Station 83
Thomas Reid
Age: 39 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Clarify the reason for today’s call, confirm worsening joint symptoms and impact on function
- Ask about symptoms of RA flare: morning stiffness, joint swelling, pain, fatigue
- Ask which joints are currently affected and whether any other joints are involved.
- Ask if the patient is having difficulty moving the affected joint or is unable to move it at all. Ask whether the joint is hot or swollen, and enquire about any systemic symptoms such as fever or feeling unwell. This helps to rule out septic arthritis, which should be suspected if a single joint is hot, swollen, immobile, and accompanied by systemic features.
- Ask about extra-articular features of rheumatoid arthritis, including: Eyes (any redness or changes in vision, which may suggest episcleritis or scleritis), Lungs (any shortness of breath, persistent cough, or chest pain, which could indicate interstitial lung disease), Heart (any chest pain, palpitations, or breathlessness, which may suggest pericarditis) , Skin (any unusual rashes, easy bruising, or painful red spots, which may be signs of vasculitis)
- Ask about the functional impact of symptoms on activities of daily living, including the ability to work, write or type, and carry out domestic tasks such as cooking, cleaning, and self-care.
- Confirm last dose of methotrexate, any side effects experienced
- Ask if still taking folic acid
- Ask about other medications used in the meantime (e.g., NSAIDs)
- Explore any symptoms of infection (cough, fever, UTI, sore throat)- This is particularly important as restarting methotrexate in the presence of an active infection can delay recovery and increase the risk of serious complications, including sepsis.
- Clarify why bloods were missed – explore understanding of monitoring requirements
- Ask about social history including occupation, smoking and alcohol history.
- Explore Ideas, Concerns, Expectations
- Give a diagnosis of likely Rheumatoid Arthritis flare due to discontinuation of methotrexate
Example of explanation to patient
Thomas, thank you for getting in touch today and for being so open about what’s been going on. I’m really sorry to hear how much your symptoms have flared, I can appreciate how difficult that must be, especially given the demands of your work.
I agree with you, it does sound like you’re experiencing a flare of your rheumatoid arthritis, and the stopping of methotrexate has likely contributed to that. You had good control previously, so it’s understandable you’re keen to restart it.
The challenge is that methotrexate can affect your liver, kidneys, and reduce your blood cells, which can make you more vulnerable to infections. Because of this, national safety guidelines and our shared care agreement with Rheumatology require regular blood tests before we can safely prescribe it. That’s why it was stopped when the routine monitoring was missed.
I completely understand that work got hectic and that this wasn’t intentional. The important thing now is to get a new set of blood tests done. We’ll check your full blood count, kidney and liver function. Once we have the results, and everything looks safe, we can then get you restarted on methotrexate without further delay.
In the meantime, you mentioned you only just started taking ibuprofen yesterday. Taking it regularly, three times a day with food can help control the inflammation. Alternatively, we can prescribe naproxen, which is a stronger anti-inflammatory, along with omeprazole to protect your stomach.
If those don’t give enough relief, we also have the option of short-term steroid tablets to settle the flare, but I’d prefer to hold off unless really necessary.
I’ll also send a message to the rheumatology team today to inform them of your symptoms and ask if they have any additional advice or would like to see you sooner.
Would it help if we booked your blood test today and arranged a follow-up call once the results are back, so we can keep things moving quickly?
Exploring future support and safety-netting:
Going forward, how do you think we can support you in making sure these routine blood tests aren’t missed again?
One idea might be to set a recurring reminder on your phone or choose a set day well in advance to make it part of your schedule. We can also send you a reminder a month before your next blood test is due, to give you plenty of time to get it booked. What do you think would work best for you?
Finally, if your symptoms get significantly worse, for example, if your hands become very swollen, extremely painful, hot to touch, or you develop a fever or feel unwell — please contact us immediately. That could indicate an infection in the joint, which would need urgent attention.
Management
Management
- Acknowledge patient is likely experiencing a flare of rheumatoid arthritis due to methotrexate being withheld
- Explain methotrexate cannot be restarted until up-to-date blood tests are done to ensure safety
- Arrange urgent blood tests: full blood count, liver function tests, kidney function (U&Es), and CRP.
- Reinforce importance of regular monitoring for methotrexate due to risk of liver, kidney, and blood-related complications.
- Prescribe anti-inflammatory treatment for symptom relief: advise taking ibuprofen regularly with food and prescribe omeprazole for stomach protection. Alternatively, offer naproxen with omeprazole if stronger anti-inflammatory relief is needed or preferred
- Consider short course of oral steroids if symptoms are severe or not controlled with NSAIDs
- Advice that you will send an update to rheumatology team informing them of current symptoms and your intentions on restarting methotrexate once all blood tests are back and within reference range
- Discuss practical strategies to support future blood test compliance to avoid missed bloods (e.g. setting reminders, booking well in advance)
- Offer pneumococcal and annual influenza vaccination to reduce infection risk due to immunosuppressive therapy
- Safety-net: advise patient to seek urgent review if symptoms worsen, especially if joint becomes hot, swollen, immobile, or if they develop a fever or feel systemically unwell
- Book a follow-up appointment or telephone review once blood results are available
Learning point from this station:
This case highlights the critical importance of safety monitoring in patients prescribed immunosuppressive medications such as methotrexate. As per NICE guidelines and shared care protocols, patients on disease-modifying anti-rheumatic drugs (DMARDs) require regular blood tests, typically every 2 to 3 months, to monitor for potentially serious adverse effects.
These adverse effects may include:
- Myelosuppression (reduced blood cell production)
- Hepatotoxicity
- Renal impairment
- Pulmonary toxicity
- And an increased risk of infection
If a patient misses their monitoring, it is the GP’s duty to withhold methotrexate until updated blood results confirm it is safe to resume. Restarting treatment without appropriate monitoring can result in severe complications, including bone marrow suppression and organ toxicity.
In patients presenting with a flare of rheumatoid arthritis, it is important to liaise with rheumatology or seek specialist advice where possible. However, while awaiting a specialist review, GPs may consider interim management to alleviate symptoms and maintain function.
Management options during a flare include:
- NSAIDs (e.g. ibuprofen or naproxen with gastroprotection)
- Oral corticosteroids
- Intra-articular steroid injections (if a single joint is significantly affected)
For oral steroid use, a reducing course of glucocorticoids over 2–4 weeks can be started in appropriate cases while awaiting specialist input. An example 2-week course could be: Prednisolone 10 mg daily for 7 days, then 5 mg daily for 7 days, then stop.
Importantly, this scenario also illustrates the value of health promotion and practical planning. Helping patients develop strategies to avoid missing future blood tests, such as setting reminders or scheduling tests well in advance, can: support long-term medication adherence, prevent disease recurrence and reduce the risk of complications from delayed treatment.
This station integrates key principles of safe prescribing, flare management, and patient engagement in long-term condition care.