MCQ Quiz: Complex Patient Cases: Ambulatory

Managing patients in an ambulatory care setting often involves navigating the complexities of multiple chronic conditions, polypharmacy, and unique patient-specific factors. Unlike single-disease state scenarios, complex cases require pharmacists to integrate their knowledge across various therapeutic areas to identify drug therapy problems, prioritize interventions, and optimize outcomes. The advanced skills lab curriculum, particularly the module on complex ambulatory patient cases, is designed to build this critical competency. This quiz will challenge your ability to apply the Pharmacists’ Patient Care Process to multifaceted patient scenarios involving common comorbidities like diabetes, hypertension, heart failure, and chronic kidney disease, reflecting the real-world challenges faced by ambulatory care pharmacists.

1. A 65-year-old male with a history of T2DM, HFrEF (EF 30%), and CKD (eGFR 40 mL/min) has an A1c of 8.2%. His current medications include metformin, lisinopril, and metoprolol succinate. Which of the following would be the most appropriate agent to add for glycemic control?

• a) Glipizide
• b) Pioglitazone
• c) Empagliflozin
• d) Sitagliptin

Answer: c) Empagliflozin

2. A patient with resistant hypertension is currently taking lisinopril, amlodipine, and hydrochlorothiazide at maximum tolerated doses. Their blood pressure remains 150/94 mmHg. What is the most appropriate fourth-line agent to add?

• a) Clonidine
• b) Hydralazine
• c) Spironolactone
• d) Propranolol

Answer: c) Spironolactone

3. An ambulatory care pharmacist is managing a patient on warfarin for atrial fibrillation who has a target INR of 2-3. The patient is started on amiodarone for a ventricular arrhythmia. The pharmacist should anticipate the need to:

• a) Increase the warfarin dose.
• b) Decrease the warfarin dose by 30-50%.
• c) Discontinue warfarin.
• d) Make no change to the warfarin dose.

Answer: b) Decrease the warfarin dose by 30-50%.

4. When performing a comprehensive medication review (CMR) for a complex patient, the first step is to:

• a) Immediately identify drug interactions.
• b) Create a personal medication record (PMR).
• c) Collect necessary subjective and objective information to create a best possible medication history (BPMH).
• d) Formulate a medication action plan (MAP).

Answer: c) Collect necessary subjective and objective information to create a best possible medication history (BPMH).

5. A patient with HFrEF is on an ACE inhibitor and a beta-blocker. They still have symptoms and their eGFR is 50 mL/min with a K+ of 4.5 mEq/L. Which medication class should be added next according to guidelines?

• a) A calcium channel blocker
• b) A mineralocorticoid receptor antagonist (MRA) like spironolactone.
• c) A thiazide diuretic
• d) Digoxin

Answer: b) A mineralocorticoid receptor antagonist (MRA) like spironolactone.

6. A 70-year-old patient with T2DM and a recent MI is found to have an A1c of 7.8%. In addition to metformin, which medication offers a proven cardiovascular benefit?

• a) Glyburide
• b) Liraglutide
• c) Saxagliptin
• d) Insulin 70/30

Answer: b) Liraglutide

7. A patient with COPD and asthma (Asthma-COPD Overlap Syndrome) requires a new inhaler for maintenance. Which regimen would be most appropriate?

• a) A LAMA monotherapy.
• b) A SABA as needed only.
• c) An inhaled corticosteroid (ICS) combined with a long-acting beta-agonist (LABA).
• d) An oral corticosteroid daily.

Answer: c) An inhaled corticosteroid (ICS) combined with a long-acting beta-agonist (LABA).

8. An ambulatory care pharmacist is documenting a patient encounter. In which section of the SOAP note would the A1c value of 9.1% be placed?

• a) Subjective
• b) Objective
• c) Assessment
• d) Plan

Answer: b) Objective

9. In the “Assessment” portion of the same SOAP note, how would the pharmacist describe the A1c of 9.1%?

• a) “Diabetes Mellitus, Type 2”
• b) “A1c is 9.1%.”
• c) “Diabetes Mellitus, Type 2, uncontrolled based on elevated A1c above goal.”
• d) “Start Lantus 10 units at bedtime.”

Answer: c) “Diabetes Mellitus, Type 2, uncontrolled based on elevated A1c above goal.”

10. A patient with a history of gout and hypertension requires a new add-on agent for blood pressure control. Which agent should generally be avoided?

