Set 1: For each patient, select the most appropriate management option.
A. Start allopurinol at a high dose during the flare with no prophylaxis
B. Start long-term urate-lowering therapy after discussion, with flare prophylaxis and treat-to-target monitoring
C. Stop allopurinol permanently during every gout flare
D. Prescribe long-term diclofenac without gastroprotection
E. Treat as septic arthritis only if both knees are affected
F. Treat the acute flare with colchicine if suitable, considering renal function and interacting medicines
G. Give aspirin for acute gout pain
H. Reassure and provide no treatment because gout is self-limiting
1. A 63-year-old man has sudden severe pain, redness and swelling of his first metatarsophalangeal joint. He has chronic kidney disease stage 3, takes ramipril and apixaban, and has a previous NSAID-related gastrointestinal bleed. He has no fever and no spreading cellulitis.
Which option is most appropriate?
2. A 49-year-old man has had four gout flares in the last year. His serum urate remains high between attacks. He asks whether there is treatment to reduce future flares. He is not currently having an acute flare.
Which option is most appropriate?
Set 2: For each patient, select the most appropriate action.
A. Start oral bisphosphonate
B. Treat as mechanical back pain and review in 6 weeks
C. Start colchicine for 3 days
D. Emergency assessment for possible septic arthritis
E. Supply topical NSAID only
F. Start methotrexate
G. Emergency assessment for possible cauda equina syndrome
H. Recommend bed rest for 2 weeks
3. A 44-year-old man has severe lower back pain radiating down both legs. He reports new urinary retention, numbness around the saddle area and progressive leg weakness.
Which option is most appropriate?
4. A 71-year-old woman with diabetes has an acutely hot, swollen, very painful knee. She is febrile and unable to weight-bear. There is no history of trauma. She takes prednisolone for polymyalgia rheumatica.
Which option is most appropriate?
Set 3: For each patient, select the most appropriate pharmacist intervention.
A. Increase methotrexate dose immediately
B. Treat as osteoarthritis with paracetamol only
C. Urgent review for possible methotrexate toxicity and bone marrow suppression
D. Stop folic acid permanently
E. Reassure because mouth ulcers are expected and harmless
F. Recommend ibuprofen without assessment
G. Delay referral until symptoms have been present for 2 years
H. Urgent referral for suspected inflammatory arthritis
5. A 36-year-old woman has 9 weeks of symmetrical pain and swelling in the small joints of both hands. Morning stiffness lasts 90 minutes. Her symptoms are affecting work, and her mother has rheumatoid arthritis.
Which option is most appropriate?
6. A 59-year-old man with rheumatoid arthritis takes methotrexate 15 mg once weekly. He accidentally took 15 mg daily for 5 days and now has mouth ulcers, bruising and a sore throat.
Which option is most appropriate?
Set 4: For each patient, select the most appropriate option.
A. Stop bisphosphonate and arrange assessment for possible atypical femoral fracture
B. Take alendronate at bedtime with food
C. Start ibuprofen as bone protection
D. Delay osteoporosis treatment until a second fracture occurs
E. Offer oral alendronate if suitable, with administration counselling and calcium/vitamin D review
F. Start high-dose oral prednisolone
G. Reassure that bisphosphonates never cause adverse effects
H. Take alendronate with milk to reduce irritation
7. A 72-year-old woman has a low-trauma distal radius fracture. She has no swallowing difficulty, no severe renal impairment and no contraindication to oral bisphosphonate therapy. Her calcium and vitamin D status are being reviewed.
Which option is most appropriate?
8. A 76-year-old woman has taken alendronate for 8 years. She reports new persistent dull pain in her left thigh, worse on weight-bearing, without a fall or injury.
Which option is most appropriate?
Set 5: For each patient, select the most appropriate medicine-related action.
A. Add oral diclofenac to apixaban without review
B. Start long-term oral prednisolone for osteoarthritis pain
C. Avoid oral NSAID and review safer analgesic options because of renal/GI/cardiovascular risk
D. Recommend ibuprofen despite previous NSAID-induced asthma
E. Stop all pain relief permanently
F. Start methotrexate for acute mechanical back pain
G. Consider topical NSAID and non-pharmacological measures for localised osteoarthritis if suitable
H. Add aspirin for knee osteoarthritis pain
9. A 79-year-old man with knee osteoarthritis asks to buy naproxen. He takes ramipril, furosemide, apixaban and sertraline. He has stage 3 chronic kidney disease and a previous peptic ulcer bleed.
Which option is most appropriate?
10. A 64-year-old woman has localised hand osteoarthritis. She has hypertension, dyspepsia with oral NSAIDs and wants something to use on painful joints before gardening.
Which option is most appropriate?
Set 6: For each patient, select the most appropriate management option.
A. Treat with colchicine and review in 3 months
B. Emergency same-day assessment for possible giant cell arteritis
C. Reassure because visual symptoms are expected in polymyalgia
D. Start alendronate only
E. Stop prednisolone abruptly
F. Start oral iron
G. Treat as uncomplicated tension headache
H. Assess for polymyalgia rheumatica and consider corticosteroid treatment with monitoring and bone protection
11. A 74-year-old woman has new bilateral shoulder and hip girdle pain with morning stiffness lasting over an hour. She feels fatigued and struggles to get out of a chair. She has no headache, jaw pain or visual symptoms.
Which option is most appropriate?
12. A 78-year-old man with recent shoulder stiffness develops a new temporal headache, scalp tenderness, jaw pain while chewing and transient visual disturbance.
Which option is most appropriate?
Set 7: For each patient, select the most appropriate pharmacist action.
A. Start live vaccine immediately during biologic therapy
B. Ignore infection symptoms if arthritis is controlled
C. Stop all DMARDs permanently without specialist advice
D. Prescribe antibiotics for all patients taking biologics
E. Withhold biologic dose and arrange urgent clinical review for possible serious infection
F. Increase biologic dose during infection
G. Give intranasal live influenza vaccine routinely
H. Review vaccination status before biologic treatment and avoid live vaccines once significantly immunosuppressed unless specialist advice supports use
13. A 52-year-old woman with rheumatoid arthritis is due to start adalimumab. She asks whether vaccines matter because she “never gets infections”. Her records show incomplete pneumococcal and shingles vaccination history.
Which option is most appropriate?
14. A 60-year-old man taking etanercept for psoriatic arthritis develops fever, productive cough, shortness of breath and oxygen saturation of 92% on air.
Which option is most appropriate?
Set 8: For each patient, select the most likely diagnosis or action.
A. Treat as uncomplicated osteoarthritis only
B. Refer for suspected axial spondyloarthritis
C. Treat as gout without considering alternatives
D. Treat as simple muscle strain
E. Start oral fluconazole
F. Consider calcium pyrophosphate crystal arthritis and arrange clinical assessment
G. Start long-term benzodiazepine
H. Reassure because inflammatory back pain occurs only over age 70
15. A 29-year-old man has lower back pain for 8 months. It improves with exercise but not rest, wakes him in the second half of the night and is associated with alternating buttock pain. His father has ankylosing spondylitis.
Which option is most appropriate?
16. An 82-year-old woman has an acutely painful swollen wrist. X-ray from a previous episode showed chondrocalcinosis. Serum urate is normal. She has chronic kidney disease and takes apixaban.
Which option is most appropriate?
Set 9: For each patient, select the most appropriate pharmacist contribution.
A. Counsel on hydroxychloroquine adherence, retinal monitoring and red-flag visual symptoms
B. Stop hydroxychloroquine because it is never used long term
C. Add ibuprofen without considering renal disease
D. Increase steroid dose without review
E. Treat chest pain in lupus as anxiety only
F. Urgent assessment for possible serious lupus complication or thromboembolism
G. Reassure because pregnancy planning is irrelevant in lupus
H. Avoid all vaccines permanently
17. A 43-year-old woman with systemic lupus erythematosus takes hydroxychloroquine. She asks why she needs eye checks when her arthritis symptoms are controlled.
Which option is most appropriate?
18. A 34-year-old woman with lupus and antiphospholipid syndrome develops sudden pleuritic chest pain, breathlessness and haemoptysis. She recently stopped warfarin for a procedure.
Which option is most appropriate?
Set 10: For each patient, select the most appropriate management option.
