Undifferentiated Symptoms Practice Questions

Question 1

A 72-year-old man with chronic kidney disease stage 4 (eGFR 24 ml/min/1.73m²), type 2 diabetes, hypertension, and gout presents for medication review. His current medications include: metformin 1g twice daily, gliclazide 80mg twice daily, ramipril 10mg once daily, amlodipine 10mg once daily, aspirin 75mg once daily, atorvastatin 80mg once daily, allopurinol 100mg once daily, and omeprazole 20mg once daily. His HbA1c is 58 mmol/mol, and he reports intermittent episodes of feeling 'shaky and sweaty'. Which medication requires MOST urgent modification?

Accepted Answer

Metformin should be stopped immediately due to risk of lactic acidosis

Answer

Allopurinol should be increased to 300mg daily for adequate urate control

Answer

Ramipril should be reduced due to advanced chronic kidney disease

Answer

Gliclazide should be reviewed and reduced due to hypoglycaemia risk

Answer

Aspirin should be stopped as cardiovascular protection is inadequate at this dose

Question 2

According to the Beers Criteria for potentially inappropriate medication use in older adults, which of the following medications should be avoided in elderly patients regardless of diagnosis or condition?

Accepted Answer

Long-acting benzodiazepines such as diazepam and chlordiazepoxide

Answer

Non-selective beta-blockers in patients with peripheral vascular disease

Answer

First-generation antihistamines in patients with cognitive impairment

Answer

Proton pump inhibitors when used for longer than 8 weeks

Answer

Thiazide diuretics in patients with a history of gout

Question 3

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 4

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 5

Understanding the concept of 'diagnostic uncertainty' in managing undifferentiated symptoms in primary care involves recognizing that certain presentations cannot be immediately diagnosed. Which of the following statements best describes the evidence-based approach to managing diagnostic uncertainty?

Accepted Answer

Safety-netting with clear instructions for re-consultation if symptoms persist, worsen, or new features develop is an essential component of managing uncertainty

Answer

Immediate referral to secondary care is always appropriate when a diagnosis cannot be made in primary care to ensure patient safety

Answer

Extensive investigation should be undertaken immediately to exclude all possible serious diagnoses before adopting a watch-and-wait approach

Answer

Patients should be reassured that the absence of abnormal findings on initial tests means serious pathology is excluded and no follow-up is needed

Answer

Empirical treatment should be started for the most likely diagnosis to avoid delays in management

Question 6

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 7

A 66-year-old man with a 15-week history of fatigue and 8kg weight loss has been investigated extensively in primary care. Blood tests including FBC, U&E, LFT, TFT, calcium, glucose, CRP, and PSA are normal. Chest X-ray and abdominal ultrasound are unremarkable. He has no specific symptoms beyond fatigue and weight loss. His appetite is reduced but he has no dysphagia. He is a lifelong non-smoker. What is the most appropriate next step in management?

Accepted Answer

Request CT chest, abdomen and pelvis with contrast

Answer

Arrange colonoscopy under routine pathway as he is >60 years

Answer

Arrange urgent upper GI endoscopy under 2-week wait pathway

Answer

Refer to general surgery under 2-week wait for further assessment

Answer

Reassure and arrange review in 4 weeks with repeat blood tests

Question 8

A 41-year-old woman presents with a 15-week history of fatigue and 5kg weight loss. She reports heat intolerance and palpitations. Her grandmother had 'thyroid problems'. Examination shows pulse 96 bpm regular, BP 138/72 mmHg, fine tremor, and a smooth thyroid gland enlarged to twice normal size with an audible bruit. Blood tests show: TSH <0.01 mU/L, free T4 42 pmol/L, free T3 12.8 pmol/L. TSH receptor antibodies are strongly positive. What is the most important counselling point before initiating definitive treatment?

Accepted Answer

She must use reliable contraception and avoid pregnancy during and for 6 months after radioiodine treatment

Answer

Carbimazole may cause agranulocytosis and she should seek urgent medical attention if she develops a sore throat or fever

Answer

Radioiodine treatment is contraindicated in women of childbearing age due to long-term fertility effects

Answer

Thyroid surgery carries a high risk of recurrent laryngeal nerve damage causing permanent voice changes

Answer

Propranolol should not be used if she has a history of asthma or COPD

Question 9

A 62-year-old man presents with an 11-week history of intermittent fevers up to 38.6°C, night sweats, and 7kg weight loss. He has a 35-year history of Crohn's disease managed with adalimumab. Examination shows temperature 38.2°C, no lymphadenopathy, chest clear, abdomen soft with no masses. Blood tests show: Hb 102 g/L, WCC 11.2 × 10⁹/L, neutrophils 8.4 × 10⁹/L, CRP 78 mg/L. Chest X-ray is normal. Three sets of blood cultures are negative. What is the most appropriate next investigation?

Accepted Answer

CT chest, abdomen and pelvis with contrast

Answer

Colonoscopy with multiple biopsies

Answer

Faecal calprotectin and Crohn's disease activity index

Answer

Interferon-gamma release assay (IGRA) for tuberculosis

Answer

Transthoracic echocardiography

Question 10

A 48-year-old woman presents with a 16-week history of severe fatigue, widespread pain, and 4kg weight loss. She scores 7/10 on a pain scale and reports poor sleep with frequent waking. Examination shows multiple tender points on palpation but no synovitis or muscle weakness. Blood tests show: Hb 118 g/L, WCC 6.2 × 10⁹/L, ESR 8 mm/hr, CRP 3 mg/L, TSH 2.4 mU/L, calcium 2.38 mmol/L, vitamin D 28 nmol/L. She meets fibromyalgia diagnostic criteria. What feature most strongly suggests an alternative or additional diagnosis requires investigation?

Accepted Answer

The presence of unintentional weight loss

Answer

The elevated ESR relative to normal CRP

Answer

The vitamin D insufficiency

Answer

The severity of fatigue and sleep disturbance

Answer

The widespread pain with multiple tender points

Undifferentiated Symptoms

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Fever of unknown origin

Pain assessment in primary care

Weight loss and fatigue

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