Screening & Prevention — MCQs

A 72-year-old man with type 2 diabetes for 20 years attends for review. His diabetic eye screening report states: 'Background diabetic retinopathy with scattered microaneurysms and dot hemorrhages in both eyes. Several hard exudates noted within the temporal arcade of the right macula. No neovascularization. Graded as R2M1 right eye, R1M0 left eye.' What is the most appropriate action?

Q53

A 48-year-old woman with a BMI of 39 kg/m² attends for weight management review. She has been following a calorie-controlled diet and exercising regularly for 6 months but has lost only 3 kg. She has hypertension, type 2 diabetes (HbA1c 64 mmol/mol), and obstructive sleep apnoea. She asks about weight loss medication. What is the most appropriate pharmacological option?

Q54

A 52-year-old man attends requesting lifestyle advice. He currently drinks 4-5 pints of lager (4.5% ABV) on Friday and Saturday nights. He wants to reduce his drinking. On calculation, his weekly alcohol consumption is approximately 36 units. He has no features of alcohol dependence. Which intervention strategy has the strongest evidence base for effectiveness in this primary care setting?

Q55

A 59-year-old woman with type 2 diabetes attends for annual review. She has not attended diabetic eye screening for 3 years despite invitations. She explains she doesn't attend because she can see perfectly well and has no eye symptoms. Her HbA1c is 78 mmol/mol. What is the best approach to encourage screening attendance?

Q56

A 46-year-old man attends for an NHS Health Check. He smokes 15 cigarettes daily, drinks 28 units of alcohol weekly, and has a BMI of 31 kg/m². Blood pressure is 138/86 mmHg. Fasting blood tests show: total cholesterol 6.2 mmol/L, HDL 0.9 mmol/L, non-HDL 5.3 mmol/L, HbA1c 41 mmol/mol, eGFR 78 ml/min. His QRISK3 score is 18%. Considering the hierarchy of intervention priorities, which lifestyle modification should be the primary focus?

Q57

A 34-year-old woman attends with her cervical screening result showing hrHPV positive with normal cytology. She is anxious and asks what this means. She is in a long-term monogamous relationship and has had the same partner for 8 years. What is the most appropriate explanation and management?

Q58

A 57-year-old woman attends for her NHS breast screening mammogram. She has been taking combined HRT (oestrogen and progestogen) for 4 years for menopausal symptoms. She asks whether her HRT use affects the accuracy of mammography. Which statement best explains the effect of HRT on breast screening?

Q59

What is the screening interval for cervical screening in women aged 50-64 years in the NHS Cervical Screening Programme in England?

Q60

A 62-year-old woman attends for discussion of her NHS bowel cancer screening result. Her FIT result is 95 micrograms Hb/g faeces. She has no symptoms and examination is unremarkable. She is on clopidogrel following a TIA 18 months ago. Which of the following factors is most likely to have contributed to her positive FIT result?

Screening & Prevention UK Medical PG Practice Questions and MCQs

Question 51: A 33-year-old woman attends for cervical screening. She is 16 weeks pregnant. She mentions she received a letter but wasn't sure if she should attend while pregnant. Her last cervical screen was 3.5 years ago and was normal. What is the most appropriate management?

A. Proceed with cervical screening today as scheduled
B. Defer cervical screening until 12 weeks postpartum (Correct Answer)
C. Defer cervical screening until 3 months postpartum
D. Arrange urgent colposcopy due to pregnancy
E. Perform cervical screening only if she has symptoms

Explanation: ***Defer cervical screening until 12 weeks postpartum*** - In routine cases, **cervical screening** should be delayed until at least **12 weeks (3 months) postpartum** to allow the cervix to recover from physiological changes. - Pregnancy-induced changes like **increased vascularity** and **decidualization** interfere with accurate cytological interpretation, leading to a high rate of **inadequate samples**. *Proceed with cervical screening today as scheduled* - Routine screening is not recommended during pregnancy because the result is likely to be **unreliable** or **inconclusive**. - There is also a slightly increased risk of **minor bleeding** from the hyperemic cervix, which can cause unnecessary patient anxiety. *Defer cervical screening until 3 months postpartum* - While 3 months is equivalent to 12 weeks, the standard clinical guideline specifies waiting until **12 weeks postpartum** for the cervix to return to its non-pregnant state. - This timing ensures that the **transformation zone** has fully regressed and inflammatory changes have resolved for an accurate test. *Arrange urgent colposcopy due to pregnancy* - **Colposcopy** is only indicated during pregnancy if there is a clinical suspicion of **malignancy** or a high-grade abnormal smear prior to conception. - Routine screening intervals or being slightly overdue are not indications for **referral** in the absence of symptoms or previous high-grade dyskaryosis. *Perform cervical screening only if she has symptoms* - If a pregnant woman presents with symptoms like **postcoital bleeding**, she should be referred for **clinical assessment** or colposcopy rather than routine screening. - Routine screening represents a preventive tool for asymptomatic women and should follow the **standard deferral protocol** regardless of pregnancy timing unless pathology is suspected.

Question 52: A 72-year-old man with type 2 diabetes for 20 years attends for review. His diabetic eye screening report states: 'Background diabetic retinopathy with scattered microaneurysms and dot hemorrhages in both eyes. Several hard exudates noted within the temporal arcade of the right macula. No neovascularization. Graded as R2M1 right eye, R1M0 left eye.' What is the most appropriate action?

