Paper031. A 48-year-old on lithium carbonate for bipolar disorder has been stable for 2 years. eGFR 70 mL/min/1.73 m². What routine monitoring is required?A. Serum lithium every 3 months once stable, plus U&E and TSH at least every 6 months (NICE NG185/BNF)B. No blood tests are needed after the first year, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Daily lithium levels in GP for all stable patients, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. ALT only, never lithium levels, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper032. A 55-year-old on lithium starts regular ibuprofen for backache. Two weeks later he is ataxic. What is the most likely mechanism?A. Ibuprofen always lowers lithium levels, which is not the safest next step in NHS general practiceB. Ataxia proves the lithium dose is too low, which is not the safest next step in NHS general practiceC. NSAIDs have no lithium interaction, which is not the safest next step in NHS general practiceD. NSAIDs reduce lithium clearance and precipitate toxicityCheck
Paper033. A 31-year-old on lithium has a positive pregnancy test at 5 weeks. What is the most appropriate action? Select TWO correct statements.Select all that apply.A. Most appropriate: Urgent perinatal psychiatry/specialist advice the same week; do not stop lithium abruptly without a plan (teratogenicity vs relapse risk)B. The following is not the most appropriate next step: Double the dose because pregnancy increases clearance only, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: Valproate is safer in pregnancy so switch in GP today, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Most appropriate: Stop lithium today without any cover and discharge, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper034. A 36-year-old on clozapine has a sore throat and fever. What is the most appropriate GP action?A. Reassure that clozapine never affects neutrophils, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careB. Urgent FBC and stop/hold via the clozapine clinic protocol — do not wait until Monday if unwell (BNF)C. Increase clozapine for a 'viral prodrome', which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Give trimethoprim and continue clozapine without a blood test, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper035. A 38-year-old has panic disorder. She wants daily diazepam 'like her mother'. What is first-line long-term treatment? Select TWO correct statements.Select all that apply.A. Most appropriate: CBT and/or an SSRI (NICE CG113); benzodiazepines only short-term if at allB. The following is not the most appropriate next step: Propranolol as the only NICE option, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: Indefinite diazepam 10 mg four times daily, which is not the safest next step in NHS general practiceD. Most appropriate: Clozapine, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper036. A 19-year-old has had whispering voices and social withdrawal for 4 months. What service?A. Urgent early-intervention in psychosis (NICE NG23)B. Watch until he is 25, which is not the safest next step in NHS general practiceC. Start clozapine in GP, which is not the safest next step in NHS general practiceD. Routine bereavement counselling in 9 months, which is not the safest next step in NHS general practiceCheck
Paper037. A 84-year-old with moderate Alzheimer's wants to give her house to a new 'friend'. She cannot explain the consequences. What is the MCA approach?A. Capacity is proven if she can state her name, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline care despite sounding plausible in a hospital protocolB. You must always facilitate the gift the same day, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline care despite sounding plausible in a hospital protocolC. She may lack capacity for this specific decision — instruct a solicitor/safeguarding; best-interests/LPA processes, not a GP signature of convenienceD. Anyone with dementia lacks all capacity forever, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline care despite sounding plausible in a hospital protocolCheck
Paper038. A patient with myasthenia needs an antibiotic for a UTI. Which class is most likely to worsen MG? The most appropriate action is: Nitrofurantoin is the classic MG-worsening class in all texts, which is not the safest next step in NHS general practiceTRUE. TrueFALSE. FalseCheck
Paper039. A 27-year-old has painful visual loss in one eye and a relative afferent pupillary defect. What is the most appropriate action?A. Glaucoma drops in GP, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careB. Urgent ophthalmology/neurology for optic neuritis; do not start random COPD-dose prednisoloneC. Chloramphenicol drops, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Reassure as migraine aura lasting 2 weeks, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper0310. A 73-year-old with Parkinson's still drives. He has unpredictable off-periods and a recent minor collision. What is the most appropriate advice? Select TWO correct statements.Select all that apply.A. Most appropriate: He must not drive if he cannot safely control the vehicle; notify DVLA — Parkinson's is a relevant diagnosis (At a Glance)B. The following is not the most appropriate next step: Parkinson's never needs DVLA notification, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: He must drive more to 'practise', which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline care despite sounding plausible in a hospital protocolD. Most appropriate: Only Group 2 licences care about Parkinsonism, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck