1. A 67-year-old woman has gradually worsening knee pain that is worse on activity and improves with rest. She has morning stiffness lasting less than 20 minutes and crepitus on movement. She has no joint swelling, fever or systemic symptoms.
Which ONE of the following is the most appropriate initial management approach?
A. Start long-term oral prednisolone.
B. Refer urgently for suspected septic arthritis.
C. Offer education, exercise advice and consider topical NSAID treatment if analgesia is needed.
D. Start allopurinol.
E. Begin methotrexate immediately.
2. A 72-year-old man presents with a 12-hour history of a hot, swollen, painful knee. He is febrile and unable to weight-bear. He has type 2 diabetes and recently had a corticosteroid injection into the joint.
Which ONE of the following is the most appropriate action?
A. Treat as osteoarthritis and recommend topical ibuprofen.
B. Start allopurinol and review in 4 weeks.
C. Recommend rest and oral paracetamol only.
D. Diagnose gout without further assessment.
E. Arrange urgent hospital assessment for possible septic arthritis.
3. A 69-year-old man with chronic kidney disease stage 4 presents with an acute gout flare affecting his first metatarsophalangeal joint. He has a history of peptic ulcer bleeding and takes apixaban for atrial fibrillation.
Which ONE of the following is the most appropriate treatment consideration?
A. Consider a short course of oral corticosteroid after clinical assessment, as NSAIDs and colchicine may be unsuitable.
B. Start high-dose ibuprofen without gastroprotection.
C. Start allopurinol at a high dose to treat the flare immediately.
D. Use aspirin as first-line flare treatment.
E. Delay all treatment until serum urate is repeated in 6 months.
4. A 58-year-old man with established gout takes allopurinol 300 mg once daily. He develops an acute gout flare after a weekend of heavy alcohol intake. He asks whether he should stop allopurinol until the flare settles.
Which ONE of the following is the most appropriate advice?
A. Stop allopurinol permanently.
B. Double the allopurinol dose during the flare.
C. Take allopurinol only when the joint is painful.
D. Continue allopurinol and treat the acute flare appropriately.
E. Replace allopurinol with aspirin.
5. A 61-year-old woman with rheumatoid arthritis has accidentally taken methotrexate 15 mg daily for 5 days instead of once weekly. She reports mouth ulcers and nausea.
Which ONE of the following is the most appropriate pharmacist action?
A. Reassure her and advise continuing daily dosing.
B. Arrange urgent medical assessment for possible methotrexate toxicity.
C. Advise taking folic acid only and waiting for the next clinic appointment.
D. Suggest increasing the methotrexate dose.
E. Treat symptoms as uncomplicated reflux.
6. A 54-year-old man taking methotrexate for rheumatoid arthritis contacts the pharmacy with fever, sore throat and mouth ulcers. He had blood monitoring 6 weeks ago but missed his most recent test.
Which ONE of the following is the most appropriate advice?
A. Continue methotrexate and book routine bloods next month.
B. Increase folic acid and continue methotrexate unchanged.
C. Take ibuprofen and monitor symptoms at home.
D. Skip the next dose only if symptoms persist for 2 weeks.
E. Seek urgent medical assessment because of possible infection or bone marrow suppression.
7. A 43-year-old woman has symmetrical pain, swelling and stiffness affecting the small joints of both hands for 10 weeks. Morning stiffness lasts over 1 hour and inflammatory markers are raised.
Which ONE of the following is the most appropriate action?
A. Refer urgently for specialist assessment of suspected inflammatory arthritis.
B. Diagnose osteoarthritis and supply topical NSAID only.
C. Reassure because rheumatoid arthritis affects only older adults.
D. Start long-term oral prednisolone without review.
E. Delay referral until symptoms have been present for 2 years.
8. A 52-year-old woman recently started methotrexate for rheumatoid arthritis. After 3 weeks she reports no major improvement and asks whether treatment has failed.
