treatment. In addition, pharmacists are responsible for ensuring that their staff provide appropriate advice and recommendations. Key skills are as follows:
In this book we refer to the people seeking advice about symptoms as patients. It is important to recognise that many of these patients will in fact be healthy people. We use the word ‘patient’ because we feel that the terms ‘customer’ and ‘client’ do not capture the nature of consultations about health.
Pharmacists are skilled and knowledgeable about medicines and about the likely causes of illness. In the past the approach has been to see the pharmacist as expert and the patient as beneficiary of the pharmacist's information and advice. But patients are not blank sheets or empty vessels. They have choices to make and they are experts in their own and their children's health. The patient
The pharmacist needs to take this into account during the consultation with the patient and to enable patients to participate by actively eliciting their views and preferences. Not all patients will want to engage in decision making about how to manage their symptoms, but research shows that many do. Some will want the pharmacist to simply make a decision on their behalf. What the pharmacist needs to do is to find out what the patient wants.
Much lip service has been paid to the idea of partnership working with patients. The question is how to achieve this. Healthcare professionals can only truly learn how to go about working in partnership by listening to what patients have to say. The list below comes from a study of lay people's ‘tips’ on how consultations could be more successful. Although the study was concerned with medical consultations, many of the tips are equally relevant to pharmacists' response to patients' symptoms.
Source: Reproduced from Bensing et al. (2011). Copyright 2011 with permission from Elsevier.
Use these tips to reflect on your own consultations about minor illness both during and afterwards. Try to feel how the consultation is going from the patient's perspective.
Reading and listening to patients' accounts of their experience can provide valuable insights. Websites and blogs can give a window into common problems and questions, can help to see the patient perspective, and can also show how powerful social media can be in sharing experience and information (Netmums is a good example, www.netmums.com). Do not be patronising about lay networks; why not contribute your own expertise?
Do be aware that some information from these sources can be inaccurate or have poor quality, and some can create unrealistic beliefs and expectations. Others may be overtly promotional. Being a world wide web, occasionally information relates to medicines in different countries. If you are concerned about the quality or relevance of health information that has been accessed by a patient, one suggestion is to gently or tactfully point the patient towards accredited sources of information such as that provided on NHS Choices (www.nhs.uk). Another useful resource that rapidly interrogates and translates news coverage of health topics, and debunks these if necessary, is Behind the Headlines from NHS Choices (http://www.nhs.uk/News/Pages/NewsArticles.aspx).
When a request is made to purchase a named medicine, the approach should be to consider if the person making the request might already be an expert user or may be a novice. We define the expert user as someone who has used the medicine before for the same or a similar condition and is familiar with it. While pharmacists and their staff need to ensure that the requested medicine is appropriate, they also need to bear in mind the previous knowledge and experience of the purchaser.
Research shows that the majority of pharmacy customers do not mind being asked questions about their medicine purchase. An exception to this is those who wish to buy a medicine they have used before and would prefer not to be subjected to the same questions each time they ask for the product. There are two key points here for the pharmacist: firstly, it can be helpful to briefly explain why questions are needed, and secondly, fewer questions are normally needed when customers request a named medicine that they have used before.
Ask whether the person has used the medicine before, and if the answer is yes, consider if any further information is needed. Quickly check on whether other medicines are being taken. If the person has not used the medicine before, more questions will be needed. One option is to follow the sequence for responding to requests for advice about symptoms (see below). It can be useful to ask how the person came to request this particular medicine; for example, have they seen an advertisement for it? Has it been recommended by a friend or family member?
Pharmacists will use their professional judgement in dealing with regular customers whom they know well and where the individual's medication history is known. The pharmacy patient medication records (PMRs) are a source of backup information for regular customers. However, for new customers where such information is not known, more questions are likely to be needed.
Most information required to make a decision and recommended treatment can be gleaned from just listening to the patient. In some cases, the patient may have prepared a story to tell you and may be dissatisfied if the story is not heard; experience suggests that the story can give you much of the information you might need. The process should start with open-type questions and perhaps an explanation of why it is necessary to ask personal questions. Some patients do not yet understand why the pharmacist needs to ask questions before recommending treatment. An example might be the following:
Hopefully, this will lead to a description of most of the symptoms required for the pharmacist to make an assessment. Other forms of open questions could include the following: How does that affect you? What sort of problems does it cause you? By carefully listening and possibly reflecting on comments made by the patient, the pharmacist can obtain a more complete picture.
This form of listening can be helped by asking questions to clarify points: ‘I'm not sure I quite understand when you say…’, or ‘I'm not quite clear what you meant by…’. Another useful technique is to summarise the information so far: ‘I'd just like to make sure I've got it right. You tell me you've had this problem since…’.