A. Assess fracture risk, consider bone protection and counsel on steroid adverse effects
B. Stop prednisolone abruptly after several months
C. Reassure that inhaled and oral steroids have identical systemic risks
D. Discuss adrenal suppression risk and need for gradual withdrawal/clinical review
E. Give live vaccine without checking immunosuppression status
F. Use NSAID gastroprotection only and ignore bones
G. Increase steroid dose for insomnia
H. Stop calcium and vitamin D automatically
19. A 69-year-old woman is prescribed prednisolone 15 mg daily for at least 4 months for inflammatory disease. She has a previous fragility fracture and low body weight.
Which option is most appropriate?
20. A 57-year-old man has taken prednisolone 30 mg daily for 9 weeks. He wants to stop immediately because of mood changes, poor sleep and increased appetite.
Which option is most appropriate?
Answers and Rationale
1. F
The presentation is typical of acute gout, but NSAIDs are high risk due to CKD, apixaban and previous GI bleeding. Colchicine may be suitable if renal function, dose and interacting medicines are carefully considered.
2. B
Frequent gout flares and persistently high urate are indications to discuss urate-lowering therapy. This should include treat-to-target urate monitoring and flare prophylaxis when starting treatment.
3. G
Bilateral sciatica, urinary retention, saddle numbness and progressive leg weakness are red flags for cauda equina syndrome. This needs emergency assessment.
4. D
A hot swollen joint with fever, inability to weight-bear, diabetes and steroid use suggests septic arthritis until proven otherwise. This is an emergency because joint destruction and sepsis can develop rapidly.
5. H
Symmetrical small-joint swelling with prolonged morning stiffness suggests inflammatory arthritis. Early referral is important because prompt DMARD treatment improves outcomes.
6. C
Daily methotrexate dosing is a serious medication error. Mouth ulcers, bruising and sore throat suggest mucositis and possible bone marrow suppression, requiring urgent clinical review and blood tests.
7. E
After a low-trauma fracture, osteoporosis treatment should be considered. Oral alendronate is suitable if there are no contraindications, with counselling on administration and calcium/vitamin D optimisation.
8. A
Persistent thigh or groin pain in a long-term bisphosphonate user may indicate an atypical femoral fracture. The bisphosphonate should be withheld and urgent assessment arranged.
9. C
This patient has multiple NSAID risk factors: CKD, ACE inhibitor, diuretic, anticoagulant, SSRI and previous GI bleed. Oral NSAIDs should be avoided unless there is a compelling reason and specialist oversight.
10. G
For localised osteoarthritis, topical NSAIDs can provide local benefit with less systemic exposure than oral NSAIDs. Non-drug measures and hand function support should also be considered.
11. H
Bilateral shoulder and hip girdle pain with prolonged morning stiffness in an older adult suggests polymyalgia rheumatica. Corticosteroid treatment may be needed, alongside monitoring and bone protection considerations.
12. B
New temporal headache, scalp tenderness, jaw claudication and visual disturbance suggest giant cell arteritis. This requires same-day emergency assessment to reduce risk of permanent visual loss.
13. H
Before biologic therapy, vaccination status should be reviewed and optimised where possible. Live vaccines are generally avoided once significantly immunosuppressed unless specialist guidance supports use.
14. E
Fever, productive cough, breathlessness and reduced oxygen saturation in a patient taking a biologic may indicate serious infection. The biologic should be withheld and urgent clinical review arranged.
15. B
Back pain that improves with exercise, not rest, wakes the patient at night and is associated with alternating buttock pain suggests inflammatory back pain. Family history increases suspicion for axial spondyloarthritis.
16. F
An acutely swollen wrist with chondrocalcinosis and normal urate suggests calcium pyrophosphate crystal arthritis. NSAID choice is complicated by CKD and apixaban, so clinical assessment is needed.
17. A
Hydroxychloroquine can rarely cause retinal toxicity, especially with long-term use or higher risk factors. Patients need adherence support, retinal monitoring and advice to report visual symptoms.
18. F
Lupus with antiphospholipid syndrome and recent warfarin interruption increases thromboembolic risk. Sudden pleuritic chest pain, breathlessness and haemoptysis need urgent assessment for possible pulmonary embolism or other serious complication.
19. A
Longer-term systemic corticosteroids increase fracture risk, especially with previous fragility fracture and low body weight. Fracture risk assessment, bone protection and adverse-effect counselling are needed.
20. D
Stopping systemic corticosteroids abruptly after several weeks can cause adrenal insufficiency and disease relapse. Gradual withdrawal and clinical review are needed, especially after high-dose therapy.
Here are 20 extended matching questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.