KFP – Older persons’ health (Geriatrics)

Elizabeth Cartwright, aged 87, presents with her daughter who is concerned about a gradual decline in her mother’s memory, mood, and functioning over the past year. Elizabeth has been repeating questions, misplacing items, and struggling to manage her medications and finances. Her daughter reports a recent episode where Elizabeth got lost walking to a local shop she has visited for decades.

Medications: Aspirin 100 mg daily, Atorvastatin 20 mg nocte, Temazepam 10 mg PRN (several times a week), Perindopril 4 mg daily

Allergies: Nil known

Past history: Hypertension, Hyperlipidaemia, Osteoarthritis (knees)

Family history: Non-contributory

Social history: Lives alone in a retirement village unit, with daughter visiting weekly. Previously very independent. No smoking. One glass of wine most nights. No formal home support in place.

Psychiatric history: Nil formal diagnosis, but daughter notes periods of tearfulness and withdrawal over the past few months.

Preventative Healthcare: Influenza and pneumococcal vaccinations up to date. Last cervical screening >30 years ago. No recent breast screening.

Examination findings: MMSE 21/30, GPCOG not completed. BP 144/76, HR 76 regular, weight stable. No focal neurological signs. Mild bilateral knee crepitus.

Investigations: FBC, UEC, TFT, B12, Folate, LFTs all within normal limits. Non-contrast CT brain shows moderate generalised cerebral atrophy, no infarct or mass lesion.

What are the most appropriate next steps in management? Select four (4) from the following list:

George Fletcher, aged 79, presents with a 3-month history of worsening lower back pain that radiates to the right groin and anterior thigh. The pain is worse with standing and walking and relieved by sitting or leaning forward. He reports unsteadiness and occasional numbness in both legs. There is no recent trauma. He lives with his wife and uses a walking stick for mobility.

Medications: Paracetamol 1g TDS, Pregabalin 75mg BD, Atorvastatin 40mg nocte

Allergies: Nil known

Past history: Type 2 Diabetes Mellitus, Hypertension, Osteoarthritis, Hyperlipidaemia

Social history: Former builder, non-smoker, drinks one beer per day. Independent in all ADLs. Enjoys gardening but has had to stop recently due to symptoms.

Examination findings: BMI 31. Gait is wide-based with forward stooping posture. Mild weakness in right hip flexion (4/5), diminished right patellar reflex, reduced sensation in the right anterior thigh. Negative straight leg raise. Peripheral pulses normal.

Investigations: Lumbar spine X-ray shows multilevel spondylosis with moderate canal narrowing at L3-L4 and L4-L5.

What are the most appropriate next steps in management? Select three (3) from the following list:

Marion Edwards, aged 84, presents with her son following a recent hospitalisation for a fall in the bathroom resulting in a fractured wrist. She was discharged from hospital three days ago. Marion has a history of osteoporosis and mild cognitive impairment. Her son is concerned about her risk of future falls and her ability to remain living independently at home.

Medications: Alendronate 70mg weekly, Vitamin D 1000 IU daily, Sertraline 50mg daily, Metoprolol 25mg BD

Past history: Hypertension, Osteoporosis, Depression (well-controlled)

Social history: Lives alone in a two-storey home with bedroom and bathroom upstairs. Son visits once weekly. Recently started forgetting to take medications. Has not been using her walking frame consistently.

Examination findings: BP 136/78 sitting, 112/70 standing (lightheaded); HR 58 regular. Mildly unsteady gait; MMSE 24/30. No focal neurology. Bruising over left forearm with plaster cast in place.

What are the most appropriate next steps in her care? Select four (4) from the following list:

Josephine Reed, aged 92, is brought in by her niece for assessment of worsening confusion and agitation over the past three days. She is normally lucid, lives in a high-care residential aged care facility (RACF), and has moderate Alzheimer’s disease. Staff report she is now frequently calling out, refusing meals, and appears increasingly disoriented. She has not had a bowel movement in five days and has been scratching at her perineum.

Medications: Donepezil 10mg daily, Lactulose 15mL BD, Paracetamol 1g QID, Ferrous fumarate 325mg daily

Past history: Alzheimer’s dementia, Chronic constipation, Iron-deficiency anaemia, Osteoarthritis

Social history: Lives in RACF. No known family except niece who visits weekly. No advanced care directive in place.

Examination findings: Alert but confused. Temperature 37.9°C, HR 88, BP 136/82. Abdomen soft, non-tender, but distended. Bowel sounds present. Perineal area erythematous with excoriation. No dysuria. No focal neurological deficits. Mini-Cog not completed due to agitation.

Investigations: Urinalysis: cloudy appearance, leukocytes ++, nitrites negative. BSL: 6.1 mmol/L. FBC and UEC ordered but pending.

What are the most appropriate next steps in management? Select three (3) from the following list:

Robert Hughes, aged 76, presents with his partner concerned about recent episodes of dizziness and two falls in the past month. He describes a lightheaded sensation when standing from a chair or bed, especially in the morning. He denies chest pain, palpitations, or loss of consciousness. There is no recent illness or new medications.

Medications: Irbesartan 300mg daily, Tamsulosin 400mcg daily, Metformin XR 1g daily, Simvastatin 20mg nocte

Past history: Type 2 Diabetes Mellitus, Hypertension, Benign prostatic hyperplasia, Hyperlipidaemia

Social history: Lives independently with partner. Walks daily. No smoking or alcohol use. Diet controlled diabetes with stable HbA1c. No recent travel.

Examination findings: Lying BP 132/78, HR 68 regular. Standing BP after 1 minute 108/64, HR 72. No focal neurology. ECG: Normal sinus rhythm. Cardiovascular and neurological exams otherwise normal.

Investigations: Hb 129 g/L (130–180), eGFR 64 mL/min, Na 136 mmol/L, K 4.3 mmol/L, HbA1c 6.6%

What are the most appropriate next steps in management? Select three (3) from the following list:

Margaret Linwood, aged 81, is brought in by her daughter, concerned about progressive weight loss and reduced appetite over the past six months. Margaret has lost approximately 8 kg (from 62 kg to 54 kg) without attempting to do so. She reports early satiety and fatigue. There are no red-flag gastrointestinal symptoms. Her daughter is also concerned about Margaret’s dentition and notes that she is having increasing difficulty shopping and preparing meals.