Once this form of information gathering has occurred, there will be some facts still missing. It is now appropriate to move onto some direct questions.
Other questions could include the following: What treatments have you tried so far this time? What sort of treatment were you hoping for today? What other medications are you taking at present? Do you have any allergies?
Triaging is the term given to assessing the level of seriousness of a presenting condition and thus the most appropriate action. It has come to be associated with both prioritisation (e.g. as used in accident and emergency [A&E] departments) and clinical assessment. Community pharmacists have developed procedures for information gathering when responding to requests for advice that identify when the presenting problem can be managed within the pharmacy and when referral for medical advice is needed. The use of questioning to obtain the sorts of information needed is discussed below. Furthermore, in making this clinical assessment, pharmacists incorporate management of certain conditions and make recommendations about them.
The use of protocols and algorithms in the triaging process is common in many countries including the United Kingdom, with computerised decision-support systems increasingly used. It is possible that in the future computerised decision support may play a greater part in face-to-face consultations, perhaps including community pharmacies.
If the following information were obtained, then a referral would be required.
For more information on when to refer see ‘D: Danger/Red flag symptoms’ under the ASMETHOD pneumonic below.
The pharmacist's background in pharmacology, therapeutics and pharmaceutics gives a sound base on which to make logical treatment choices based on the individual patient's need, together with the characteristics of the medicine concerned. In addition to the effectiveness of the active ingredients included in the product, the pharmacist will need to consider potential interactions, cautions, contraindications and adverse reaction profile of each constituent. Evidence-based practice requires that pharmacists need to carefully think about the effectiveness of the treatments they recommend, combining this with their own and the patient's experience.
Concordance in the use of OTC medicines is important and the pharmacist will elicit the patient's preferences and discuss treatment options in this context. Some pharmacies have developed their own OTC formularies with preferred treatments that are recommended by their pharmacists and their staff. In some areas these have been discussed with local general practitioners (GPs) and practice nurses to cover the referral of patients from the GP practice to the pharmacy. These may be area initiatives arranged by local healthcare organisations (clinical commissioning groups or health boards).
PMRs can play an important part in supporting the process of responding to symptoms. Prior to the introduction of the new community pharmacy contractual framework (CPCF) in 2005, research showed that only one in four pharmacists recorded OTC treatment on the pharmacist's own PMR system. Yet such recording can complete the profile of medication, and review of concurrent prescribed drug therapy can identify potential drug interactions and adverse effects. In addition, such record keeping can make an important contribution to clinical governance. Improvements in IT systems in pharmacies will make routine record keeping more feasible; community pharmacies now have access to part of the NHS primary care medical record (Summary Care Record, SCR). Keeping records for specific groups of patients, for example, older people, is one approach in the meantime. The CPCF for England and Wales includes a requirement to keep a record of OTC advice and treatment:
“Pharmacies will help manage minor ailments and common conditions, by the provision of advice and where appropriate, the sale of medicines, including dealing with referrals from NHS 111. Records will be kept where the pharmacist considers it relevant to the care of the patient.”
At the time of writing, digital integration of community pharmacy with the wider NHS is under active development, for example, so that electronic referrals can be made for an Urgent Medicine Supply Advanced Service (NUMSAS) from the NHS 111 service in England. The NHS 111 call handler will take and record patient consent for receipt of service and data sharing with GP.
Pharmacists and their staff should, wherever possible, base treatment recommendations on evidence. For more recently introduced medicines and for those that have moved from prescription-only medicine (POM) to pharmacy (P) medicine, there is usually an adequate evidence base. For some medicines, particularly older ones, there may be little or no evidence. Here, pharmacists need to bear in mind that absence of evidence does not in itself signify absence of effectiveness. Current evidence of effectiveness is summarised in the relevant British National Formulary (BNF) monograph. The BNF is now updated every month online and can be found at https://bnf.nice.org.uk/.
Useful websites for clinical guidelines in the United Kingdom are NHS Evidence (www.evidence.nhs.uk), which includes links to the BNF (https://www.evidence.nhs.uk/ and https://bnf.nice.org.uk/), Clinical Knowledge Summaries (CKS) (https://cks.nice.org.uk), the Scottish Intercollegiate Guideline Network (SIGN) (www.sign.ac.uk) and the National Institute for Health and Care Excellence (www.nice.org.uk). The website for NHS Choices (www.nhs.uk) includes symptom checkers and management advice for minor ailments.
