CCFP priority topic 14 of 105
Chronic Disease on the CCFP exam
5 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 5 key features for Chronic Disease. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 5
New acute symptoms
When someone with a long-term illness falls acutely ill, work out the cause.
CFPC skill Clinical reasoningPhase DiagnosisSources Choosing Wisely Canada / national participating organizations, Choosing Wisely Canada
On the exam
A teen with type 1 diabetes has vomited all night, and her belly pain has moved low on the right. Expect a short menu (pick several from a list) of diagnoses.
Pick the diagnoses to keep on the list.
Common mistakes
Blaming the diabetes for everything, or stopping at stomach flu. A glucose that looks manageable does not rule out ketoacidosis, and pain that moves to the right lower belly can be appendicitis.
Approach
- Sort each new symptom three ways: a complication of the illness, a flare of it, or a new problem.
- Diabetes with vomiting: think of ketoacidosis, even if the glucose looks only mildly high. Send the patient in today; do not wait to recheck.
- Then look past the diabetes. Pain that moves to the right lower belly needs appendicitis ruled out. Both can happen at once.
- In a long-term care resident without a catheter, confusion alone is not a urinary tract infection. Look first for dehydration, constipation, skin breakdown, medicines and other infections.
- Send a urine culture only when the signs in the table below are present.
- In an older patient whose thinking has changed, do not test the urine unless there are clear signs of infection.
- Ask why a positive culture was sent. If that reason settled without antibiotics, do not treat.
| No catheter | Catheter in place | |
|---|---|---|
| Signs needed | New burning on passing urine, or two or more of: fever, new or worse urgency, frequency, pain above the pubic bone, visible blood, flank pain, urinary incontinence | Any one of: fever, flank pain, shaking chills, new delirium, once other causes are ruled out |
| Confusion alone | Not a sign of urinary infection | New delirium counts only once other causes are ruled out |
| Before you collect | Rule out other causes of the change | Rule out other causes. Replace a catheter in place over 14 days, then collect |
| Fever means | Above 37.9 °C, or 1.5 °C above usual twice in 12 hours | Same |
Key feature 2 of 5
Checking adherence
At each follow-up, keep asking whether the patient really takes each medicine as agreed.
CFPC skill Clinical reasoningPhase History, follow-upSources Choosing Wisely Canada
On the exam
A teen with type 1 diabetes had ketoacidosis with no clear trigger. Her glycated hemoglobin (A1C) keeps rising. Expect one best answer.
Pick the next step at this visit.
Common mistakes
Raising her insulin, or starting a pump, before asking whether doses are missed. If doses are skipped, a bigger dose brings lows on the days she takes it.
Approach
- Ask about missed doses at every visit, without blame: "Most people miss some. How many this week?"
- Ask before you change a dose. More medicine on top of skipped doses causes harm on the days it is taken.
- Check what you can: refill dates, pill counts, and glucose meter or sensor downloads.
- Review the whole medication list before you add or change a drug. Many medicines go with poorer adherence and more side effects.
- Treat a rising A1C, a flare with no cause or a lapsed prescription as a cue to ask again.
- After an emergency with no clear cause, see the patient again soon, not at the next routine visit.
Key feature 3 of 5
Pain
Ask every patient with a long-term illness about pain, then treat it safely and fully.
CFPC skill Clinical reasoningPhase History, treatment, hypothesis generationSources Choosing Wisely Canada
On the exam
A 9 kg infant with sickle cell disease has swollen hands and feet and no fever. Expect a short menu (pick several from a list) for his pain plan.
Pick the parts of a safe pain plan.
Common mistakes
Accepting teething as the cause and sending the infant home without a pain plan. Swollen hands and feet in sickle cell disease point to blocked vessels.
Approach
- Ask about pain at every visit, even when the visit is for something else. Many patients do not raise it.
- In an infant with sickle cell disease, swollen hands and feet without fever fit blocked small blood vessels, called dactylitis.
- Work out each dose in mg per kg, and check the daily maximum before you write it.
- Before you add a drug, check the full list for interactions and for illnesses it can worsen.
- For long-term pain, do not start long-term opioids. Build the plan on physical activity for osteoarthritis and chronic low back pain.
- For a short spell of severe pain, use the lowest opioid dose that works, and stop when the episode ends.
Key feature 4 of 5
Mood and coping
Ask how the illness affects the patient's mood, daily life, safety and use of substances.