Medications: Amlodipine 5mg daily, Mirtazapine 15mg nocte

Past history: Depression, Hypertension, Macular degeneration, Osteoarthritis

Social history: Widowed, lives alone in a suburban home. Receives minimal home assistance. Vision is significantly impaired. No smoking or alcohol use. Financially independent.

Examination findings: Weight 54 kg (BMI 19.1), BP 118/72, HR 72. Pale conjunctivae, poor dentition with several missing teeth. Mild mid-thoracic kyphosis. No lymphadenopathy or palpable masses. Normal bowel sounds.

Investigations: Hb 108 g/L (115–160), MCV 72 fL (80–96), Ferritin 14 mcg/L (30–300), eGFR 68 mL/min

What are the most appropriate next steps in management? Select four (4) from the following list:

Walter Jennings, aged 88, presents with increasing urinary incontinence over the past two months. He reports frequent urgency and nocturia (3–4 times nightly), with occasional leakage before he can reach the toilet. His daughter, who assists with his care, notes that he has been more confused at night and recently wet the bed. Walter lives in a granny flat behind his daughter’s house.

Medications: Furosemide 20mg mane, Perindopril 5mg daily, Tamsulosin 400mcg nocte, Paracetamol SR 665mg TDS

Past history: Benign prostatic hyperplasia, Chronic kidney disease (Stage 3), Hypertension, Osteoarthritis

Social history: Retired accountant. Mobilises independently with a frame. Lives semi-independently but relies on daughter for meals, cleaning, and shopping. Cognitively intact during the day.

Examination findings: BP 134/76, HR 70 regular. Abdomen soft, non-tender, no palpable bladder. Gait stable. Neurological exam non-focal. Digital rectal examination: smooth, mildly enlarged prostate. Urine dipstick: negative for nitrites/leukocytes/blood.

Investigations: Recent UEC: eGFR 48 mL/min, Creatinine 115 µmol/L, Na 138 mmol/L, K 4.1 mmol/L. HbA1c 5.8%

What are the most appropriate next steps in management? Select three (3) from the following list:

Helen Peterson, aged 85, presents with her son due to concerns about increasing drowsiness and reduced responsiveness over the past two days. She has advanced dementia (Alzheimer’s type), is bed-bound, and receives full nursing care at home. She has a history of multiple hospitalisations for aspiration pneumonia and is no longer eating solids. Her son notes she has only taken sips of water in the past 24 hours and has had no urine output since yesterday evening.

Medications: Donepezil 10mg daily, Sertraline 50mg daily, Paracetamol 1g QID, Coloxyl with senna nocte PRN

Past history: Advanced dementia, recurrent aspiration pneumonia, hypertension, osteoarthritis

Social history: Lives at home with full-time carer and daily nursing visits. Advanced care directive is in place requesting comfort care only. Son has medical power of attorney.

Examination findings: Pale, minimally responsive. BP 94/58, HR 92, Temp 37.2°C, RR 22. Dry mucous membranes, sunken eyes, cool peripheries. Chest clear. Abdomen soft. No signs of pain or agitation.

Investigations: None yet performed. Son declines hospital transfer.

What are the most appropriate next steps in her management? Select four (4) from the following list:

Frank Donnelly, aged 75, presents with new-onset low mood, loss of interest in gardening, poor sleep, and reduced appetite over the past two months. He tearfully discloses that his wife died 9 months ago and that he has felt increasingly isolated. He denies suicidal thoughts or psychosis. He is hesitant about counselling and is not currently receiving any formal support.

Medications: Ramipril 5mg daily, Atorvastatin 40mg nocte

Past history: Hypertension, Ischaemic heart disease, hyperlipidaemia

Social history: Lives alone. Former teacher. One daughter lives interstate. Retired. No regular social activities. No smoking or alcohol. Independent in all ADLs.

Examination findings: Appears well-groomed but subdued. Affect is low. No psychomotor agitation or retardation. Montreal Cognitive Assessment (MoCA) score: 25/30.

Investigations: Recent FBC, UEC, TSH, B12, and folate are within normal limits. ECG normal sinus rhythm.

What are the most appropriate next steps in management? Select three (3) from the following list:

Joan Wallis, aged 78, presents for follow-up after a recent hospitalisation for a fragility fracture of the left hip following a fall. She underwent surgical fixation and has returned home with support from her daughter. Joan reports ongoing pain on movement, reduced mobility, and fear of falling again. She has not previously been investigated for osteoporosis.

Medications: Paracetamol 1g QID, Rosuvastatin 10mg nocte, Amlodipine 5mg daily

Past history: Hypertension, Hyperlipidaemia

Social history: Lives alone in a single-level home. Daughter assists with meals and shopping. Former nurse. No smoking or alcohol. Previously independent in all ADLs.

Examination findings: Mobilising short distances with 4-wheeled walker. BP 128/74, HR 72. No signs of delirium. Mild bruising around surgical site. Cognition intact.

Investigations: Recent eGFR 56 mL/min, adjusted serum calcium 2.24 mmol/L (2.15–2.55), Vitamin D 43 nmol/L (50–150), TSH normal. No prior bone mineral density scan.

What are the most appropriate next steps in her care? Select four (4) from the following list:

Arthur Wallace, aged 82, presents with his daughter who is concerned about progressive slowness of movement, resting tremor, and small, shuffling steps over the past year. He also reports increasing difficulty getting up from chairs, a soft voice, and occasional episodes of constipation. He denies falls but admits to feeling stiff in the mornings.

Medications: Aspirin 100mg daily, Amlodipine 5mg daily

Past history: Hypertension, Hyperlipidaemia

Social history: Lives alone in his home. No formal support. Daughter visits twice weekly. Independent with ADLs but slower. No alcohol or smoking history.

Examination findings: Masked facies, resting tremor in right hand, bradykinesia, reduced arm swing on the right, and a stooped posture. Gait is slow and shuffling, with difficulty turning. No cerebellar signs. Cognition intact. BP 130/76, HR 68 regular.

Investigations: FBC, UEC, TSH, B12 all within normal limits. No neuroimaging performed to date.

What are the most appropriate next steps in his care? Select three (3) from the following list:

Patricia Green, aged 80, presents with increasing confusion over the past week. She is usually independent and cognitively intact. Her daughter reports poor oral intake and a two-day history of vomiting. Patricia also complains of muscle weakness and light-headedness. There has been no recent travel, fever, or diarrhoea.

