TDM Examination sample cases
Get familiar with the multiple-choice and short-menu question types.
These eight free sample cases will help you become familiar with the style and format of the Therapeutics Decision-Making (TDM) Examination. Select your response(s) by clicking the answer choices, then scroll down to compare your selections with the correct answers, rationales and references. You can change your selections at any time while viewing the case, but your selections will not be saved when you move to another case. Each question indicates how many responses should be selected; however, unlike the actual examination, these sample cases do not prevent you from selecting more than the required number of responses. Use the “return” and “continue” arrows at the bottom of the webpage to move through the cases.
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A 50-year-old man presents to your clinic with a 4-day history of fever, shortness of breath, and a cough productive of yellow-green sputum. He has a 30 pack-year smoking history and a chronic morning cough. His vital signs include the following:
On examination, he is able to speak in full sentences, and there is wheezing over both lung fields on auscultation.
Which of the following medications are most appropriate for this patient’s acute presentation? Select 3.
The patient returns for follow-up. Which of the following are the most important interventions to prevent further episodes? Select 3.
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This presentation is best managed as an acute exacerbation of chronic obstructive pulmonary disease (COPD). The symptoms of fever, shortness of breath, and productive cough with yellow-green sputum define the exacerbation. The patient has a chronic morning cough, and his long-term history of smoking tobacco fits into a possible COPD diagnosis. Salbutamol provides rapid bronchodilation to relieve wheezing and shortness of breath. Prednisone shortens recovery and improves airflow by reducing acute airway inflammation during an exacerbation. Yellow-green sputum suggests bacterial involvement, making amoxicillin-clavulanate a reasonable first-line outpatient antibiotic choice. Ciprofloxacin does not cover the typical pathogens seen in COPD exacerbations. Fluticasone or budesonide (inhaled corticosteroids) are controller therapies and do not provide the rapid short-course anti-inflammatory effect that is needed here, but they may be considered if there is a contraindication to oral prednisone use. Tiotropium and salmeterol are maintenance bronchodilators rather than acute-relief agents. Acetaminophen and acetylsalicylic acid (ASA) only address fever, pain, or both without treating the exacerbation. Cefprozil is not a preferred first-line choice in this setting—it is used as a second-line antibiotic. Theophylline has limited benefit and a higher toxicity risk.
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Interventions to prevent further chronic obstructive pulmonary disease (COPD) exacerbations are focused on reducing ongoing airway injury and lowering the risk of respiratory infections that commonly precipitate flare-ups. Smoking cessation is the most impactful intervention because ongoing tobacco exposure drives chronic bronchitis symptoms and increases exacerbation frequency. Influenza immunization reduces seasonal viral infections that often trigger worsening cough and breathlessness, and pneumococcal immunization lowers the risk for pneumococcal pneumonia and invasive disease in people with chronic lung disease. A healthy well-balanced diet is good general advice but does not specifically reduce COPD exacerbations. Pertussis or meningococcal vaccinations are not routinely prioritized for preventing COPD exacerbations. Avoiding environmental pollution or allergens may help some individuals, but this intervention is less reliable and harder to implement than smoking cessation and vaccinations. Switching to a vaping device still exposes the airways to irritants and is not a proven prevention strategy. Tapering prednisone does not add any extra benefit once the short course ends. Frequent handwashing helps reduce transmission risk but is not as high yield as immunization as most pathogens are airborne. Prophylactic trimethoprim-sulfamethoxazole is not used to prevent COPD exacerbations and carries adverse effects and resistance pressure.