This book has drawn wherever possible on these types of clinical guidelines and resources (CKS, NHS Choices [which draws on CKS and could be thought of as the portal to evidence for members of the public], BNF, NICE, SIGN, etc.) when discussing clinical management. When necessary, it has also drawn on evidence from high quality systematic reviews such as those produced by the Cochrane collaboration. In the absence of such reviews, randomised controlled trials may be referred to. For many common conditions, research evidence may be lacking as treatment approaches have evolved and developed over many years, and in such cases a consensus of best practice has usually been agreed (e.g. within CKS, or public health guidance).
Key interactions between OTC treatments and other drugs are included in each section of this book. For further information, the BNF provides an alphabetical listing of drugs and interactions, together with an indication of clinical significance. In this book, generic drug names are italicised.
For symptoms discussed in this book, the section ‘Management’ includes brief information about the efficacy, advantages and disadvantages of possible therapeutic options. Also included are useful points of information for patients about the optimum use of OTC treatments, under the heading ‘Practical points’. At any one time, not all of the medicines that could be sold OTC are available as OTC products. Throughout the book we have included the names of medicines and, where possible, have also said where there is an OTC product available at the time of writing.
Some sections of the book use the expression ‘referral to doctor’. This is a commonly used expression within pharmacies and is generally well understood by patients. Increasingly in primary care and out of hours (OOH) centres and Emergency Departments (EDs, also referred to as accident and emergency or A & E) patients may not see the doctor directly. Often trained nurses may assess patients, and sometimes suitably qualified clinical pharmacists, and they may prescribe treatment. We have used this phrase for convenience, but sometimes if these alternative systems are fairly well established in your area, this may need explaining to patients.
Pharmacists are likely to be increasingly involved in the management of long-term chronic or intermittent conditions. Here, monitoring of progress is important and a series of consultations is likely rather than just one.
Effective consultation skills are the key to finding out what the patient's needs are and deciding whether you can manage the symptoms or whether they might need to be referred to another practitioner. A useful framework for thinking about and improving your consultation skills is provided by Roger Neighbour's five ‘checkpoints’.
| A | Connecting | ‘Have we got a rapport?’ | Rapport building skills |
| B | Summarising (clinical process) | ‘Can I demonstrate to the patient I have understood why she has come?’ | Listening and eliciting skills (history taking and summarising to the patient) |
| C | Handing over | ‘Has the patient accepted the management plan we agreed?’ | Concordance skills |
| D | Safety netting | ‘Have I anticipated all likely outcomes?’ | Contingency plans |
| E | Housekeeping* | ‘Am I in good condition for the next patient?’ | Taking care of yourself |
* Housekeeping – This is a period of reflection where practitioners look at themselves and their response to the consultation. It may involve having a brief chat with a colleague, a coffee, or merely acknowledging to oneself the effect a particular consultation has had.
It is very useful to adopt a framework to help structure the consultation. Pharmacists need to develop a method of information seeking that works for them. There is no right and wrong here. Some pharmacists find that a mnemonic such as the two shown below can be useful, although care needs to be taken not to recite questions in rote fashion without considering their relevance to the individual case. Good listening will glean much of the information required. The mnemonic can be a prompt to ensure all relevant information has been obtained. Developing rapport is essential to obtain good information, and reading out a list of questions can be off-putting and counterproductive.
W: The pharmacist must first establish the identity of the patient: the person in the pharmacy might be there on someone else's behalf. The exact nature of the symptoms should be established: patients often self-diagnose illnesses, and the pharmacist must not accept such a self-diagnosis at face value.
H: Duration of symptoms can be an important indicator of whether referral to the doctor might be required. In general, the longer the duration, the more likely the possibility of a serious rather than a minor case. Most minor conditions are self-limiting and should clear up within a few days.
A: Any action taken by the patient should be established, including the use of any medication to treat the symptoms. About one in two patients will have tried at least one remedy before seeking the pharmacist's advice. Treatment may have consisted of OTC medicines bought from the pharmacy or elsewhere, other medicines prescribed by the doctor on this or a previous occasion or medicines borrowed from a friend or neighbour or found in the medicine cabinet. Homoeopathic or herbal remedies may have been used. The cultural traditions of people from different ethnic backgrounds include the use of various remedies that may not be considered medicines.
If the patient has used one or more apparently appropriate treatments without improvement, referral to the family doctor may be the best course of action.
M: The identity of any medicines taken regularly by the patient is important for two reasons: possible interactions and potential adverse reactions. Such medicines will usually be those prescribed by the doctor but may also include OTC products and complementary or alternative remedies. The pharmacist needs to know about all the medicines being taken by the patient because of the potential for interaction with any treatment that the pharmacist might recommend.