Medications: Hydrochlorothiazide 12.5mg daily, Perindopril 4mg daily, Calcium carbonate + Vitamin D BD

Past history: Hypertension, Osteoporosis

Social history: Lives alone. Receives meals-on-wheels and community nursing for weekly medication supervision. Daughter visits weekly.

Examination findings: Confused, disoriented to time and place. BP 96/64, HR 88, Temp 36.4°C. Dry mucous membranes. Muscle tone reduced. No focal neurological signs. ECG: prolonged QT interval.

Investigations: Na 132 mmol/L (135–145), K 2.6 mmol/L (3.5–5.0), Mg 0.60 mmol/L (0.7–1.1), Ca 2.41 mmol/L (2.15–2.55), Creatinine 102 µmol/L, eGFR 62 mL/min

What are the most appropriate next steps in management? Select four (4) from the following list:

Dorothy Slater, aged 86, is brought in by her neighbour who found her wandering outside confused and looking for her deceased husband. She appears dishevelled and is unable to provide her address. The neighbour reports increasing concerns about Dorothy’s memory and self-care over the past six months, including unpaid bills and spoiled food in the fridge.

Medications: Irbesartan 150mg daily, Aspirin 100mg daily

Past history: Hypertension, Hyperlipidaemia

Social history: Widowed. Lives alone in her original home. No known family nearby. Previously independent. No formal supports in place.

Examination findings: Disoriented to time and place. MMSE 18/30. BP 128/74, HR 70. No focal neurological signs. Poor hygiene noted. Weight 45 kg (BMI 18).

Investigations: FBC, UEC, B12, folate, TFTs all within normal limits. CT brain shows moderate cortical atrophy, no infarcts or mass.

What are the most appropriate next steps in management? Select four (4) from the following list:

Bruce McAllister, aged 79, presents for routine review. He mentions occasional choking and coughing while eating and a recent 3 kg weight loss over two months. He lives alone but attends a local men’s shed twice weekly. His daughter reports that he’s taking longer to eat meals and prefers softer foods. There have been no overt neurological symptoms.

Medications: Perindopril 4mg daily, Metformin XR 1g daily, Aspirin 100mg daily

Past history: Type 2 Diabetes Mellitus, Hypertension, Hyperlipidaemia

Social history: Lives alone in a single-storey unit. Active in community. No smoking or alcohol. No known cognitive impairment.

Examination findings: BMI 22.5. Speech clear but slow. Cough noted after sipping water. Cranial nerve examination shows mild tongue fasciculations. No focal limb weakness or sensory deficit.

Investigations: FBC, UEC, LFTs, CRP, and HbA1c within normal limits. No prior swallowing studies.

What are the most appropriate next steps in management? Select four (4) from the following list:

Elizabeth Rowe, aged 89, presents with worsening shortness of breath on exertion, bilateral lower limb swelling, and increasing fatigue. She has a history of longstanding hypertension and atrial fibrillation. She is compliant with medications but has recently stopped attending her walking group due to breathlessness.

Medications: Bisoprolol 5mg daily, Warfarin (target INR 2.0–3.0), Perindopril 5mg daily, Furosemide 20mg PRN

Past history: Hypertension, Atrial fibrillation (permanent), Osteoarthritis

Social history: Lives with her daughter. Independent in personal care but no longer able to manage housework. Non-smoker. No alcohol. No recent infections.

Examination findings: BP 118/74, HR 78 irregularly irregular. Raised JVP, bilateral pitting oedema to mid-shin, bibasal crackles. No peripheral cyanosis. Weight increased by 3 kg over past month.

Investigations: ECG: Atrial fibrillation. INR 2.3. Recent bloods: Creatinine 96 µmol/L, eGFR 55 mL/min, Na 137 mmol/L, K 4.2 mmol/L. CXR pending.

What are the most appropriate next steps in management? Select four (4) from the following list:

Nancy Freeman, aged 77, presents with her daughter for cognitive assessment. Her daughter has noticed increasing forgetfulness, difficulty following conversations, and occasional inappropriate word substitutions. Nancy also recently left the stove on and got lost walking to her local shops. She is frustrated and tearful when questioned.

Medications: Amlodipine 5mg daily, Escitalopram 10mg daily

Past history: Depression (stable), Hypertension

Social history: Lives alone in a retirement unit. Widowed. Daughter visits twice weekly. No alcohol or smoking.

Examination findings: Alert and cooperative. Oriented to person but not time. Montreal Cognitive Assessment (MoCA): 21/30. BP 134/72, HR 68. No focal neurology.

Investigations: FBC, UEC, TSH, B12, Folate all normal. CT brain: mild generalised cerebral atrophy, no infarct or mass.

What are the most appropriate next steps in management? Select four (4) from the following list:

John Mackie, aged 84, presents to your clinic with increasing fatigue and difficulty rising from chairs over the past few months. He reports that he is feeling weaker, has lost 4 kg unintentionally, and has been walking less due to knee pain. His daughter notes that he is less engaged with social activities and spends most of his day sitting or lying down.

Medications: Paracetamol SR 665mg TDS, Atorvastatin 20mg nocte, Amlodipine 5mg daily

Past history: Osteoarthritis (knees), Hypertension, Hyperlipidaemia

Social history: Lives with his wife in a retirement village. Previously independent. No alcohol or smoking. Minimal formal support.

Examination findings: Weight 58 kg (previously 62 kg, BMI 20), BP 124/68, HR 72. Gait slow and cautious. Chair stand test: unable to rise without using arms. No focal neurological deficit.

Investigations: Hb 118 g/L (130–180), eGFR 62 mL/min, CRP 4 mg/L (<5), Vitamin D 39 nmol/L (50–150)

What are the most appropriate next steps in management? Select four (4) from the following list:

Maureen Gilbert, aged 82, presents with her son for review following a fall at home. She tripped over a rug and sustained a minor wrist sprain. Her son is concerned as this is the third fall in six months. Maureen reports that she feels unsteady when walking and avoids going out alone. She does not use a walking aid. No loss of consciousness was reported with the fall.

Medications: Citalopram 20mg daily, Metoprolol 25mg BD, Amlodipine 5mg daily

Past history: Depression, Hypertension, Osteoarthritis

Social history: Lives alone in a small unit. Son visits twice weekly. Independent with ADLs but no formal support. No smoking or alcohol.

Examination findings: BP 138/74 sitting, 112/66 standing after 1 minute. HR 64. Gait cautious with reduced stride length. Negative Romberg. Lower limb strength reduced bilaterally (4/5). No focal neurology.