• a) Amlodipine
• b) Losartan
• c) Hydrochlorothiazide
• d) Lisinopril

Answer: c) Hydrochlorothiazide

11. A complex patient case in an ambulatory care setting is defined by:

• a) The presence of a single, well-controlled chronic condition.
• b) The presence of multiple comorbidities, polypharmacy, and potential social barriers.
• c) Any patient over the age of 65.
• d) A patient who has private insurance.

Answer: b) The presence of multiple comorbidities, polypharmacy, and potential social barriers.

12. A patient with atrial fibrillation has a CHA₂DS₂-VASc score of 4 and an eGFR of 25 mL/min. Which anticoagulant regimen is most appropriate?

• a) Full-dose rivaroxaban
• b) Dabigatran 150 mg BID
• c) Warfarin with a target INR of 2-3
• d) Edoxaban 60 mg daily

Answer: c) Warfarin with a target INR of 2-3

13. A patient with heart failure should be counseled to avoid which over-the-counter medication class for pain?

• a) Acetaminophen
• b) NSAIDs (e.g., ibuprofen, naproxen)
• c) Topical capsaicin
• d) Topical lidocaine

Answer: b) NSAIDs (e.g., ibuprofen, naproxen)

14. An ambulatory care pharmacist uses the “teach-back” method while counseling. This involves:

• a) Asking the patient “do you have any questions?”
• b) Asking the patient to repeat the instructions verbatim.
• c) Asking the patient to explain in their own words how they will take their medication.
• d) Giving the patient a written quiz.

Answer: c) Asking the patient to explain in their own words how they will take their medication.

15. A patient on spironolactone and lisinopril should be monitored closely for which electrolyte abnormality?

• a) Hyperkalemia
• b) Hypokalemia
• c) Hyponatremia
• d) Hypomagnesemia

Answer: a) Hyperkalemia

16. Which of the following is an example of a medication-related problem a pharmacist would address in a complex case?

• a) Therapeutic duplication
• b) Need for additional therapy (e.g., statin for secondary prevention)
• c) Subtherapeutic dosing
• d) All of the above

Answer: d) All of the above.

17. A patient with T2DM and albuminuria (UACR > 30 mg/g) should be on which class of medication for both glycemic control and kidney protection?

• a) A sulfonylurea
• b) An SGLT2 inhibitor
• c) A meglitinide
• d) A DPP-4 inhibitor

Answer: b) An SGLT2 inhibitor

18. A patient on high-intensity statin therapy complains of severe muscle pain and has dark-colored urine. The pharmacist should suspect rhabdomyolysis and advise the patient to:

• a) Continue the statin and monitor symptoms.
• b) Decrease the statin dose by half.
• c) Stop the statin and seek immediate medical attention.
• d) Take the statin every other day.

Answer: c) Stop the statin and seek immediate medical attention.

19. When managing complex cases, prioritizing problems is key. Which of the following issues should be addressed first?

• a) A need for a refill on a multivitamin.
• b) An INR of 9.0 in a patient on warfarin.
• c) A slightly elevated LDL cholesterol.
• d) A need for a routine vaccination.

Answer: b) An INR of 9.0 in a patient on warfarin.

20. A patient with asthma has been using their albuterol inhaler 4-5 times per week. This indicates:

• a) Their asthma is well-controlled.
• b) They are using their controller medication too often.
• c) Their asthma is not well-controlled, and their daily controller therapy may need to be initiated or stepped up.
• d) They should stop using their albuterol inhaler.

Answer: c) Their asthma is not well-controlled, and their daily controller therapy may need to be initiated or stepped up.

21. A key skill for an ambulatory care pharmacist, as emphasized in the skills lab curriculum, is the ability to:

• a) Perform surgery.
• b) Interpret complex radiographic images.
• c) Present a succinct oral patient summary and therapeutic plan to another healthcare provider.
• d) Compound complex sterile IV products.

Answer: c) Present a succinct oral patient summary and therapeutic plan to another healthcare provider.

22. A patient with a history of ischemic stroke and hypertension should have a target blood pressure of:

• a) <150/90 mmHg
• b) <140/90 mmHg
• c) <130/80 mmHg
• d) <160/100 mmHg

Answer: c) <130/80 mmHg

23. Which of the following is a common barrier to medication adherence in complex patients?

• a) Low pill burden
• b) High health literacy
• c) Financial constraints and high co-pays
• d) Simple medication regimens

Answer: c) Financial constraints and high co-pays

24. Deprescribing is the process of:

• a) Adding new medications to a patient’s regimen.
• b) Systematically withdrawing inappropriate or unnecessary medications.
• c) Switching from a brand to a generic medication.
• d) Lowering the dose of a single medication.

