Paper051. Idris, 44, a warehouse picker, has 18 hours of low back pain, bilateral sciatica, new urinary retention and perianal numbness to pin-prick. He can still walk. Most appropriate action?A. Same-day emergency MRI pathway for cauda equina syndrome (NICE NG59/GIRFT)B. Routine physiotherapy in 6 weeks with a lumbar X-ray first, which is not the safest next step in NHS general practiceC. Increase modified-release morphine and review after a fortnight, which is not the safest next step in NHS general practiceD. Chiropractic manipulation in the practice car park today, which is not the safest next step in NHS general practiceCheck
Paper052. Eilidh, 81, has 10 days of right temporal headache, scalp tenderness when brushing her hair, and 24 hours of binocular diplopia. CRP 46 mg/L. ESR is pending. Next step?A. Prednisolone 15 mg daily as for isolated PMR and review in 4 weeks, 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. Sumatriptan and an optician appointment in 3 months, 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. Withhold steroids until a temporal-artery biopsy is reported next month, 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. Treat as cranial GCA with ocular involvement: same-day rheumatology/ophthalmology and high-dose glucocorticoid now — do not wait for ESR or biopsy (NICE NG77/BSR)Check
Paper053. Callum, 13, has a limp and left knee pain for 3 weeks. He is overweight. Knee exam is normal; internal rotation of the hip is limited and painful. Next step? Select TWO correct statements.Select all that apply.A. Most appropriate: Urgent orthopaedic referral for slipped upper femoral epiphysis — do not force the hip through a full rangeB. The following is not the most appropriate next step: Intra-articular steroid injection of the knee in GP today, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: Request bilateral hip MRI from GP and wait 8 weeks before any referral, which is not the safest next step in NHS general practiceD. Most appropriate: Reassure as Osgood–Schlatter and discharge, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper054. Sian, 41, has 8 weeks of early-morning MCP and PIP swelling lasting 2 hours. RF and anti-CCP are negative. CRP 11. Most appropriate? The most appropriate action is: Reassure because seronegative disease cannot be rheumatoid arthritis, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careTRUE. TrueFALSE. FalseCheck
Paper055. Owain, 27, has 9 months of buttock and lumbar pain that wakes him at 04:00, eases with movement, and is associated with psoriasis and a swollen toe. HLA-B27 is unknown. Next step? The most appropriate action is: Lumbar X-ray to reassure and discharge, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careTRUE. TrueFALSE. FalseCheck
Paper056. Gareth, 76, a retired roofer, has a 12 mm expanding crusted nodule on the right helix that bleeds when he wears glasses. It has grown over 8 weeks. Action? The most appropriate action is: Suspected-cancer 2WW skin pathway for possible squamous cell carcinoma (NICE NG12)TRUE. TrueFALSE. FalseCheck
Paper057. Freya, 3, with atopic eczema develops punched-out vesicles, fever, and a painful face overnight. Mum used clobetasol from a relative. Action?A. Increase the clobetasol and add a bandage for 2 weeks at home, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careB. Oral aciclovir from leftover genital tubes without assessment, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Reassure as a flare of eczema alone, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Emergency paediatric/dermatology assessment for eczema herpeticum — stop potent steroid on infected skinCheck
Paper058. Pavel, 55, with plaque psoriasis is now red over more than 90% of his skin, shivering, and tachycardic. He stopped his topical regimen during a holiday. Action?A. Same-day dermatology/medical admission for erythroderma — thermoregulatory and fluid riskB. Restart vitamin D analogue cream only and review after 6 weeks, which is not the safest next step in NHS general practiceC. High-dose methotrexate 25 mg daily in GP, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Reassure as sunburn, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper059. Luca, 17, has moderate inflammatory acne. He used benzoyl peroxide alone for 2 weeks. NICE NG198 next pharmacological step?A. Isotretinoin issued from GP today, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careB. Dietary exclusion of all dairy as first-line NICE care, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. A fixed combination (e.g. topical retinoid plus benzoyl peroxide) — do not start long-term oral antibiotic monotherapyD. Oral lymecycline alone for 18 months with no topical agent, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper0510. Doreen, 71, far-sighted, has 2 hours of severe left eye pain, haloes around lights, vomiting, a mid-dilated oval pupil and a steamy cornea. Action?A. Immediate ophthalmology/999 for acute angle-closure glaucoma — do not dilateB. Chloramphenicol drops and review next week, which is not the safest next step in NHS general practiceC. Tropicamide in GP to get a better view of the disc, which is not the safest next step in NHS general practiceD. Oral pilocarpine from an old glaucoma relative and home observation, which is not the safest next step in NHS general practiceCheck