Which ONE of the following is the most appropriate advice?
A. Stop methotrexate immediately because it should work within 48 hours.
B. Take methotrexate only when joints are painful.
C. Replace methotrexate with long-term antibiotics.
D. Continue as advised because DMARDs may take several weeks to months to show full benefit.
E. Double the dose without specialist advice.
9. A 31-year-old woman with rheumatoid arthritis is taking leflunomide. She tells you she is planning a pregnancy.
Which ONE of the following is the most appropriate pharmacist action?
A. Reassure her that leflunomide is safe throughout pregnancy.
B. Advise urgent specialist review because leflunomide is teratogenic and may require a washout procedure.
C. Recommend stopping contraception only after the next dose.
D. Suggest taking folic acid alone without informing the specialist team.
E. Switch to methotrexate for pregnancy planning.
10. A 60-year-old woman has been taking hydroxychloroquine for inflammatory arthritis for several years. She asks why she has been invited for eye screening.
Which ONE of the following is the most appropriate explanation?
A. Hydroxychloroquine commonly causes cataracts within days.
B. Eye screening replaces blood monitoring for all DMARDs.
C. Long-term hydroxychloroquine can rarely cause retinal toxicity, so screening helps detect early changes.
D. Screening is needed because hydroxychloroquine causes acute glaucoma in all patients.
E. Screening is only required if the dose is missed.
11. A 78-year-old woman with osteoarthritis asks for oral ibuprofen. She takes apixaban for atrial fibrillation and ramipril for hypertension. She has a history of peptic ulcer disease.
Which ONE of the following is the most appropriate pharmacist action?
A. Recommend high-dose ibuprofen regularly for 4 weeks.
B. Advise ibuprofen is safe because she is already anticoagulated.
C. Suggest taking ibuprofen with alcohol to reduce stomach irritation.
D. Avoid routine oral NSAID supply and review safer analgesic options or prescriber input.
E. Recommend aspirin as a safer anti-inflammatory.
12. A 71-year-old man has localised knee osteoarthritis. He has hypertension, chronic kidney disease stage 3 and a previous gastrointestinal bleed. He asks about pain relief.
Which ONE of the following is the most appropriate initial pharmacological option to consider?
A. Topical NSAID applied to the affected knee.
B. Regular high-dose oral diclofenac.
C. Long-term oral prednisolone.
D. Methotrexate.
E. Allopurinol.
13. A 46-year-old man presents with acute low back pain after lifting at work. He also reports new urinary retention and numbness around the saddle area.
Which ONE of the following is the most appropriate action?
A. Recommend stretching and review in 6 weeks.
B. Supply codeine and advise bed rest.
C. Treat as uncomplicated mechanical back pain.
D. Refer routinely to physiotherapy.
E. Arrange emergency assessment for possible cauda equina syndrome.
14. A 28-year-old man has chronic lower back pain and stiffness for 8 months. Symptoms are worse at night, improve with exercise and do not improve with rest. He also has alternating buttock pain.
Which ONE of the following diagnosis should be considered?
A. Acute gout.
B. Osteoarthritis of the knee.
C. Axial spondyloarthritis.
D. Septic arthritis.
E. Tennis elbow.
15. A 72-year-old woman develops bilateral shoulder and hip girdle pain with morning stiffness lasting over 1 hour. She feels generally unwell and inflammatory markers are raised.
Which ONE of the following is the most likely diagnosis?
A. Osteoarthritis.
B. Polymyalgia rheumatica.
C. Fibromyalgia.
D. Acute gout.
E. Carpal tunnel syndrome.
16. A 74-year-old woman presents with new severe temporal headache, jaw pain when chewing and blurred vision. She also has shoulder stiffness and raised inflammatory markers.
Which ONE of the following is the most appropriate action?
A. Recommend topical NSAID.
B. Treat as migraine and review in 2 weeks.
C. Start allopurinol.
D. Arrange same-day urgent assessment for suspected giant cell arteritis.
E. Supply oral iron.
17. A 76-year-old woman is prescribed alendronic acid once weekly after a fragility fracture. She asks how to take it.
Which ONE of the following advice is most appropriate?
A. Take it first thing in the morning with a full glass of water and remain upright afterwards.
B. Take it at bedtime with milk.
C. Crush it and mix with yoghurt.
D. Take it with calcium tablets at the same time.
E. Take it only when bone pain occurs.
18. A 68-year-old woman taking alendronic acid is due to have several dental extractions. She is worried about jaw problems after reading online.
Which ONE of the following is the most appropriate pharmacist advice?
A. Stop alendronic acid permanently without telling anyone.
B. Avoid all dental treatment.
C. Double calcium intake for 1 week.
D. Continue without mentioning bisphosphonate therapy to the dentist.
E. Ensure the dentist and prescriber are aware, and discuss individual risk and dental management.
19. A 73-year-old woman has taken alendronic acid for 7 years. She reports new dull pain in her thigh and groin that has gradually worsened over several weeks.
Which ONE of the following is the most appropriate concern?
A. Acute gout flare.
B. Methotrexate toxicity.
C. Possible atypical femoral fracture requiring clinical assessment.
D. Carpal tunnel syndrome.
E. Fibromyalgia.
20. A 70-year-old woman takes alendronic acid once weekly and calcium carbonate twice daily. She asks whether she can take all her tablets together at breakfast.
Which ONE of the following is the most appropriate advice?
A. Take calcium and alendronic acid together to improve absorption.
B. Separate calcium from alendronic acid because calcium reduces bisphosphonate absorption.
C. Take alendronic acid with orange juice and calcium.
D. Crush both tablets together.
E. Take alendronic acid only after meals.
21. An 82-year-old woman falls from standing height and sustains a hip fracture. She has not previously had a fracture risk assessment.
Which ONE of the following is the most appropriate pharmacist contribution after acute management?
A. Reassure that low-trauma hip fractures are unrelated to osteoporosis.
B. Recommend stopping vitamin D permanently.
C. Advise that fracture risk assessment is unnecessary after age 80.
D. Suggest NSAIDs alone for bone protection.
E. Ensure osteoporosis and falls risk assessment are considered to reduce future fracture risk.
22. A 77-year-old woman receives denosumab for osteoporosis. She missed her planned injection several months ago because she felt well.
Which ONE of the following is the most appropriate concern?
A. Missing denosumab has no clinical relevance.
B. Denosumab can be stopped at any time without planning.
C. Delayed or stopped denosumab may increase rebound vertebral fracture risk and should be reviewed.
D. Denosumab only works if taken orally.
E. Denosumab should be replaced with aspirin.
23. A 69-year-old man has started long-term prednisolone for an inflammatory condition. He has additional risk factors for osteoporosis.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Recommend assessment of fracture risk and need for bone protection.
B. Reassure that corticosteroids strengthen bone.
C. Advise avoiding calcium-containing foods.
D. Stop prednisolone abruptly.
E. Recommend long-term bed rest.
24. A 56-year-old man presents with a sudden painful, red, swollen first metatarsophalangeal joint. He has had similar attacks previously and gout is suspected. He has normal renal function and no major contraindications.
Which ONE of the following treatment options may be appropriate for the acute flare?
A. Allopurinol dose escalation only.
B. NSAID, colchicine or short-course oral corticosteroid, selected according to comorbidities and co-prescriptions.
C. Methotrexate.
D. Alendronic acid.
E. Hydroxychloroquine.
25. A 62-year-old man has recurrent gout attacks and serum urate remains above target. Allopurinol is being initiated.
Which ONE of the following counselling points is most appropriate?