Investigations: Vitamin D 48 nmol/L (50–150), Hb 128 g/L, eGFR 60 mL/min, Na 137 mmol/L

What are the most appropriate next steps in management? Select four (4) from the following list:

Henry O’Neill, aged 91, is brought in by his son after Henry was found confused and disoriented at home. His son reports that Henry has not been eating well and has had several recent episodes of constipation. He is known to have moderate vascular dementia but usually recognises family and can hold a conversation. There is no history of fever, incontinence, or new medications.

Medications: Aspirin 100mg daily, Donepezil 10mg daily, Coloxyl with senna PRN

Past history: Vascular dementia, Ischaemic heart disease, Chronic constipation

Social history: Lives alone with support from a visiting carer. Son lives nearby. Usually independent with supervision.

Examination findings: BP 110/68, HR 88, Temp 36.8°C. Alert but disoriented. Abdomen distended but soft. Bowel sounds sluggish. Rectal exam: hard stool palpable. Gait not assessed. No focal neurological findings.

Investigations: UEC: Na 138 mmol/L, K 3.8 mmol/L, Creatinine 98 µmol/L. FBC and CRP normal. No recent imaging.

What are the most appropriate next steps in management? Select three (3) from the following list:

Frances Cooper, aged 79, presents for review of her medications and general health. She has no current complaints but is concerned about memory lapses, reduced energy, and mild balance issues. Her past medical history includes type 2 diabetes and hypothyroidism. She takes multiple medications and asks whether any could be affecting her cognition or function.

Medications: Metformin XR 1g daily, Gliclazide MR 60mg daily, Levothyroxine 75mcg daily, Diazepam 2mg nocte, Simvastatin 20mg nocte, Omeprazole 20mg daily

Past history: Type 2 Diabetes Mellitus, Hypothyroidism, GERD, Hyperlipidaemia, Anxiety

Social history: Lives alone independently. Recently widowed. Enjoys gardening. No alcohol, non-smoker. Daughter visits weekly.

Examination findings: BP 122/72, HR 72. Cognition mildly impaired on MOCA (24/30). Gait steady but cautious. No focal neurology. Weight stable.

Investigations: HbA1c 7.1%, TSH 2.4 mIU/L, B12, folate, FBC, UEC all within normal limits

What are the most appropriate next steps in management? Select four (4) from the following list:

Lucille Sanders, aged 87, is brought in by her niece, concerned about poor oral intake, increasing fatigue, and several small bruises over the arms and legs. Lucille has lost 5 kg over the past 3 months and appears withdrawn. She lives in a residential aged care facility and has advanced osteoarthritis but no formal cognitive diagnosis. Her niece is concerned that Lucille may be depressed and possibly neglected.

Medications: Paracetamol SR 665mg TDS, Calcium/Vitamin D BD, Bisacodyl PRN

Past history: Osteoarthritis, Hypertension (previously diet-controlled), Hearing impairment

Social history: Resides in RACF. Widowed. No children. Niece visits weekly. Minimal participation in facility activities.

Examination findings: BMI 18.3. Pale. Multiple small bruises over forearms. Mild dehydration. Appears low in affect. No focal neurological findings. Cognition screen: MMSE 22/30.

Investigations: Hb 102 g/L, MCV 76 fL, Ferritin 12 mcg/L, Vitamin B12 280 pmol/L, Na 136 mmol/L, eGFR 58 mL/min

What are the most appropriate next steps in management? Select four (4) from the following list:

Eric Johnston, aged 90, presents for review following a recent hospital discharge for community-acquired pneumonia. He has now completed antibiotics and reports persistent fatigue and difficulty managing his daily activities. He lives alone and is concerned he may not cope if he becomes unwell again. He is continent, cognitively intact, and has no active medical complaints today.

Medications: Perindopril 2.5mg daily, Atorvastatin 10mg nocte, Salbutamol MDI PRN

Past history: COPD (mild), Hypertension, Hyperlipidaemia

Social history: Lives alone. Daughter lives interstate. Previously independent in ADLs. Receives no formal support. Attends local RSL club weekly.

Examination findings: BP 126/70, HR 74. Chest clear. Appears mildly frail. Gait steady with effort. Weight unchanged.

Investigations: Recent bloods (FBC, UEC, LFTs, CRP) all normal. Oxygen saturation 96% on room air. ECG unchanged from baseline.

What are the most appropriate next steps in his care? Select four (4) from the following list:

Margaret Wells, aged 76, presents with her daughter due to worsening hearing loss that is affecting her communication and social engagement. Her daughter reports that Margaret has become more withdrawn, avoids conversations in groups, and appears frustrated during family gatherings. Margaret has no ear pain or discharge, but reports occasional tinnitus. She has no history of noise exposure or ototoxic medications.

Medications: Amlodipine 5mg daily, Atorvastatin 20mg nocte

Past history: Hypertension, Hyperlipidaemia

Social history: Lives independently in a retirement unit. Widowed. No formal supports in place. Enjoys reading and gardening but has stopped attending her book club.

Examination findings: Bilateral tympanic membranes intact. No wax or obstruction. Rinne test: air conduction > bone conduction bilaterally. Weber test: midline. Whispered voice test abnormal bilaterally.

Investigations: Not yet performed.

What are the most appropriate next steps in management? Select four (4) from the following list:

Thomas Yates, aged 80, presents with his wife, who is concerned about his driving safety. Over the past year, she has noticed him getting lost in familiar areas, struggling with lane positioning, and reacting slowly to hazards. Thomas has been diagnosed with mild Alzheimer’s disease and is on donepezil. He insists that he is a safe driver and continues to drive short distances daily.

Medications: Donepezil 5mg daily, Amlodipine 5mg daily

Past history: Alzheimer’s dementia (early), Hypertension

Social history: Lives with wife. Retired teacher. Previously active and independent. No recent accidents but a near miss reported by his wife.

Examination findings: BP 130/76, HR 72. Cognition: MMSE 23/30. Oriented to person only. No focal neurological findings. Visual acuity 6/9 bilaterally with glasses.

Investigations: FBC, UEC, LFTs, B12, folate, TSH all normal. CT brain: mild cortical atrophy consistent with age.