Answer: b) Systematically withdrawing inappropriate or unnecessary medications.

25. A patient with osteoporosis and CKD (eGFR 25 mL/min) requires treatment. Which medication is generally contraindicated?

• a) Calcium/Vitamin D
• b) Denosumab
• c) Alendronate
• d) Teriparatide

Answer: c) Alendronate

26. The “Plan” section of a SOAP note for a complex patient should include:

• a) The patient’s vital signs.
• b) A list of all active medical problems.
• c) The pharmacist’s rationale for their recommendations.
• d) Specific pharmacologic recommendations, monitoring parameters, and patient education points.

Answer: d) Specific pharmacologic recommendations, monitoring parameters, and patient education points.

27. A patient with stable coronary artery disease should be on which two classes of medications for secondary prevention?

• a) An antiplatelet agent and a high-intensity statin.
• b) A beta-blocker and a diuretic.
• c) A calcium channel blocker and an ARB.
• d) An anticoagulant and an ACE inhibitor.

Answer: a) An antiplatelet agent and a high-intensity statin.

28. An ambulatory care pharmacist managing a patient starting insulin should provide education on:

• a) Proper injection technique.
• b) Signs and symptoms of hypoglycemia and how to treat it.
• c) The importance of blood glucose monitoring.
• d) All of the above.

Answer: d) All of the above.

29. A complex patient case often requires collaboration with multiple providers. This is an example of:

• a) Independent practice.
• b) Interprofessional care.
• c) A medication error.
• d) A barrier to care.

Answer: b) Interprofessional care.

30. A patient on allopurinol for gout is started on azathioprine for an autoimmune condition. This is a severe drug interaction because allopurinol:

• a) Increases the metabolism of azathioprine.
• b) Inhibits the metabolism of azathioprine, leading to life-threatening toxicity.
• c) Decreases the absorption of azathioprine.
• d) Causes a hypersensitivity reaction when combined with azathioprine.

Answer: b) Inhibits the metabolism of azathioprine, leading to life-threatening toxicity.

31. In a patient with HFrEF, which medication class has been shown to reduce mortality but can cause a benign, temporary increase in serum creatinine upon initiation?

• a) Loop diuretics
• b) Digoxin
• c) ACE Inhibitors/ARBs
• d) Calcium channel blockers

Answer: c) ACE Inhibitors/ARBs

32. The primary goal of managing a complex patient in an ambulatory care setting is to:

• a) Increase the number of prescriptions filled.
• b) Achieve optimal outcomes for all chronic conditions while ensuring safety and adherence.
• c) See the patient as quickly as possible.
• d) Focus on only one disease state at a time.

Answer: b) Achieve optimal outcomes for all chronic conditions while ensuring safety and adherence.

33. Which of the following is a common challenge when managing geriatric patients with multiple comorbidities?

• a) They have faster drug metabolism than younger adults.
• b) They are at higher risk for adverse drug events due to polypharmacy and altered pharmacokinetics.
• c) They rarely have adherence issues.
• d) They have very few chronic conditions.

Answer: b) They are at higher risk for adverse drug events due to polypharmacy and altered pharmacokinetics.

34. A patient with asthma and hypertension should ideally avoid which class of blood pressure medication?

• a) ACE Inhibitors
• b) Non-selective beta-blockers
• c) Calcium channel blockers
• d) Thiazide diuretics

Answer: b) Non-selective beta-blockers

35. A pharmacist is reviewing labs for a patient on digoxin and furosemide. Which electrolyte abnormality increases the risk of digoxin toxicity?

• a) Hyperkalemia
• b) Hypokalemia
• c) Hypernatremia
• d) Hypercalcemia

Answer: b) Hypokalemia

36. A key part of managing a complex patient is assessing their health literacy. This can be done by:

• a) Assuming the patient understands everything if they do not ask questions.
• b) Asking “do you understand?” repeatedly.
• c) Observing how they interact with educational materials and using techniques like the teach-back method.
• d) Looking at their level of education.

Answer: c) Observing how they interact with educational materials and using techniques like the teach-back method.

37. Which of the following is NOT a guideline-directed medical therapy (GDMT) class for HFrEF?

• a) ARNI/ACEi/ARB
• b) Beta-Blocker
• c) Mineralocorticoid Receptor Antagonist (MRA)
• d) Dihydropyridine Calcium Channel Blocker

Answer: d) Dihydropyridine Calcium Channel Blocker

38. When titrating medications for a complex patient, the best approach is:

• a) “Start low, go slow.”
• b) “Start high and titrate down.”
• c) Change all medications at every visit.
• d) Only adjust one medication per year.