A. Start at the maximum dose immediately.
B. Use allopurinol only during painful attacks.
C. Stop allopurinol once serum urate first improves.
D. Start at a low dose and titrate according to serum urate and tolerability.
E. Allopurinol gives immediate pain relief during flares.
26. A 74-year-old man with gout is prescribed colchicine. He has chronic kidney disease and is also prescribed clarithromycin for pneumonia.
Which ONE of the following is the most appropriate pharmacist action?
A. Query the combination because colchicine toxicity risk is increased by renal impairment and interacting medicines.
B. Advise doubling colchicine to overcome interaction.
C. Reassure that colchicine has no interactions.
D. Add simvastatin to prevent gout flares.
E. Take colchicine daily indefinitely without monitoring.
27. A 69-year-old woman with knee osteoarthritis asks for stronger pain relief after using paracetamol intermittently. She has mild pain at rest and worse pain on stairs. She has not tried exercise or topical NSAIDs.
Which ONE of the following is the most appropriate approach?
A. Start strong opioids as first-line long-term therapy.
B. Recommend long-term oral prednisolone.
C. Refer immediately for joint replacement without conservative treatment.
D. Start methotrexate.
E. Optimise non-pharmacological measures and consider topical NSAID before escalating to higher-risk analgesia.
28. A 51-year-old man with rheumatoid arthritis is about to start adalimumab. He asks why he needs screening before treatment.
Which ONE of the following is the most appropriate explanation?
A. Screening is only needed for patients taking paracetamol.
B. Biologics prevent all infections.
C. Screening helps identify infections such as tuberculosis or hepatitis before immunosuppression.
D. Screening replaces all future monitoring.
E. Adalimumab is not an immunosuppressant.
29. A 46-year-old woman taking a biologic DMARD for rheumatoid arthritis asks whether she can receive a live travel vaccine next week.
Which ONE of the following is the most appropriate advice?
A. Live vaccines are always safe with biologic therapy.
B. Double the vaccine dose to improve response.
C. Stop the biologic for one day and vaccinate.
D. Seek specialist advice because live vaccines may be contraindicated during biologic immunosuppression.
E. Use antibiotics instead of vaccination.
30. A 35-year-old woman taking sulfasalazine for inflammatory arthritis notices her urine has become orange-yellow. She has no dysuria, fever or flank pain.
Which ONE of the following is the most appropriate advice?
A. Stop sulfasalazine permanently.
B. Explain that sulfasalazine can harmlessly discolour urine, but assess for other symptoms if present.
C. Treat as pyelonephritis.
D. Start nitrofurantoin immediately.
E. Diagnose haematuria without assessment.
31. A 58-year-old man taking methotrexate for rheumatoid arthritis asks why he also takes folic acid once weekly.
Which ONE of the following is the most appropriate explanation?
A. Folic acid increases methotrexate toxicity.
B. Folic acid helps reduce some methotrexate adverse effects.
C. Folic acid replaces blood monitoring.
D. Folic acid is used to treat acute joint pain.
E. Folic acid prevents all infections.
32. A patient has been prescribed methotrexate 15 mg once weekly. The hospital letter states she should take it every Monday. She asks whether she can split the tablets across the week to reduce nausea.
Which ONE of the following is the most appropriate pharmacist response?
A. Take one tablet every day until the supply finishes.
B. Take the weekly dose whenever pain is worse.
C. Stop folic acid if nausea occurs.
D. Confirm methotrexate is usually taken once weekly and discuss nausea management with the prescriber before changing the regimen.
E. Replace methotrexate with ibuprofen.
33. A 74-year-old man with osteoarthritis takes ramipril and bendroflumethiazide. He asks to buy regular ibuprofen for worsening knee pain.
Which ONE of the following is the most appropriate concern?
A. NSAIDs with ACE inhibitors and diuretics can increase acute kidney injury risk.
B. Ibuprofen improves renal perfusion in this combination.
C. NSAIDs prevent hypertension.
D. Ibuprofen should always be combined with another NSAID.
E. Diuretics remove all NSAID risk.
34. A 63-year-old woman with psoriasis reports swollen painful fingers, morning stiffness and nail pitting. She has no previous diagnosis of inflammatory arthritis.