What are the most appropriate next steps in management? Select four (4) from the following list:

Evelyn Martin, aged 85, presents with her daughter for a routine health assessment. She appears well but her daughter reports concerns about increasing forgetfulness, occasional incontinence, and declining mobility. Evelyn has had two falls in the past six months and is becoming less steady on her feet. She is cognitively intact but walks slowly with a stooped posture.

Medications: Paracetamol SR 665mg TDS, Calcium + Vitamin D BD, Amlodipine 5mg daily

Past history: Hypertension, Osteoarthritis (knees), Constipation

Social history: Lives with daughter. Attends community centre weekly. Independent with dressing and meals. No formal home care.

Examination findings: BP 132/78 sitting, 110/66 standing. HR 76. Gait slow, stooped with narrow base. Timed Up and Go test: 18 seconds. Cognition: MoCA 26/30. No focal neurology. MMSE not performed.

What are the most appropriate next steps in management? Select four (4) from the following list:

Leonard Park, aged 83, presents with worsening visual hallucinations over the past six months. His wife reports that he sees people in the house who aren’t there, but he is often aware that they are not real. He also shows fluctuating attention and occasional episodes of marked confusion, especially in the evenings. Leonard has a history of REM sleep behaviour disorder and falls.

Medications: Atorvastatin 20mg nocte, Amlodipine 5mg daily, Zopiclone 3.75mg nocte

Past history: Hypertension, Hyperlipidaemia, REM sleep disorder

Social history: Lives with wife. Previously independent but now needs assistance with shopping and bills.

Examination findings: BP 126/68, HR 72. Alert but slow to respond. MMSE 24/30. Gait slow with reduced arm swing. Mild resting tremor. Neurology otherwise non-focal.

Investigations: FBC, UEC, LFTs, TSH, B12 all within normal limits. CT brain: generalised atrophy, no infarct or mass.

What are the most appropriate next steps in management? Select four (4) from the following list:

Barbara Cheng, aged 81, presents with new-onset urinary incontinence and lower abdominal discomfort. She is usually independent and continent. Over the past two days she has also seemed mildly confused, according to her daughter. She denies dysuria but has needed to void more frequently and feels generally ‘off’.

Medications: Perindopril 4mg daily, Metformin XR 1g daily, Sertraline 50mg daily

Past history: Type 2 Diabetes Mellitus, Hypertension, Depression (stable)

Social history: Lives alone in a unit. Daughter visits regularly. Normally active in community groups.

Examination findings: Temp 37.8°C, HR 82, BP 124/70. Mild suprapubic tenderness. Alert but distractible. No flank pain. No neurological deficits. MMSE not performed due to acute confusion.

Investigations: Urinalysis: leukocytes +++, nitrites +. BSL: 8.2 mmol/L. FBC: WCC 12.1 ×10⁹/L, CRP 32 mg/L

What are the most appropriate next steps in management? Select four (4) from the following list:

Ronald Blake, aged 78, presents with his wife who is concerned about increasing daytime sleepiness and loud snoring at night. She reports episodes where he seems to stop breathing during sleep. Ronald feels tired during the day, has had difficulty concentrating, and recently fell asleep while watching TV. He has no known respiratory disease.

Medications: Amlodipine 5mg daily, Metformin XR 1g daily, Atorvastatin 20mg nocte

Past history: Type 2 Diabetes Mellitus, Hypertension, Hyperlipidaemia

Social history: Retired bus driver. Lives with wife. Previously active but has reduced participation in volunteer activities. No alcohol or smoking.

Examination findings: BMI 32, neck circumference 44 cm. BP 138/82. No craniofacial abnormalities. Cardiovascular and respiratory examinations unremarkable.

Investigations: HbA1c 7.2%, eGFR 68 mL/min, TSH normal. No previous sleep studies.

What are the most appropriate next steps in management? Select four (4) from the following list:

Emily Bradford, aged 88, presents with her son due to concerns about frequent bruising over her arms and legs. She has not experienced any recent trauma and is unaware of how the bruises occurred. She is otherwise well and denies dizziness or falls. Her son is worried about her safety and whether her medications might be contributing.

Medications: Aspirin 100mg daily, Atorvastatin 20mg nocte, Amlodipine 5mg daily

Past history: Hypertension, Hyperlipidaemia, Ischaemic heart disease (no recent events)

Social history: Lives independently with home help twice a week. No cognitive impairment. No alcohol or smoking.

Examination findings: Multiple small ecchymoses over forearms and shins, non-tender. No hepatosplenomegaly or lymphadenopathy. Cardiovascular, neurological, and abdominal exams unremarkable. No signs of neglect or injury patterns.

Investigations: Hb 122 g/L, Platelets 186 ×10⁹/L, INR 1.1, APTT 31s, LFTs normal. Renal function stable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Gwen Taylor, aged 86, is brought in by her son for evaluation after a recent episode of dizziness and near-syncope while gardening. She recovered quickly after sitting down but has felt light-headed several times in the past week. There is no chest pain or palpitations. She has a history of hypertension and is on several medications.

Medications: Amlodipine 10mg daily, Perindopril 5mg daily, Hydrochlorothiazide 12.5mg daily, Paracetamol 1g TDS

Past history: Hypertension, Osteoarthritis, No known cardiac disease

Social history: Lives alone with assistance from son. Active in garden and walks daily. No alcohol or smoking.

Examination findings: BP 138/80 sitting, 104/68 standing after 1 minute. HR 72 and regular. Cardiorespiratory exam normal. No focal neurology. Weight stable.

Investigations: ECG: normal sinus rhythm. FBC, UEC, and TSH all within normal limits.

What are the most appropriate next steps in management? Select four (4) from the following list:

Alan Hughes, aged 80, is brought in by his daughter, who is concerned about his recent social withdrawal and poor self-care. He has stopped attending his local bowling club, rarely leaves the house, and has lost interest in hobbies. He has lost 3 kg in two months and has become more irritable. There is no known cognitive diagnosis. He denies suicidal thoughts but feels that ‘life has lost its spark.’

Medications: Perindopril 5mg daily, Atorvastatin 20mg nocte

Past history: Hypertension, Hyperlipidaemia

Social history: Widowed for 5 years. Lives alone with occasional visits from family. No alcohol or smoking.

Examination findings: BP 126/72, HR 68. Mildly dishevelled appearance. Slow speech and affect. MoCA: 26/30. No focal neurology. No psychotic features.

Investigations: FBC, UEC, TSH, B12, and folate all within normal limits. Recent ECG: normal sinus rhythm.