The community pharmacist has an increasingly important role in detecting adverse drug reactions, and consideration should be given to the possibility that the patient's symptoms might be an adverse effect caused by medication. For example, whether gastric symptoms such as indigestion might be due to a non-steroidal anti-inflammatory drug (NSAID) taken on prescription or a cough might be due to an angiotensin-converting enzyme (ACE) inhibitor being taken by the patient. When the pharmacist suspects an adverse drug reaction to a prescribed medicine, the pharmacist should discuss with the prescriber what actions should be taken (perhaps including a Yellow Card report to the Commission on Human Medicines, which can now be made by the pharmacist or patient) and the prescriber may wish the patient to be referred back to them so that treatment can be reviewed.
The second mnemonic, ASMETHOD, was developed by Derek Balon, a community pharmacist in London:
Some of the areas covered by the ASMETHOD list have been discussed already. The others can now be considered.
A: Age and appearance
The appearance of the patient can be a useful indicator of whether a minor or more serious condition is involved. If the patient looks ill, for example, pale, clammy, flushed or grey, the pharmacist should consider referral to the doctor. As far as children are concerned, appearance is important, but in addition the pharmacist can ask the parent whether the child is generally well. A child who is cheerful and energetic is unlikely to have anything other than a minor problem, whereas one who is quiet and listless, or who is fractious, irritable and feverish, might require referral.
The age of the patient is important because the pharmacist will consider some symptoms as potentially more serious according to age. For example, acute diarrhoea in an otherwise healthy adult could reasonably be treated by the pharmacist. However, such symptoms in a baby could produce dehydration more quickly; elderly patients are also at a higher risk of becoming dehydrated. Oral thrush is common in babies, while less common in older children and adults; the pharmacist's decision about whether to treat or refer could therefore be influenced by age.
Age will play an important part in determining any treatment offered by the pharmacist. Some preparations are not recommended at all for children under 12 years, for example, loperamide. Hydrocortisone cream and ointment should not be recommended for children aged under 10 years; aspirin should not be used in children aged under 16 years; corticosteroid nasal sprays and omeprazole should not be recommended for those under 18 years of age. Others must be given in a reduced dose or as a paediatric formulation, and the pharmacist will thus consider recommendations carefully.
Other OTC preparations have a minimum specified age, for example, 16 years for emergency hormonal contraception, 12 years for nicotine replacement therapy (NRT) and 18 years for treatments of vaginal thrush. Pharmacists are used to assessing patients' approximate age and would not routinely ask for proof of age here, unless there was a specific reason to do so.
There are two aspects to the term ‘history’ in relation to responding to symptoms: first, the history of the symptom being presented and second, previous medical history. For example, does the patient have diabetes, hypertension or asthma? PMRs should be used to record relevant existing conditions.
Questioning about the history of a condition may be useful; how and when the problem began, how it has progressed and so on. If the patient has had the problem before, previous episodes should be asked about to determine the action taken by the patient and its degree of success. In recurrent mouth ulcers, for example, do the current ulcers resemble the previous ones? Was the doctor or dentist seen on previous occasions? Was any treatment prescribed or OTC medicine purchased, and, if so, did it work?
In asking about the history, the timing of particular symptoms can give valuable clues as to possible causes. The attacks of heartburn that occur after going to bed or on stooping or bending down are indeed likely to be due to reflux, whereas those that happen during exertion such as exercise or heavy work may not be.
History taking is particularly important when assessing skin disease. Pharmacists often think, erroneously, that recognition of the appearance of skin conditions is the most important factor in responding to such symptoms. In fact, many dermatologists would argue that history taking is more important because some skin conditions resemble each other in appearance. Furthermore, the appearance may be altered during the course of the condition. For example, the use of a topical corticosteroid inappropriately on infected skin may substantially change the appearance; allergy to ingredients such as local anaesthetics may produce a problem in addition to the original complaint. The pharmacist must therefore know which creams, ointments or lotions have been applied.
O: Other symptoms
Patients generally tend to complain about the symptoms that concern them most. The pharmacist should always ask whether the patient has noticed any other symptoms or anything different from usual because, for various reasons, patients may not volunteer all the important information. Embarrassment may be one such reason, so patients experiencing rectal bleeding may only mention that they have piles or are constipated.
The importance or significance of symptoms may not be recognised by patients, for example, those who have constipation as a side effect from a tricyclic antidepressant will probably not mention their dry mouth because they can see no link or connection between the two problems.