Which ONE of the following is the most appropriate action?
A. Treat as osteoarthritis only.
B. Supply topical antifungal nail treatment and ignore joint symptoms.
C. Start allopurinol without review.
D. Recommend long-term oral corticosteroids without referral.
E. Refer for assessment of possible psoriatic arthritis.
35. A 39-year-old woman with systemic lupus erythematosus takes hydroxychloroquine. She develops new pleuritic chest pain, shortness of breath and unilateral leg swelling after a long-haul flight.
Which ONE of the following is the most appropriate action?
A. Treat as a mild lupus rash.
B. Increase hydroxychloroquine dose.
C. Arrange urgent assessment for possible venous thromboembolism.
D. Recommend topical NSAID.
E. Reassure because lupus protects against clotting.
36. A 44-year-old woman has widespread musculoskeletal pain, fatigue and poor sleep for 18 months. Inflammatory markers, thyroid function and autoimmune screening are normal. She has no joint swelling.
Which ONE of the following is the most likely diagnosis?
A. Septic arthritis.
B. Acute gout.
C. Osteomyelitis.
D. Fibromyalgia.
E. Giant cell arteritis.
37. A 70-year-old woman falls onto her outstretched hand and develops wrist pain, swelling and deformity. She has a history of osteoporosis.
Which ONE of the following is the most appropriate action?
A. Treat as uncomplicated osteoarthritis.
B. Arrange same-day assessment for possible fracture.
C. Recommend topical NSAID only and review in 2 months.
D. Start methotrexate.
E. Advise immediate resistance training using the wrist.
38. A 65-year-old man taking prednisolone for polymyalgia rheumatica is prescribed ciprofloxacin for a urinary infection. He reports new Achilles tendon pain after 3 days.
Which ONE of the following is the most appropriate concern?
A. Fluoroquinolone-associated tendinopathy or tendon rupture risk.
B. Methotrexate toxicity.
C. Alendronate-induced oesophagitis.
D. Hyperthyroidism.
E. Fibromyalgia flare.
39. A 61-year-old man with diabetes presents with a painful swollen foot, a deep ulcer and fever. The ulcer probes close to bone.
Which ONE of the following is the most appropriate action?
A. Supply antifungal cream and review in 4 weeks.
B. Treat as uncomplicated gout.
C. Recommend extra walking.
D. Provide topical ibuprofen.
E. Arrange urgent assessment for possible infected diabetic foot ulcer or osteomyelitis.
40. A 57-year-old man has a serum urate above the reference range but has never had gout, kidney stones or urate-related symptoms.
Which ONE of the following is the most appropriate interpretation?
A. Allopurinol must always be started immediately.
B. Hyperuricaemia alone confirms gout.
C. Asymptomatic hyperuricaemia does not automatically require urate-lowering therapy.
D. Acute colchicine is required indefinitely.
E. NSAIDs should be taken lifelong.
41. A 49-year-old man has recurrent gout flares and is starting allopurinol. His prescriber also supplies colchicine for the first few months.
Which ONE of the following is the best explanation?
A. Flare prophylaxis can reduce the risk of gout attacks when urate-lowering therapy is started.
B. Colchicine lowers serum urate more effectively than allopurinol.
C. Colchicine prevents allopurinol hypersensitivity.
D. Colchicine replaces the need for dose titration.
E. Colchicine cures gout after one dose.
42. A 63-year-old woman with knee osteoarthritis is worried that exercise will “wear the joint out”. She has pain on stairs but no red flags.
Which ONE of the following is the most appropriate advice?