What are the most appropriate next steps in management? Select four (4) from the following list:

Rachel Holmes, aged 87, is brought in by her niece after noticing that Rachel has been forgetting to take her medications and has burned food on the stove twice in the past month. Rachel lives alone and has no formal home supports. She is cooperative but minimises her difficulties. There is no known prior cognitive diagnosis.

Medications: Irbesartan 150mg daily, Aspirin 100mg daily, Calcitriol 0.25mcg daily

Past history: Osteoporosis, Hypertension, Hyperlipidaemia

Social history: Lives alone in a private home. Widowed. Limited social contact apart from weekly shopping with niece.

Examination findings: BP 132/76, HR 72. No focal neurology. Cognition: GPCOG scored 3/9 (with informant section completed: 2/6). Appears pleasant but vague on some history. No delusions or behavioural disturbance.

Investigations: FBC, UEC, TSH, B12, folate all within normal limits. CT brain: moderate cerebral atrophy, no infarct or mass.

What are the most appropriate next steps in management? Select four (4) from the following list:

Kevin Andrews, aged 79, presents for review after experiencing several weeks of poor appetite, early satiety, and a 6 kg weight loss. He denies abdominal pain, dysphagia, or gastrointestinal bleeding. His wife notes he seems more fatigued and has lost interest in meals. He has known type 2 diabetes and reports stable glycaemic control. There are no red-flag symptoms such as vomiting or overt blood loss.

Medications: Metformin XR 1g daily, Ramipril 5mg daily, Simvastatin 20mg nocte

Past history: Type 2 Diabetes Mellitus, Hypertension, Hyperlipidaemia

Social history: Lives with wife. Retired carpenter. Walks daily. No alcohol or smoking. Meals mostly prepared at home.

Examination findings: BMI 21 (previously 24). Pale but not cachectic. No lymphadenopathy. Abdominal exam unremarkable. No focal neurological findings.

Investigations: Hb 112 g/L (130–180), MCV 80 fL, Ferritin 26 mcg/L (30–300), CRP 5 mg/L (<5), eGFR 62 mL/min, LFTs normal. Faecal occult blood test: pending.

What are the most appropriate next steps in management? Select four (4) from the following list:

Judith Evans, aged 81, is brought in by her son due to increasing concerns about her safety at home. Over the past month, Judith has accidentally left the oven on twice, missed multiple doses of medication, and recently wandered out of the house at night. She has moderate Alzheimer’s disease, lives alone, and receives daily community nursing support. Her son lives 45 minutes away and visits on weekends.

Medications: Donepezil 10mg daily, Metoprolol 25mg BD, Aspirin 100mg daily

Past history: Alzheimer’s dementia, Hypertension, Ischaemic heart disease

Social history: Widowed. No pets. Has a community alarm but no in-home monitoring. Limited family support during weekdays.

Examination findings: BP 118/70, HR 72. Pleasant but disoriented to time and place. MMSE: 18/30. No focal neurological signs.

Investigations: Recent bloods: Normal FBC, UEC, TSH, and B12. ECG normal sinus rhythm.

What are the most appropriate next steps in management? Select four (4) from the following list:

Arthur Bell, aged 84, presents with recent onset of bilateral lower limb swelling, shortness of breath on exertion, and fatigue. He has a long-standing history of osteoarthritis and hypertension. He has been increasingly sedentary due to joint pain. There is no history of chest pain, palpitations, or orthopnoea. He denies recent travel or immobility due to illness.

Medications: Amlodipine 10mg daily, Paracetamol SR 665mg TDS

Past history: Hypertension, Osteoarthritis

Social history: Lives independently. Recently reduced mobility due to knee pain. No smoking or alcohol. Diet adequate. No recent changes in medications.

Examination findings: BP 138/76, HR 78. Bilateral pitting oedema to knees. Chest clear. No raised JVP. No hepatomegaly. Peripheral pulses normal. No calf tenderness.

Investigations: FBC and UEC normal. eGFR 58 mL/min. LFTs: Albumin 32 g/L, ALT 28 U/L. ECG: Normal sinus rhythm. Urinalysis: protein +, no haematuria. BNP not yet performed.

What are the most appropriate next steps in management? Select four (4) from the following list:

Dorothy Naylor, aged 82, presents with worsening mobility over the past six months. She has difficulty climbing stairs and rising from low chairs. She reports muscle weakness but no pain. There is no sensory loss or joint swelling. She has a history of polymyalgia rheumatica but has not taken corticosteroids in over a year.

Medications: Amlodipine 5mg daily, Paracetamol 1g TDS

Past history: Polymyalgia rheumatica (in remission), Hypertension

Social history: Lives independently with weekly cleaning support. No smoking or alcohol. Previously walked daily but now struggles to do so.

Examination findings: BP 132/74, HR 76. Proximal muscle weakness in both upper and lower limbs (4/5). No fasciculations. Normal tone and reflexes. Gait slow and effortful. No joint deformity or tenderness. Sensation intact.

Investigations: CK 218 IU/L (normal 30–200), ESR 18 mm/hr, TSH normal, Vitamin D 46 nmol/L, HbA1c 6.5%, LFTs normal

What are the most appropriate next steps in management? Select four (4) from the following list:

Elaine Morton, aged 79, presents with a one-month history of progressive hoarseness, dry throat, and occasional choking on liquids. She reports difficulty initiating swallowing, but denies weight loss or overt aspiration. Her medical history includes long-standing gastro-oesophageal reflux disease (GORD), hypertension, and hypothyroidism. She has become more socially withdrawn and avoids eating out.

Medications: Omeprazole 20mg daily, Levothyroxine 75mcg daily, Amlodipine 5mg daily

Past history: GORD, Hypothyroidism, Hypertension

Social history: Lives with husband. Retired librarian. Non-smoker. No alcohol. Previously active in local choir.

Examination findings: Voice hoarse. Cranial nerve exam normal. Gag reflex intact. No lymphadenopathy. No oral thrush or visible lesions. Weight stable.

Investigations: FBC, TSH, and UEC all within normal limits. Vitamin B12: 182 pmol/L (normal 140–650). No prior ENT assessment or swallow studies performed.

What are the most appropriate next steps in management? Select four (4) from the following list:

George Duncan, aged 86, presents with complaints of chronic constipation, abdominal bloating, and reduced appetite. He reports having a bowel movement only once every 4–5 days and often strains during defecation. He denies weight loss, rectal bleeding, or significant abdominal pain. He drinks 1–1.5 litres of fluid daily and is on minimal medications.