D: Danger/red flag symptoms
These are the symptoms or combinations of symptoms that should ring warning bells for pharmacists because immediate referral to the doctor is required. They are often called ‘red flag’ symptoms and we refer to them as such throughout the rest of this book. Blood in the sputum, vomit, urine or faeces would be examples of such symptoms, as would unexplained weight loss. Red flag symptoms are included and discussed in each section of this book so that their significance can be understood by the pharmacist.
Most of the symptoms dealt with by the community pharmacist will be of a minor and self-limiting nature and should resolve within a few days. However, sometimes this will not be the case, and it is the pharmacist's responsibility to make sure that patients know what to do if they do not get better. This is sometimes called ‘safety netting’. Here, a defined timescale should be used, as suggested in the relevant sections of this book, so that when offering treatment, the pharmacist can set a time beyond which the patient should seek medical advice if symptoms do not improve. The ‘treatment timescales’ outlined in this book naturally vary according to the symptom and sometimes according to the patient's age, but are usually less than 1 week.
In making decisions the pharmacist assesses the possible risk to the patient of different decision paths. The possible reasons for referral for further advice include the following:
As a general rule, the following indicate a higher risk of a serious condition and should make the pharmacist consider referring the patient to the doctor:
Discussions with local family doctors can assist the development of protocols and guidelines for referral, and we recommend that pharmacists take the opportunity to develop such guidelines with their medical and nursing colleagues in primary care, where possible. Often this process can be facilitated by the local healthcare organisation (clinical commissioning group or health board). Joint discussions of this sort can lead to effective two-way referral systems and local agreements about preferred treatments.
Pharmacists are often asked to offer advice about injuries, many of which are likely to be minor with no need for onward referral. The list below shows the types of injuries that would be classified as ‘minor’.
Pharmacists need to be familiar with the assessment and treatment of minor injuries in order to make a decision about when and where referral is needed. Referral to the ED may need to be considered in certain circumstances. The list below provides general guidance on when a person might need to immediately go to the ED.
Each attendance at the ED costs the NHS over £100 and pharmacies have an important role in considering whether to refer a patient to a minor injuries unit or walk-in service (if there is one locally) and explaining to patients about when ED attendance is needed.
The vast majority of community pharmacies in England and Wales have a consultation area. Research shows that most pharmacy customers feel that the level of privacy available for a pharmacy consultation is now acceptable. There is some evidence of a gap between patients' and pharmacists' perceptions of privacy.
Pharmacists observe from their own experience that some patients are content to discuss even potentially sensitive subjects in the pharmacy. While this is true for some people, others are put off asking for advice because of insufficient privacy.
The pharmacist should always bear the question of privacy in mind and, when possible, seek to create an atmosphere of confidentiality if sensitive problems are to be discussed. Using professional judgement and personal experience, the pharmacist can look for signs of hesitancy or embarrassment on the patient's part and can suggest moving to a quieter part of the pharmacy or to the consultation area to continue the conversation.
A patient group direction (PGD) is a legal framework to allow the safe supply of a medicine for specific patients. PGDs are widely used in the NHS and in some areas community pharmacies are commissioned to provide a service that may include one or more PGDs, the most common being stop smoking services, the supply of emergency hormonal contraception, and the provision of influenza vaccinations. PGDs can also be used in private sector services. Pharmacies providing NHS or private PGDs are required to meet specific criteria for quality and safety of services. Such requirements usually include demonstration of competencies and the keeping of certain records. The list below shows the range of PGDs that might be seen in community pharmacies.
Community pharmacists are the key gateway into the formal NHS through their filtering of symptoms, with referral to the GP surgery, the OOH service or the ED when necessary. This filtering is more correctly termed triaging and is increasingly important in maximising the skills and input of pharmacists and nurses.
Many community pharmacists are now working more closely with local GP practices and local healthcare organisations by participating in NHS minor ailment schemes. Scotland has had a national service with electronic records for several years, and there has been discussion about a national service in England. Currently in England and Wales, this is a locally-commissioned service decided upon by local healthcare organisations.
Some areas have policies to dissuade GPs from prescribing OTC medicines and require patients to buy these.
There is a great deal of scope for joint working in the area of OTC medicines. We suggest that pharmacists might consider the following steps:
Actions like these will help to improve communication, will increase GPs' and nurses' confidence in the contribution the pharmacist can make to patient care and will also support the pharmacist's integration into the primary care team. Patients will also appreciate this work and have greater confidence and understanding of pharmacists as part of their clinical support network.
This book is accompanied by a companion website:
www.wiley.com/go/Blenkinsopp/SymptomsPharmacy8e
The website includes:
- Multiple choice questions and answers for practice.