Chronic Disease Management Practice Questions

Question 1

During a practice audit of patients over 75 years taking 10 or more regular medications, you identify several patients who would benefit from structured medication reviews. You are prioritising which patients to review first based on risk stratification. According to best practice guidance on medication reviews in primary care, which patient characteristic indicates HIGHEST priority for urgent structured medication review?

Accepted Answer

A patient recently discharged from hospital with five new medications added to their existing regimen

Answer

A patient taking 15 medications who has been stable on the same regimen for 3 years with no recent adverse events

Answer

A patient taking multiple high-risk medications including warfarin, methotrexate, and lithium who attends regular monitoring

Answer

A patient who has reached the age of 75 and is now eligible for routine medication review under the Quality and Outcomes Framework

Answer

A patient with declining renal function (eGFR decreased from 68 to 54 over 12 months) taking eight regular medications

Question 2

A 35-year-old woman presents with a 10-week history of severe fatigue, aching limbs, and subjective fever. She works as a veterinary nurse. She reports a flu-like illness that never fully resolved. Examination shows temperature 37.8°C, no rash or lymphadenopathy. Blood tests show: Hb 128 g/L, WCC 3.8 × 10⁹/L (lymphocytes 1.2 × 10⁹/L), platelets 156 × 10⁹/L, CRP 12 mg/L, ALT 124 U/L, AST 96 U/L. Blood film shows atypical lymphocytes. Monospot test is negative. What is the most appropriate next investigation?

Accepted Answer

Serology for Coxiella burnetii (Q fever)

Answer

HIV antibody and antigen test

Answer

EBV serology (IgM and IgG)

Answer

CMV serology (IgM and IgG)

Answer

Toxoplasma serology

Question 3

A 74-year-old man attends for medication review. He has heart failure (LVEF 32%), atrial fibrillation, type 2 diabetes, stage 3b CKD (eGFR 36 ml/min/1.73m²), and benign prostatic hyperplasia. Current medications: bisoprolol 10mg, ramipril 10mg, furosemide 40mg, spironolactone 25mg, apixaban 5mg twice daily, metformin 1g twice daily, empagliflozin 10mg, finasteride 5mg, tamsulosin 400mcg, atorvastatin 80mg. Blood tests show potassium 5.4 mmol/L, sodium 134 mmol/L, urea 12.8 mmol/L, creatinine 168 μmol/L (stable). He reports good symptom control but occasional dizziness on standing. Which represents the BEST management approach?

Accepted Answer

Continue current regimen with close monitoring as benefits outweigh risks

Answer

Stop spironolactone due to hyperkalaemia risk and continue other heart failure medications

Answer

Reduce ramipril to 5mg daily to decrease potassium and improve renal function

Answer

Stop empagliflozin as it may be contributing to hyperkalaemia and renal impairment

Answer

Stop tamsulosin as it may be causing orthostatic hypotension and reduce polypharmacy

Question 4

A 75-year-old man with COPD (post-bronchodilator FEV1 42% predicted), ischaemic heart disease, atrial fibrillation, and type 2 diabetes attends for medication review. He is on multiple inhalers: tiotropium, salmeterol/fluticasone 25/250 twice daily, and salbutamol as needed. Other medications include apixaban, bisoprolol, ramipril, atorvastatin, and metformin. He has had two exacerbations requiring oral steroids in the past year, the last one being 8 months ago. His current COPD symptoms are well-controlled with no exacerbations recently. Sputum cultures from his last exacerbation grew Pseudomonas aeruginosa. Which change to his inhaler therapy is MOST appropriate?

Accepted Answer

Switch from salmeterol/fluticasone to a triple therapy inhaler (LABA/LAMA/ICS combination)

Answer

Add a regular azithromycin prophylaxis regimen due to previous Pseudomonas infection

Answer

Stop inhaled corticosteroids and continue bronchodilators only, given limited recent exacerbations

Answer

Reduce fluticasone dose to minimise steroid-related adverse effects including pneumonia risk

Answer

Add regular nebulised colistin for Pseudomonas suppression in COPD

Question 5

You are conducting a structured medication review for an 80-year-old man with heart failure (NYHA class II), type 2 diabetes, chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²), and benign prostatic hyperplasia. He lives alone and manages his medications independently using a dosette box filled by his daughter. He takes 13 different medications at various times throughout the day. He mentions he sometimes forgets his evening doses and finds the regimen 'complicated'. Which approach BEST addresses medication adherence in this context according to principles of medicines optimisation?