Medications: Amlodipine 5mg daily, Paracetamol SR 665mg TDS

Past history: Osteoarthritis, Hypertension

Social history: Lives alone. Independent with meals and hygiene. No cognitive concerns. Regular walker. No alcohol. Eats modestly.

Examination findings: BP 128/76, HR 68. Abdomen soft, mildly distended, non-tender. Bowel sounds present. No palpable masses. Digital rectal exam: small amount of hard stool in rectum.

Investigations: FBC: normal. TSH: normal. Electrolytes and renal function normal. Recent colonoscopy (6 months ago): normal. No faecal occult blood testing indicated.

What are the most appropriate next steps in management? Select four (4) from the following list:

Lucinda Harper, aged 90, presents with her daughter due to recent confusion and unsteadiness. Lucinda was previously independent in most activities of daily living, but over the past three days has become drowsy and occasionally incontinent. Her daughter reports she has not been eating well and may have missed her medications. There is no history of fever, vomiting, or recent trauma.

Medications: Metoprolol 25mg BD, Amlodipine 5mg daily, Sertraline 50mg daily, Calcium carbonate + Vitamin D BD

Past history: Hypertension, Depression (stable), Osteoporosis

Social history: Lives alone with support from daughter three times a week. No known cognitive diagnosis.

Examination findings: BP 96/60, HR 66. GCS 14. Drowsy but rousable. No focal neurology. Dry mucous membranes. Chest clear. No abdominal tenderness. Capillary refill time 3 seconds.

Investigations: BSL 6.2 mmol/L. ECG: Sinus rhythm. Bloods: Na 130 mmol/L, K 4.1 mmol/L, Urea 10.8 mmol/L, Creatinine 112 µmol/L, eGFR 45 mL/min. FBC pending.

What are the most appropriate next steps in management? Select four (4) from the following list:

Brenda Knight, aged 80, presents for a routine health check. She reports increasing difficulty hearing conversations, particularly in groups or when there is background noise. She also notes occasional tinnitus but no vertigo, otalgia, or discharge. She wears reading glasses and has noticed feeling more socially withdrawn as hearing worsens. She has not had her hearing formally assessed before.

Medications: Irbesartan 150mg daily, Atorvastatin 20mg nocte

Past history: Hypertension, Hyperlipidaemia

Social history: Lives independently. Retired teacher. Enjoys reading and gardening. Attends church but has reduced participation recently due to difficulty following conversation.

Examination findings: Otoscopy: tympanic membranes intact bilaterally. Rinne test: air conduction > bone conduction bilaterally. Weber test: midline. No wax. Normal cranial nerve exam. No gait disturbance or focal neurology.

Investigations: Not yet performed. No previous audiology or ENT assessments.

What are the most appropriate next steps in management? Select four (4) from the following list:

Donald White, aged 84, presents after a fall in the bathroom. He tripped while turning quickly and hit his hip on the floor. There was no loss of consciousness, and he was able to get up with assistance. He reports intermittent dizziness on standing but no vertigo or palpitations. He walks with a cane and has had one previous fall six months ago. No injuries were sustained from today’s fall.

Medications: Metformin XR 1g daily, Perindopril 4mg daily, Tamsulosin 400mcg nocte

Past history: Type 2 Diabetes Mellitus, Hypertension, Benign prostatic hyperplasia

Social history: Lives alone in a ground-floor unit. No formal support. Meals on Wheels. Independent in ADLs. Daughter visits weekly.

Examination findings: BP 130/78 sitting, 106/64 standing. HR 72 regular. Normal gait with cane. No neurological deficits. Mild bruising on right hip. Visual acuity 6/12 bilaterally.

Investigations: HbA1c 7.1%, eGFR 61 mL/min, Na 138 mmol/L, K 4.3 mmol/L. ECG: Normal sinus rhythm.

What are the most appropriate next steps in management? Select four (4) from the following list:

Helen Armstrong, aged 87, presents with her niece for follow-up of a recent hospital discharge after treatment for community-acquired pneumonia. She has residual fatigue and reduced appetite but is otherwise improving. She was previously independent in her home but now struggles with housework and has been forgetting her medications. Her niece expresses concern about her declining function and requests support for Helen to remain at home safely.

Medications: Amoxicillin-clavulanate (just completed), Amlodipine 5mg daily, Sertraline 50mg daily

Past history: Hypertension, Depression (stable), Osteoarthritis

Social history: Lives alone in a single-level home. Widowed. Meals on Wheels provided. No formal support services. Niece visits weekly.

Examination findings: BP 124/70, HR 74. Mild frailty on observation. Weight 48 kg (BMI 19.2). No acute findings. Cognition intact on screening (MoCA 26/30).

Investigations: Recent bloods during admission: Normal FBC, UEC, LFTs. Chest X-ray (post-treatment): improved consolidation.

What are the most appropriate next steps in management? Select four (4) from the following list:

Steven McKenzie, aged 85, presents with worsening short-term memory over the past six months. His wife reports he forgets appointments, misplaces items, and repeats questions. He is still managing his finances but requires reminders. There have been no mood or behavioural changes. He has no prior psychiatric or cognitive history and is worried about dementia, as his brother was diagnosed in his early 80s.

Medications: Amlodipine 5mg daily, Aspirin 100mg daily

Past history: Hypertension, Hyperlipidaemia

Social history: Lives with wife. Retired teacher. No smoking or alcohol. Independent with ADLs and IADLs.

Examination findings: BP 130/72, HR 70. Cognition: MoCA score 24/30. No focal neurological signs. Gait normal. Affect appropriate.

Investigations: FBC, UEC, LFTs, TSH, B12, and folate all within normal limits. CT brain: mild generalised atrophy, no infarct or mass.

What are the most appropriate next steps in management? Select four (4) from the following list:

Linda Ng, aged 82, presents with her son due to concerns about worsening mobility and multiple near-falls over the past two months. She uses a walking stick but is increasingly unsteady, especially when turning. She also reports leg stiffness and difficulty initiating movement. No dizziness or recent head injury. Her son has noticed her voice has become softer, and she appears slower to respond.

Medications: Amlodipine 5mg daily, Sertraline 50mg daily

Past history: Hypertension, Depression (well-controlled)

Social history: Lives with son. Independent with ADLs but avoids outings. Previously active in her community.