A. Avoid exercise completely.
B. Use bed rest whenever pain occurs.
C. Therapeutic exercise can improve pain and function and should be encouraged within tolerance.
D. Exercise is useful only after joint replacement.
E. Exercise should be replaced by long-term opioids.
43. A 55-year-old man on etanercept for rheumatoid arthritis develops fever, productive cough and shortness of breath.
Which ONE of the following is the most appropriate advice?
A. Continue etanercept and wait until the next routine clinic appointment.
B. Take an extra dose of etanercept to reduce inflammation.
C. Treat symptoms only with cough sweets.
D. Start a live vaccine.
E. Seek urgent clinical advice because biologic therapy can increase infection risk.
44. A 62-year-old woman taking leflunomide has routine monitoring showing significantly raised liver enzymes. She feels well.
Which ONE of the following is the most appropriate pharmacist action?
A. Reassure because monitoring results do not matter if she feels well.
B. Escalate for clinical review because DMARD-related hepatotoxicity is possible.
C. Advise taking alcohol to confirm the result.
D. Increase the leflunomide dose.
E. Stop all monitoring permanently.
45. A 78-year-old woman with osteoporosis and eGFR 22 mL/min/1.73 m² is prescribed oral alendronic acid. She has difficulty swallowing tablets and reflux symptoms.
Which ONE of the following is the most appropriate pharmacist action?
A. Advise crushing alendronic acid.
B. Recommend taking it with milk at bedtime.
C. Confirm supply because bisphosphonates have no renal or administration cautions.
D. Query suitability because renal function and swallowing difficulties may affect treatment choice.
E. Replace with ibuprofen.
46. An 80-year-old man develops sudden swelling and pain in his knee. Joint aspiration shows calcium pyrophosphate crystals.
Which ONE of the following is the most likely diagnosis?
A. Rheumatoid arthritis.
B. Osteoarthritis.
C. Acute calcium pyrophosphate crystal arthritis.
D. Fibromyalgia.
E. Polymyalgia rheumatica.
47. A 6-year-old child has fever, severe hip pain and refuses to walk. The hip is held flexed and movement is very painful.
Which ONE of the following is the most appropriate action?
A. Arrange urgent hospital assessment for possible septic arthritis.
B. Recommend paracetamol and review in 2 weeks.
C. Treat as growing pains.
D. Advise school attendance as normal.
E. Start allopurinol.
48. A 52-year-old woman with diabetes has gradually worsening shoulder stiffness and pain. She has difficulty combing her hair and fastening her bra. There is global restriction of both active and passive movement.
Which ONE of the following is the most likely diagnosis?
A. Tennis elbow.
B. Frozen shoulder.
C. Acute gout.
D. Carpal tunnel syndrome.
E. Septic arthritis.
49. A 69-year-old woman has diffuse bone pain, proximal muscle weakness and difficulty climbing stairs. She rarely goes outside and has a very low vitamin D level.
Which ONE of the following is the most appropriate treatment consideration?
A. Allopurinol.
B. Methotrexate.
C. Long-term ciprofloxacin.
D. Vitamin D replacement and assessment of calcium/bone health.
E. Hydroxychloroquine.
50. A 59-year-old man with gout has been taking allopurinol for 3 months. His serum urate remains above target and he has had no recent flare. He asks whether the dose should stay unchanged forever.
Which ONE of the following is the most appropriate advice?
A. Stop allopurinol because urate is still high.
B. Use allopurinol only during flares.
C. Replace allopurinol with aspirin.
D. Serum urate does not guide gout treatment.
E. Allopurinol dose may be titrated to achieve target serum urate if tolerated and appropriate.
Musculoskeltal and Joint Diseases Questions
Answers and Rationale
1. C
The presentation is typical of knee osteoarthritis: activity-related pain, short-lived stiffness and crepitus without systemic features. Education, exercise and topical NSAIDs are appropriate early options before escalating to higher-risk analgesics.
2. E
A hot swollen joint with fever, inability to weight-bear and recent joint injection raises concern for septic arthritis. This is an emergency because delayed treatment can cause joint destruction and sepsis.
3. A
In an acute gout flare, NSAIDs and colchicine may be unsuitable in severe renal impairment, anticoagulation or previous gastrointestinal bleeding. A short course of corticosteroid may be considered after clinical assessment.
4. D
Patients already taking urate-lowering therapy should generally continue it during an acute flare. Stopping allopurinol can destabilise serum urate and increase future flare risk.
5. B
Methotrexate should usually be taken once weekly. Daily dosing is a serious medication error and symptoms such as mouth ulcers and nausea may indicate toxicity requiring urgent assessment.
6. E
Fever, sore throat and mouth ulcers in a patient taking methotrexate may suggest infection or bone marrow suppression. Missed monitoring increases concern and urgent clinical assessment is appropriate.
7. A
Persistent symmetrical small-joint swelling with prolonged morning stiffness suggests inflammatory arthritis. Early specialist referral is important to confirm diagnosis and start disease-modifying treatment promptly.
8. D
DMARDs such as methotrexate do not work immediately. Patients should be counselled that benefit may take several weeks to months, and treatment should not be stopped without specialist advice.
9. B
Leflunomide is teratogenic and has a long half-life. Pregnancy planning requires specialist review, contraception advice and possible washout procedure before conception.
10. C
Hydroxychloroquine can rarely cause retinal toxicity, particularly with long-term use. Eye screening helps detect early changes before significant visual loss occurs.
11. D
Oral NSAIDs increase bleeding, gastrointestinal and renal risks, especially in older patients taking anticoagulants or with ulcer history. Safer analgesic strategies or prescriber review are needed.
12. A
Topical NSAIDs can provide local pain relief for knee osteoarthritis with lower systemic exposure than oral NSAIDs. This is useful when oral NSAID risks are high.
13. E
Urinary retention and saddle numbness are red flags for cauda equina syndrome. This requires emergency assessment to prevent permanent neurological damage.
14. C
Inflammatory back pain in a young adult, worse at night and improved by exercise, suggests axial spondyloarthritis. Alternating buttock pain supports sacroiliac involvement.
15. B
Bilateral shoulder and hip girdle pain with prolonged morning stiffness in an older adult is typical of polymyalgia rheumatica. Raised inflammatory markers support the diagnosis.
16. D
New temporal headache, jaw claudication and visual symptoms suggest giant cell arteritis. This requires same-day urgent assessment because of the risk of irreversible sight loss.
17. A
Alendronic acid should be taken on an empty stomach with water, and the patient should remain upright afterwards. This improves absorption and reduces oesophageal irritation.
18. E
Osteonecrosis of the jaw is rare but relevant during invasive dental procedures. The dentist and prescriber should know about bisphosphonate treatment so risk can be assessed.
19. C
New thigh or groin pain after long-term bisphosphonate therapy can indicate an atypical femoral fracture. The patient should be assessed before a complete fracture occurs.
20. B
Calcium reduces oral bisphosphonate absorption. Alendronic acid should be taken separately from calcium supplements, food and other medicines according to product instructions.
21. E
A low-trauma hip fracture strongly suggests increased future fracture risk. Osteoporosis assessment, falls review and bone-protective treatment should be considered after acute management.
22. C
Stopping or delaying denosumab can lead to rapid bone turnover and increased vertebral fracture risk. Treatment gaps should be reviewed and managed with specialist advice.
23. A
Long-term systemic corticosteroids increase fracture risk. Patients starting prolonged corticosteroid therapy should be assessed for osteoporosis risk and need for bone protection.
24. B
Acute gout flares can be treated with an NSAID, colchicine or short-course oral corticosteroid. Choice depends on renal function, gastrointestinal risk, drug interactions and patient factors.
25. D
Allopurinol is usually started at a low dose and titrated to serum urate target. This improves tolerability and helps reduce urate burden over time.