Accepted Answer

Simplify the regimen by switching to once-daily preparations where possible and aligning administration times

Answer

Arrange for a district nurse to visit twice daily to supervise medication administration

Answer

Provide detailed written instructions about each medication and the importance of adherence

Answer

Reduce the total number of medications by stopping those not providing immediate symptom relief

Answer

Arrange urgent assessment of his cognitive function as non-adherence suggests early dementia

Question 6

A 70-year-old woman with rheumatoid arthritis, osteoporosis, hypertension, and gastro-oesophageal reflux disease attends for review. She takes: methotrexate 15mg weekly, folic acid 5mg weekly (taken day after methotrexate), prednisolone 5mg daily, alendronic acid 70mg weekly, omeprazole 20mg daily, amlodipine 10mg daily, and calcium/vitamin D daily. Blood tests show: Hb 102 g/L (MCV 88 fL), WCC 3.8 × 10⁹/L, platelets 156 × 10⁹/L, ALT 68 U/L (previously 32), eGFR 58 ml/min/1.73m². Which aspect of her medication regimen requires MOST urgent attention?

Accepted Answer

The elevated ALT indicating methotrexate hepatotoxicity requiring dose reduction or cessation

Answer

The alendronic acid and omeprazole combination reducing bisphosphonate absorption

Answer

The low haemoglobin suggesting methotrexate-induced bone marrow suppression requiring urgent cessation

Answer

The combination of prednisolone and alendronic acid requiring additional osteoporosis monitoring

Answer

The declining renal function requiring methotrexate dose adjustment or alternative DMARD

Question 7

A practice pharmacist is conducting a quality improvement project on anticholinergic burden in elderly patients with multimorbidity. She identifies a 73-year-old man taking 12 medications with a total Anticholinergic Cognitive Burden (ACB) score of 6. His medications include amitriptyline 50mg nocte for neuropathic pain, tolterodine 4mg for overactive bladder, lansoprazole 30mg, co-codamol 30/500, atorvastatin, ramipril, bisoprolol, aspirin, and metformin. He reports feeling 'foggy-headed' and has had two falls. Which intervention would have the GREATEST impact on reducing anticholinergic burden?

Accepted Answer

Address both amitriptyline and tolterodine simultaneously by switching to alternatives

Answer

Switch tolterodine to mirabegron, a beta-3 agonist with no anticholinergic activity

Answer

Replace amitriptyline with duloxetine for neuropathic pain management

Answer

Stop lansoprazole as proton pump inhibitors contribute to cognitive impairment

Answer

Reduce co-codamol dose as opioids can contribute to cognitive impairment

Question 8

A 76-year-old woman with dementia (MMSE 18/30), Parkinson's disease, type 2 diabetes, and recurrent falls is brought by her daughter for medication review. Current medications include: co-careldopa 25/100 three times daily, ropinirole 8mg three times daily, quetiapine 25mg twice daily, metformin 500mg twice daily, gliclazide 40mg twice daily, alendronic acid 70mg weekly, calcium/vitamin D, and PRN paracetamol. She has had three falls in the past two months. Her daughter reports increasing confusion and hallucinations. Blood glucose monitoring shows values between 4.8-8.2 mmol/L. Which medication intervention should be prioritised?

Accepted Answer

Reduce ropinirole as dopamine agonists cause hallucinations and should be withdrawn first

Answer

Reduce co-careldopa dose as dopaminergic medications contribute to hallucinations and falls

Answer

Stop quetiapine immediately as antipsychotics worsen Parkinson's disease motor symptoms

Answer

Review and rationalise diabetes medications given risk of hypoglycaemia contributing to falls

Answer

Stop alendronic acid as bisphosphonates increase fall risk in elderly patients

Question 9

A 68-year-old man with ischaemic heart disease, permanent atrial fibrillation, type 2 diabetes, and osteoarthritis takes: aspirin 75mg, apixaban 5mg twice daily, bisoprolol 5mg, atorvastatin 80mg, metformin 1g twice daily, gliclazide 80mg twice daily, and paracetamol as required. He has no history of stenting or acute coronary syndrome in the past 12 months. His most recent echocardiogram shows LVEF 55% with no wall motion abnormalities. His CHA₂DS₂-VASc score is 5. Which medication change is MOST appropriate?

Accepted Answer

Stop aspirin as dual antiplatelet and anticoagulation increases bleeding risk without additional benefit

Answer

Stop apixaban and continue aspirin alone for cardiovascular protection

Answer

Continue both medications as dual therapy is indicated in atrial fibrillation with ischaemic heart disease

Answer

Stop both aspirin and apixaban and commence warfarin for better control

Answer

Reduce apixaban to 2.5mg twice daily when used in combination with aspirin

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