Examination findings: BP 132/72, HR 70. Gait: shuffling, narrow-based with reduced arm swing. Difficulty initiating steps (start hesitation). Mild bradykinesia. No tremor. Cognition: MoCA 26/30. Cranial nerves intact. No cerebellar signs.

Investigations: FBC, UEC, TSH, B12 all within normal limits. CT brain: mild atrophy, no infarct or hydrocephalus.

What are the most appropriate next steps in management? Select four (4) from the following list:

Jeanette Walsh, aged 79, presents with progressive bilateral lower leg swelling, mild shortness of breath on exertion, and fatigue. She has a history of osteoarthritis and uses paracetamol regularly. She denies chest pain or orthopnoea. Her appetite is reduced, and she has gained 2 kg over the past month. She reports increasing difficulty with housework and walking distances.

Medications: Paracetamol SR 665mg TDS, Amlodipine 10mg daily

Past history: Hypertension, Osteoarthritis

Social history: Lives alone. No formal support. Previously active in gardening and walking group. No smoking or alcohol.

Examination findings: BP 132/74, HR 74. Bilateral pitting oedema to knees. No JVP elevation. Chest clear. Abdomen soft. No hepatomegaly. Weight: 74 kg (baseline 72 kg). ECG: sinus rhythm.

Investigations: eGFR 62 mL/min, Na 137 mmol/L, K 4.1 mmol/L, Albumin 38 g/L, TSH normal, BNP: pending.

What are the most appropriate next steps in management? Select four (4) from the following list:

Michael Foster, aged 78, presents with worsening knee pain that is impacting his mobility and quality of life. He has known bilateral knee osteoarthritis, which has progressed despite regular paracetamol use. He has difficulty getting out of chairs and climbing stairs and has recently stopped attending his walking group. He is reluctant to use opioids and prefers to avoid surgery if possible.

Medications: Paracetamol SR 665mg TDS, Amlodipine 5mg daily

Past history: Hypertension, Osteoarthritis (knees)

Social history: Lives with wife. Previously active. No smoking. No alcohol. Independent in ADLs but reduced activity due to pain.

Examination findings: BMI 30. Gait slow and antalgic. Bilateral knee crepitus with reduced range of motion. No joint effusion or redness. No neurological deficits.

Investigations: Recent knee X-rays: moderate bilateral medial joint space narrowing, osteophyte formation. Bloods: FBC, UEC, ESR all normal.

What are the most appropriate next steps in management? Select four (4) from the following list:

Patricia Moore, aged 91, is brought in by her home care nurse due to a non-healing ulcer on her left lower leg. It has been present for six weeks and appears to be slowly increasing in size. She denies significant pain but reports occasional itch. Her medical history includes chronic venous insufficiency and atrial fibrillation. She is on anticoagulation. There is no history of trauma or recent infection.

Medications: Apixaban 5mg BD, Amlodipine 5mg daily

Past history: Atrial fibrillation (non-valvular), Hypertension, Chronic venous insufficiency

Social history: Lives alone with daily nurse visits. Independent with some ADLs. Meals on Wheels. No smoking. No alcohol.

Examination findings: Left medial lower leg ulcer, 2.5 cm diameter, shallow with granulating base. Surrounding skin haemosiderin-stained, mild oedema. Pedal pulses palpable. No cellulitis or systemic signs. Right leg normal.

Investigations: FBC: normal. CRP: 4 mg/L (<5). INR not applicable (on NOAC). ABPI (Ankle Brachial Pressure Index): 1.0.

What are the most appropriate next steps in management? Select four (4) from the following list:

Barbara Lloyd, aged 88, presents for review after her daughter noticed increased forgetfulness, difficulty following conversations, and mild word-finding issues. She is independent in most daily activities but has become more socially withdrawn. There is no history of head trauma, hallucinations, or mood disturbance. She denies getting lost but often repeats herself in conversations.

Medications: Perindopril 4mg daily, Atorvastatin 20mg nocte

Past history: Hypertension, Hyperlipidaemia

Social history: Lives alone in retirement unit. Daughter visits regularly. Previously active in book club and local community centre.

Examination findings: BP 134/72, HR 72. Cognition: MoCA 23/30. No focal neurology. Gait steady. Affect appropriate.

Investigations: FBC, UEC, TSH, B12, folate all normal. CT brain: mild cerebral atrophy, no infarct or mass.

What are the most appropriate next steps in management? Select four (4) from the following list:

Graham Wallace, aged 80, presents with recent onset of urinary urgency, nocturia (x3), and occasional incontinence. He reports a slow stream and straining but no dysuria, haematuria, or weight loss. He is embarrassed by the symptoms and avoids social activities. He has no known cognitive impairment and is otherwise well. He is not on any current medications for urinary symptoms.

Medications: Perindopril 5mg daily, Atorvastatin 20mg nocte

Past history: Hypertension, Hyperlipidaemia

Social history: Lives with wife. Retired. Previously socially active. No smoking or alcohol. Independent in all ADLs.

Examination findings: BP 126/72, HR 74. Abdomen soft, no palpable bladder. DRE: enlarged, smooth, non-tender prostate. No masses. Gait and cognition normal.

Investigations: Urinalysis: no infection or haematuria. PSA: 3.5 ng/mL (age-appropriate). UEC normal.

What are the most appropriate next steps in management? Select four (4) from the following list:

Margaret Turner, aged 92, is brought in by her daughter for review of progressive frailty. Over the past six months, Margaret has lost 5 kg unintentionally, has had two falls, and now needs help with dressing and preparing meals. She has become more socially withdrawn and tires easily with minimal activity. There is no history of depression or acute illness. She takes her medications reliably.

Medications: Amlodipine 5mg daily, Aspirin 100mg daily, Calcium + Vitamin D daily

Past history: Hypertension, Osteopenia

Social history: Lives with daughter. Previously independent but now relies on help for most ADLs. No smoking or alcohol. No cognitive diagnosis but reports ‘slowed thinking’.

Examination findings: Weight 44 kg (BMI 18). BP 122/70, HR 72. Mild kyphosis. Gait slow, unsteady. Unable to rise from chair without assistance. Cognition: MoCA 25/30. No focal neurology.

Investigations: Hb 117 g/L, TSH, B12, UEC, CRP all normal. Vitamin D: 38 nmol/L.

What are the most appropriate next steps in management? Select four (4) from the following list: