A 65-year-old man attends for NHS Health Check. His cardiovascular risk score (QRISK3) is calculated as 18%. He has no known cardiovascular disease. His total cholesterol is 6.2 mmol/L, HDL 1.1 mmol/L, blood pressure 138/84 mmHg, and HbA1c 41 mmol/mol. He is a non-smoker with BMI 27 kg/m². According to NICE guidance, which intervention should be offered first?
Q152
A 38-year-old woman presents requesting cervical screening. Her last cervical sample was taken 4 years ago and showed borderline nuclear changes with negative high-risk HPV testing. She has had no abnormal bleeding or discharge. She has had the same male partner for 5 years. Examination reveals a healthy-looking cervix with no lesions. What is the most appropriate management?
Q153
A 52-year-old woman with type 2 diabetes mellitus attends for her annual review. She has a BMI of 31 kg/m². Her HbA1c is 58 mmol/mol. She currently takes metformin 1g twice daily. She smokes 15 cigarettes per day and drinks 25 units of alcohol weekly. Her blood pressure is 142/88 mmHg. Which lifestyle intervention would provide the greatest cardiovascular risk reduction for this patient?
Q154
A 60-year-old woman attends for her NHS bowel cancer screening results. Her faecal immunochemical test (FIT) result shows 85 micrograms of haemoglobin per gram of faeces. She is asymptomatic with no change in bowel habit, no weight loss, and no family history of colorectal cancer. Her abdominal examination is unremarkable. What is the most appropriate next step in her management?
Screening & Prevention UK Medical PG Practice Questions and MCQs
Question 151: A 65-year-old man attends for NHS Health Check. His cardiovascular risk score (QRISK3) is calculated as 18%. He has no known cardiovascular disease. His total cholesterol is 6.2 mmol/L, HDL 1.1 mmol/L, blood pressure 138/84 mmHg, and HbA1c 41 mmol/mol. He is a non-smoker with BMI 27 kg/m². According to NICE guidance, which intervention should be offered first?
A. Arrange carotid Doppler ultrasound
B. Commence atorvastatin 20mg once daily (Correct Answer)
C. Commence aspirin 75mg once daily
D. Lifestyle advice on diet and exercise with review in 3 months
E. Start amlodipine 5mg once daily for blood pressure
Explanation: ***Commence atorvastatin 20mg once daily***
- This patient has a **QRISK3 score of 18%**, which is significantly above the **10% threshold** for offering statin therapy for **primary prevention of cardiovascular disease** according to **NICE guidelines**.
- **Atorvastatin 20mg** is the recommended **first-line statin** for this purpose, aimed at reducing **lipid levels** and overall cardiovascular risk.
*Arrange carotid Doppler ultrasound*
- **Carotid Doppler ultrasound** is typically indicated for patients with symptoms suggestive of **carotid artery disease**, such as **transient ischemic attacks (TIAs)** or **stroke**, to assess for **carotid stenosis**.
- It is **not recommended** as a routine screening tool for asymptomatic individuals based solely on a high **QRISK3 score** for primary prevention of CVD.
*Commence aspirin 75mg once daily*
- **NICE guidance** no longer recommends **aspirin** for the **primary prevention** of cardiovascular disease due to the increased risk of **gastrointestinal bleeding** and other adverse events outweighing the small benefits.
- **Aspirin 75mg** is primarily used for **secondary prevention** in patients with established cardiovascular disease (e.g., post-MI, stroke).
*Lifestyle advice on diet and exercise with review in 3 months*
- While **lifestyle modifications** (diet, exercise) are fundamental for cardiovascular health, they are **insufficient as the sole intervention** for a patient with a **QRISK3 score of 18%**.
- **NICE guidelines** explicitly state that drug treatment (statin) should be **offered immediately** alongside lifestyle advice for individuals at this level of risk, rather than waiting for a review.
*Start amlodipine 5mg once daily for blood pressure*
- This patient's blood pressure is **138/84 mmHg**, which falls within the high-normal range but is generally **below the threshold for initiating pharmacological treatment** for hypertension in primary prevention according to **NICE guidelines**.
- **Lifestyle advice** would be the initial recommendation for blood pressure at this level, with ongoing monitoring, rather than immediate medication.
Question 152: A 38-year-old woman presents requesting cervical screening. Her last cervical sample was taken 4 years ago and showed borderline nuclear changes with negative high-risk HPV testing. She has had no abnormal bleeding or discharge. She has had the same male partner for 5 years. Examination reveals a healthy-looking cervix with no lesions. What is the most appropriate management?
A. Arrange repeat cervical screening in 6 months
B. Reassure and advise routine recall in 1 year
C. Offer HPV vaccination followed by screening in 3 months
D. Perform cervical screening now (Correct Answer)
E. Refer for colposcopy
Explanation: ***Perform cervical screening now*** - In the UK cervical screening programme, women aged **25-49** are screened every **3 years**; since her last test was 4 years ago, she is currently overdue. - A previous result showing **borderline nuclear changes** but **negative hrHPV** testing dictates a return to **routine recall**, rather than early surveillance or colposcopy. *Arrange repeat cervical screening in 6 months* - There is no clinical indication for **early recall** at 6 months because the patient is already past her **3-year routine interval**. - Six-month follow-up is typically reserved for follow-up after **treatment for CIN** or previous **hrHPV-positive** results. *Reassure and advise routine recall in 1 year* - Waiting another year would lead to a **5-year interval** between screenings, which exceeds the recommended 3-year frequency for her age group. - Immediate testing is necessary to maintain the safety and efficacy of the **screening schedule**. *Offer HPV vaccination followed by screening in 3 months* - **HPV vaccination** is not used as a clinical intervention to dictate the timing of routine screening for those already at the screening age. - Routine screening should not be delayed or advanced based on vaccination status, as the **screening protocol** remains the same regardless. *Refer for colposcopy* - **Colposcopy** is only indicated if the screening reveals **high-risk HPV** or significant cytological abnormalities (like high-grade spans). - Since her previous result was **hrHPV negative**, she remained at low risk, and there is currently no lesion or symptom to justify an urgent referral.
Question 153: A 52-year-old woman with type 2 diabetes mellitus attends for her annual review. She has a BMI of 31 kg/m². Her HbA1c is 58 mmol/mol. She currently takes metformin 1g twice daily. She smokes 15 cigarettes per day and drinks 25 units of alcohol weekly. Her blood pressure is 142/88 mmHg. Which lifestyle intervention would provide the greatest cardiovascular risk reduction for this patient?
A. Weight reduction of 5-10% body weight
B. Smoking cessation (Correct Answer)
C. Reduction of alcohol intake to <14 units per week
D. Increase physical activity to 150 minutes moderate intensity per week
E. Adoption of a Mediterranean-style diet
Explanation: ***Smoking cessation***- **Smoking cessation** is the single most impactful lifestyle intervention for reducing **cardiovascular risk**, offering a rapid and substantial risk reduction (e.g., approximately **50% reduction** in risk within one year of quitting).- In patients with **Type 2 Diabetes**, smoking significantly exacerbates **atherosclerosis**, causes **endothelial dysfunction**, and increases prothrombotic states, making its elimination the highest priority for risk mitigation.*Weight reduction of 5-10% body weight*- While beneficial for improving **insulin sensitivity**, lowering **HbA1c**, and reducing blood pressure, weight loss typically results in a smaller magnitude of **cardiovascular event reduction** (around 15-20%) compared to smoking cessation.- Although an important goal for overall metabolic health, its immediate and absolute impact on cardiovascular mortality is not as profound as discontinuing **tobacco use**.*Reduction of alcohol intake to <14 units per week*- Reducing high alcohol intake (25 units/week) to recommended limits helps in improving **blood pressure control** and reducing **caloric intake**, which positively impacts cardiovascular health.- The cardiovascular risk reduction from alcohol moderation is notable (estimated 20-30%) but does not supersede the overwhelming benefit of quitting **smoking** in a high-risk individual.*Increase physical activity to 150 minutes moderate intensity per week*- Regular **physical activity** improves lipid profiles, **glycemic control**, and blood pressure, reducing cardiovascular risk by approximately **20-30%**.- While crucial for long-term health and disease management, the absolute reduction in **mortality and morbidity** provided by exercise alone is generally less than that achieved by eliminating **smoking**.*Adoption of a Mediterranean-style diet*- A **Mediterranean-style diet** is associated with significant reductions in major cardiovascular events (e.g., a **30% reduction** in stroke and myocardial infarction) due to its emphasis on whole foods and healthy fats.- Despite its proven benefits for **metabolic health** and primary prevention, it still provides a less dramatic immediate risk reduction than the complete cessation of exposure to **tobacco smoke**.
Question 154: A 60-year-old woman attends for her NHS bowel cancer screening results. Her faecal immunochemical test (FIT) result shows 85 micrograms of haemoglobin per gram of faeces. She is asymptomatic with no change in bowel habit, no weight loss, and no family history of colorectal cancer. Her abdominal examination is unremarkable. What is the most appropriate next step in her management?
A. Reassure and repeat FIT in 2 years
B. Refer for colonoscopy within 2 weeks (Correct Answer)
C. Arrange CT colonography
D. Repeat FIT in 3 months
E. Refer routinely to gastroenterology
Explanation: ***Refer for colonoscopy within 2 weeks*** - In the **NHS Bowel Cancer Screening Programme**, a **FIT result of 85 μg/g** is significantly above the threshold for positivity (often ≥10 μg/g or a higher action threshold) and requires urgent investigation. - A **colonoscopy** is the **gold-standard investigation** for a positive screening test, as it allows for direct visualization, **biopsy** of suspicious lesions, and removal of **precancerous polyps** within a **2-week wait** pathway.*Reassure and repeat FIT in 2 years* - This approach is only appropriate for participants with a **negative FIT result** (below the threshold). - Delaying investigation for a positive test by 2 years would significantly increase the risk of missing a **colorectal malignancy**.*Arrange CT colonography* - While used in some clinical pathways, it is not the **first-line investigation** for a positive screening FIT unless the patient is unfit for a colonoscopy. - Unlike colonoscopy, **CT colonography** does not allow for immediate biopsy or **polypectomy**, necessitating a second procedure if abnormalities are found.*Repeat FIT in 3 months* - There is no role for repeating a **positive FIT**; any single result above the threshold demands definitive investigation. - Repeating the test leads to a **delayed diagnosis** and ignores the established evidence that a single positive result is predictive of pathology.*Refer routinely to gastroenterology* - Screening-positive patients must be managed via the **fast-track 2-week wait (2WW)** pathway to ensure timely cancer diagnosis. - A **routine referral** is inappropriate because the probability of finding cancer or high-risk adenomas is high enough to justify urgent secondary care assessment.
