Paper061. Morwenna, 54, RA, methotrexate 15 mg once weekly. A locum writes 'methotrexate 15 mg daily' on a new FP10. Most appropriate action? Select TWO correct statements.Select all that apply.A. Most appropriate: Do not issue daily methotrexate — this is a never-event; rewrite as once weekly on a named day with folic acid (BNF/MHRA)B. The following is not the most appropriate next step: Issue the daily prescription because more is stronger for RA, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: Advise her to take 15 mg whenever the joints hurt, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Most appropriate: Switch to 2.5 mg three times daily to 'spread the dose', which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper062. Saffron, 68, has taken methotrexate 10 mg daily for 8 days in error. She has mouth ulcers and a dry cough. Action?A. Give extra folic acid 5 mg as if it were identical to folinic rescue in severe toxicity, which is not the safest next step in NHS general practiceB. Start trimethoprim for the mouth ulcers, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Stop methotrexate, urgent FBC/LFT, and hospital/NPIS advice — folinic acid rescue may be required (BNF/TOXBASE)D. Reassure and give the next weekly dose tonight, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper063. Kezia, 47, starts methotrexate 15 mg every Monday. What folic acid advice is typical in UK shared care? Select TWO correct statements.Select all that apply.A. Most appropriate: Folic acid 5 mg once weekly on a different day from methotrexate (local protocols vary; BNF expects supplementation)B. The following is not the most appropriate next step: Folinic acid 15 mg daily long term in all stable patients, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: Folic acid 5 mg every morning including the MTX morning as a way to cancel the MTX, which is not the safest next step in NHS general practiceD. Most appropriate: No folate is ever used with MTX, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper064. Jago, 34, and his partner are trying to conceive. He takes methotrexate 20 mg weekly for psoriasis. Advice?A. Effective contraception and specialist advice on washout/timing for both sexes — do not continue MTX in a conception plan without dermatology/rheumatology (BNF)B. Methotrexate is proven safe in early pregnancy so continue, 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. Only women need contraception; men can ignore washout advice, 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. Double the dose to 'clear psoriasis before pregnancy', 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
Paper065. Anwen, 59, has been on a stable methotrexate dose for 9 months with normal bloods. Typical BSR-style monitoring interval? The most appropriate action is: No blood tests after month 3 ever, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careTRUE. TrueFALSE. FalseCheck
Paper066. Blythe, 86, started sertraline 9 days ago. She is confused. Sodium 118 mmol/L, potassium 4.1, clinically euvolaemic. Most likely cause and action? Select TWO correct statements.Select all that apply.A. Most appropriate: SSRI-induced SIADH — stop the SSRI and admit for severe symptomatic hyponatraemia (MHRA/BNF)B. The following is not the most appropriate next step: Add indapamide to lift the sodium, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: Reassure that 118 mmol/L is a normal geriatric sodium, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Most appropriate: Increase sertraline because confusion means depression is worse, which is not the safest next step in NHS general practiceCheck
Paper067. Efsane, 71, euvolaemic, sodium 124 mmol/L, plasma osmolality 255 mOsm/kg, urine osmolality 620 mOsm/kg, urine sodium 55 mmol/L, TSH and morning cortisol normal. Interpretation?A. Hypertonic dehydration from pure water loss, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careB. Biochemical SIADH — investigate drugs, lung and CNS causes; do not give free water as first-lineC. Primary polydipsia (urine would be maximally dilute), which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Unreplaced GI losses (she would be hypovolaemic), which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper068. Ciaran, 64, vomiting 4 days, dry mucosa, sodium 126 mmol/L, urea 14 mmol/L, postural drop 28 mmHg. First principle?A. Hypovolaemic hyponatraemia — restore volume with saline in hospital as needed; fluid restriction is the wrong first moveB. Strict fluid restriction as if this were SIADH, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. 3% saline in GP, 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. Demeclocycline in the treatment room, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck
Paper069. Isolde, 77, sodium 112 mmol/L, has a seizure in the waiting room. Immediate action?A. Oral sodium tablets in GP as equivalent to 3% saline, 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. Rapid correction to 140 mmol/L within 2 hours in the surgery, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. 999 — hospital management of severely symptomatic hyponatraemia (hypertonic saline under specialist protocols) (NICE/Society for Endocrinology)D. Water restriction at home for 2 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 protocolCheck
Paper0610. Quorra, 22, after an all-night dance event with MDMA, is confused with sodium 119 mmol/L. Mechanism to recall? Select TWO correct statements.Select all that apply.A. Most appropriate: MDMA can cause SIADH plus water intoxication — emergency hospital care, not more free waterB. The following is not the most appropriate next step: Start an SSRI to cover serotonin, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careC. Most appropriate: Give 3 litres of water in the waiting room, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careD. Most appropriate: Diagnose simple hangover and discharge, which is not the safest next step in NHS general practice and this would delay appropriate UK-guideline careCheck