CFPC skill Patient-centred approach, clinical reasoningPhase HistorySources Choosing Wisely Canada
On the exam
A woman with rheumatoid arthritis has stopped working and sleeps badly. Expect a short menu (pick several from a list) of things to ask.
Pick what to ask about.
Common mistakes
A visit spent only on joint counts and blood tests. Or skipping the suicide question in case it upsets her: asking does not plant the idea.
Approach
- Ask what the diagnosis means to the patient: fear, grief, anger, worry about work and family.
- Ask what the patient can no longer do: work, self-care, chores, driving, sex, hobbies.
- Ask about low mood and loss of interest. Depression is common in long-term illness and makes the illness harder to manage.
- If mood is low, ask directly about thoughts of suicide, a plan and access to means.
- Ask about alcohol, cannabis, opioids and sedatives, including drugs taken for pain or sleep.
- In older adults, sleeping pills are not a first choice for insomnia. They raise the risk of falls and hip fractures.
Key feature 5 of 5
Why doses are missed
When a patient is not following the plan, learn what gets in the way, then fix that.
CFPC skill Patient-centred approachPhase HistorySources Choosing Wisely Canada
On the exam
An infant with sickle cell disease has had no penicillin for 6 weeks. His parent is at the visit. Expect a short menu (pick several from a list) of questions.
Pick the questions that find the barrier.
Common mistakes
Spending the visit on family history, past admissions or vaccines. Each matters, but none explains why his doses stopped. Blaming one new routine, such as daycare, misses doses that should be given at home.
Approach
- Ask open, blame-free questions: what happened, when it stopped, and what made it hard.
- Check the practical barriers: an empty bottle, no refill, cost, pharmacy access, taste, a hard schedule.
- Ask what the patient or parent believes the medicine does, and about any fear of side effects.
- Ask what changed when the doses stopped: a move, a new job, a new baby, a lost drug plan.
- In teens, ask about doses at school and around friends. Embarrassment often explains missed doses.
- Leave out personal questions that do not bear on the missed doses.
- Agree on one fix aimed at the barrier: refills, a simpler regimen, fewer drugs or reminders. Book a check soon.
Flashcards
Answer it first, then check.
KF 1A resident with dementia is more confused. No fever, no urinary signs. Send a urine culture?
No. Confusion alone is not a urinary infection. Look for dehydration, constipation, medicines and other infections first. Source: Choosing Wisely Canada / national participating organizations
KF 1A resident has a urinary catheter. Which single signs justify a urine culture?
Any one of fever, flank pain, shaking chills or new delirium, once other causes are ruled out. Source: Choosing Wisely Canada / national participating organizations
KF 1A resident's urine grows bacteria, but the reason for testing has settled. Do you treat?
No. Ask why it was sent. If the reason settled without antibiotics, do not treat. Source: Choosing Wisely Canada / national participating organizations
KF 2A teen's A1C is rising on insulin doses that should work. What do you ask first?
Whether doses are missed, and which ones. Change the dose only once you know.
KF 3An infant with sickle cell disease has swollen, painful hands and feet, no fever. What is it?
Dactylitis: blocked small blood vessels in the hands and feet. It is not teething, so treat the pain.
KF 3A patient with knee osteoarthritis asks for a long-term opioid. What do you offer instead?
Physical activity as the base of the plan. Long-term opioids are not started for chronic pain. Source: Choosing Wisely Canada
KF 4A patient with a long-term illness has low mood. What must you ask next?
About thoughts of suicide, a plan and access to means, and about alcohol and drug use.
KF 5A parent stopped a child's daily penicillin weeks ago. What is your first question?
What got in the way. Ask openly when it stopped and what made it hard, without blame.
FAQ
Is this topic about one disease?
No. Any long-term illness can carry the case: diabetes, sickle cell disease, dementia, arthritis, asthma. The marks go to the approach: new symptoms, missed doses, pain and coping.
Should I say compliance or adherence?
Most clinicians now say adherence, because the plan is agreed with the patient. The exam may use either word. What counts is asking why doses are missed, without blame.
Does confusion in a long-term care resident mean a urine test?
Not on its own. Without a catheter, look for urinary signs and other causes first. With a catheter, new delirium counts only once other causes are ruled out.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Using antibiotics wisely in long-term careChoosing Wisely Canada / national participating organizations
- Choosing Wisely recommendationsChoosing Wisely Canada