Answer: a) “Start low, go slow.”

39. A patient with COPD who is a former smoker should be offered which important preventative care service?

• a) Annual lung cancer screening via low-dose CT if they meet age and pack-year criteria.
• b) Daily aspirin.
• c) Annual colonoscopy.
• d) A bone density scan.

Answer: a) Annual lung cancer screening via low-dose CT if they meet age and pack-year criteria.

40. A pharmacist is managing a patient’s diabetes and notices their blood pressure is consistently elevated. The pharmacist should:

• a) Ignore the blood pressure and focus only on the diabetes.
• b) Address the uncontrolled hypertension as a concurrent drug therapy problem.
• c) Tell the patient to stop their diabetes medication.
• d) Assume the blood pressure cuff is broken.

Answer: b) Address the uncontrolled hypertension as a concurrent drug therapy problem.

41. The Beers Criteria is a tool used by ambulatory care pharmacists to help identify:

• a) Potentially inappropriate medications in older adults.
• b) The cost of medications.
• c) Drug-drug interactions in pediatric patients.
• d) The best antibiotics for an infection.

Answer: a) Potentially inappropriate medications in older adults.

42. A complex patient case requires the pharmacist to weigh the risks and benefits of a medication that could help one condition but worsen another. This requires a high level of:

• a) Dispensing speed.
• b) Clinical judgment.
• c) Inventory management.
• d) Business acumen.

Answer: b) Clinical judgment.

43. A patient with T2DM, obesity, and fatty liver disease would benefit most from which medication class that addresses all three conditions?

• a) Sulfonylureas
• b) Insulin
• c) GLP-1 Receptor Agonists
• d) DPP-4 Inhibitors

Answer: c) GLP-1 Receptor Agonists

44. What is the role of patient-reported outcomes (PROs) in managing complex cases?

• a) They are not considered valid data.
• b) They provide valuable insight into the patient’s quality of life, symptoms, and functional status.
• c) They are only used in clinical research.
• d) They replace the need for objective lab data.

Answer: b) They provide valuable insight into the patient’s quality of life, symptoms, and functional status.

45. A patient on three antihypertensives is also taking over-the-counter ibuprofen 800 mg three times daily for arthritis pain. The pharmacist identifies this as a problem because the ibuprofen:

• a) Can increase blood pressure and antagonize the effects of the antihypertensives.
• b) Interacts with their diabetes medication.
• c) Is not effective for pain.
• d) Causes sedation.

Answer: a) Can increase blood pressure and antagonize the effects of the antihypertensives.

46. Follow-up intervals for a complex patient in an ambulatory care clinic are determined by:

• a) The patient’s insurance coverage.
• b) A fixed schedule of every 6 months for all patients.
• c) The clinical stability of the patient and the time needed to see the effects of therapy changes.
• d) The pharmacist’s personal schedule.

Answer: c) The clinical stability of the patient and the time needed to see the effects of therapy changes.

47. A core component of an ambulatory care pharmacy practice model is:

• a) A focus on acute, inpatient care.
• b) Providing longitudinal, ongoing care for chronic conditions.
• c) Dispensing medications without patient interaction.
• d) Managing the hospital’s drug budget.

Answer: b) Providing longitudinal, ongoing care for chronic conditions.

48. A patient is taking both clopidogrel and omeprazole. The pharmacist should be aware of a potential drug interaction where omeprazole:

• a) Increases the antiplatelet effect of clopidogrel.
• b) Decreases the conversion of clopidogrel to its active form by inhibiting CYP2C19.
• c) Causes severe hypertension when combined with clopidogrel.
• d) There is no interaction between these two drugs.

Answer: b) Decreases the conversion of clopidogrel to its active form by inhibiting CYP2C19.

49. For a complex patient with multiple prescribers, the ambulatory care pharmacist often acts as the:

• a) Primary care provider.
• b) Gatekeeper for all specialist appointments.
• c) Central coordinator for the patient’s medication regimen to avoid duplication and interactions.
• d) Dispensing technician.

Answer: c) Central coordinator for the patient’s medication regimen to avoid duplication and interactions.

50. The ultimate success in managing a complex ambulatory care patient is best measured by:

• a) The number of medications the patient is taking.
• b) The achievement of the patient’s personal health goals and guideline-based clinical targets.
• c) The number of clinic visits per year.
• d) The patient’s satisfaction with the pharmacist’s personality.

Answer: b) The achievement of the patient’s personal health goals and guideline-based clinical targets.