26. A
Colchicine toxicity risk increases with renal impairment and interacting medicines such as macrolides. The prescription should be reviewed to avoid serious harm.
27. E
Osteoarthritis management should optimise education, exercise and lower-risk analgesic options such as topical NSAIDs before escalating to higher-risk treatments like strong opioids.
28. C
Biologic DMARDs suppress immune pathways and can reactivate latent infections. Screening for conditions such as tuberculosis and hepatitis reduces serious infection risk.
29. D
Live vaccines may be contraindicated during biologic therapy. Specialist advice is needed before administration because timing and immunosuppression status matter.
30. B
Sulfasalazine can discolour urine and other body fluids orange-yellow. This can be harmless, but symptoms such as dysuria, fever or flank pain would need separate assessment.
31. B
Folic acid is used with methotrexate to reduce adverse effects such as mouth ulcers, nausea and liver enzyme abnormalities. It does not replace blood monitoring.
32. D
Methotrexate dosing errors can be serious. The patient should follow once-weekly dosing unless a specialist changes the regimen, and nausea should be managed safely.
33. A
NSAIDs combined with ACE inhibitors and diuretics can increase acute kidney injury risk, especially in older adults or during dehydration. Renal and gastrointestinal risks should be considered.
34. E
Psoriasis with swollen joints, morning stiffness and nail changes suggests psoriatic arthritis. Specialist assessment is needed because early treatment can reduce joint damage.
35. C
Pleuritic chest pain, shortness of breath and unilateral leg swelling after a long flight are concerning for venous thromboembolism. SLE can be associated with increased thrombotic risk.
36. D
Widespread pain, fatigue and poor sleep with normal inflammatory tests and no synovitis are consistent with fibromyalgia. Diagnosis requires clinical assessment and exclusion of other causes.
37. B
Wrist deformity, swelling and pain after a fall suggest fracture, particularly in osteoporosis. Same-day assessment and imaging are appropriate.
38. A
Fluoroquinolones can cause tendinopathy and tendon rupture, with higher risk in older adults and those taking corticosteroids. New Achilles pain should prompt urgent review.
39. E
A diabetic foot ulcer with fever and possible bone involvement raises concern for serious infection or osteomyelitis. Urgent multidisciplinary assessment is required.
40. C
Raised serum urate alone does not diagnose gout and does not always require urate-lowering therapy. Treatment decisions depend on symptoms, flares, stones and individual risk.
41. A
Starting urate-lowering therapy can trigger gout flares as urate levels change. Short-term flare prophylaxis with colchicine or another suitable option may be used.
42. C
Therapeutic exercise is a core part of osteoarthritis management. It can improve pain, function and confidence when tailored to the person’s ability.
43. E
Biologic DMARDs can increase infection risk. Fever, productive cough and breathlessness require clinical advice, and biologic treatment may need to be withheld during serious infection.
44. B
Leflunomide can cause hepatotoxicity. Abnormal liver function tests require clinical review even if the patient feels well.
45. D
Oral bisphosphonates have administration requirements and renal cautions. Significant renal impairment, reflux and swallowing difficulty should prompt review of suitability and alternatives.
46. C
Calcium pyrophosphate crystals in synovial fluid indicate acute calcium pyrophosphate crystal arthritis, often called pseudogout. It commonly affects older adults and large joints.
47. A
A febrile child refusing to walk with severe hip pain may have septic arthritis. This is an emergency requiring urgent hospital assessment.
48. B
Frozen shoulder causes pain and global restriction of active and passive shoulder movement. Diabetes is a recognised risk factor.
49. D
Vitamin D deficiency can cause osteomalacia, presenting with bone pain and proximal muscle weakness. Replacement and assessment of calcium and bone health are appropriate.
50. E
Allopurinol is titrated to achieve a target serum urate where appropriate. Persistent hyperuricaemia despite treatment may require dose review if tolerated and clinically suitable.
Here are 50 multiple-choice questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.