A. Continue annual diabetic eye screening and routine diabetes care
B. Arrange repeat screening in 6 months to monitor progression
C. Refer urgently (within 1 week) to ophthalmology for assessment
D. Refer routinely to ophthalmology within 6 weeks for assessment (Correct Answer)
E. Reassure patient that no specific action is needed beyond usual care

Explanation: ***Refer routinely to ophthalmology within 6 weeks for assessment*** - The grading **M1** in the right eye indicates the presence of **maculopathy**, specifically noting "several hard exudates within the temporal arcade of the right macula," which is a **sight-threatening** condition. - The **R2 grading** (pre-proliferative retinopathy) also necessitates ophthalmological review due to the increased risk of progression to proliferative disease, and both **M1** and **R2** warrant a **routine referral** for specialist assessment and potential treatment. *Continue annual diabetic eye screening and routine diabetes care* - Annual screening is appropriate for patients with **R0M0 (no retinopathy)** or stable **R1M0 (background retinopathy without maculopathy)**. - Given the presence of **R2 (pre-proliferative retinopathy)** and **M1 (maculopathy)**, this patient requires more urgent and specialized intervention than standard annual screening provides. *Arrange repeat screening in 6 months to monitor progression* - While some stable pre-proliferative cases (R2M0) might warrant closer monitoring, the presence of **M1 maculopathy** is an immediate concern requiring direct specialist ophthalmology assessment, not just another screening. - Delaying to 6 months is inappropriate as prompt assessment and treatment for maculopathy can prevent **irreversible vision loss**. *Refer urgently (within 1 week) to ophthalmology for assessment* - **Urgent referral** is typically reserved for **R3 (proliferative diabetic retinopathy)**, severe or sudden vision loss, **vitreous hemorrhage**, or suspected **retinal detachment**. - While serious, **R2M1** is generally managed via a **routine referral pathway** (e.g., within 4-6 weeks), which is less immediate than an urgent referral. *Reassure patient that no specific action is needed beyond usual care* - This is incorrect as the patient has definite **pre-proliferative retinopathy (R2)** and **maculopathy (M1)**, both of which are **referable conditions** indicating significant diabetic eye disease. - Failing to act on these findings could lead to preventable and **permanent central vision loss**, especially from the maculopathy.

Question 53: A 48-year-old woman with a BMI of 39 kg/m² attends for weight management review. She has been following a calorie-controlled diet and exercising regularly for 6 months but has lost only 3 kg. She has hypertension, type 2 diabetes (HbA1c 64 mmol/mol), and obstructive sleep apnoea. She asks about weight loss medication. What is the most appropriate pharmacological option?

A. Rimonabant 20 mg once daily
B. Orlistat 120 mg three times daily with meals
C. Liraglutide 3.0 mg subcutaneous injection once daily (Correct Answer)
D. Metformin 500 mg twice daily for weight reduction
E. Phentermine 37.5 mg once daily

Explanation: ***Liraglutide 3.0 mg subcutaneous injection once daily*** - **Liraglutide** (a GLP-1 receptor agonist) is indicated for weight management in patients with a **BMI ≥30** (or ≥27 with comorbidities) who have failed lifestyle interventions. - It is particularly beneficial for this patient as it helps manage **weight loss** while simultaneously improving **glycemic control** (HbA1c) and associated comorbidities like **Type 2 Diabetes** and **obstructive sleep apnoea**. *Orlistat 120 mg three times daily with meals* - While licensed for weight loss, it typically results in significantly **less weight reduction** compared to GLP-1 agonists and is often poorly tolerated due to **gastrointestinal side effects** like steatorrhea. - This patient's high BMI and multiple metabolic comorbidities warrant a more potent and effective pharmacological agent like **Liraglutide** as a primary choice. *Metformin 500 mg twice daily for weight reduction* - While **Metformin** is used to treat Type 2 Diabetes and can be weight-neutral or cause modest weight loss, it is not a primary **weight management medication** with robust evidence for significant weight reduction. - It does not provide the clinically significant **weight loss of ≥5%** required to address her severe obesity (BMI 39 kg/m²) and associated comorbidities effectively. *Phentermine 37.5 mg once daily* - **Phentermine** is a sympathomimetic amine that is often not licensed or recommended for long-term use in many regions (including the UK) due to **cardiovascular safety concerns**. - Given the patient's existing **hypertension**, using a stimulant-based appetite suppressant would be contraindicated or high-risk. *Rimonabant 20 mg once daily* - **Rimonabant**, an endocannabinoid receptor antagonist, was **withdrawn from the market** globally due to severe psychiatric side effects, including depression and suicidal ideation. - It is associated with a significantly increased risk of **depression and suicidal ideation**, making it an obsolete and unsafe recommendation.

Question 54: A 52-year-old man attends requesting lifestyle advice. He currently drinks 4-5 pints of lager (4.5% ABV) on Friday and Saturday nights. He wants to reduce his drinking. On calculation, his weekly alcohol consumption is approximately 36 units. He has no features of alcohol dependence. Which intervention strategy has the strongest evidence base for effectiveness in this primary care setting?

A. Provision of written information leaflets about recommended alcohol limits
B. Brief intervention using motivational interviewing techniques (Correct Answer)
C. Referral to community alcohol services for specialist counseling
D. Prescription of disulfiram to support abstinence attempts
E. Recommendation to attend Alcoholics Anonymous meetings

Explanation: ***Brief intervention using motivational interviewing techniques*** - **Brief interventions** (5-10 minutes) delivered in primary care have the strongest evidence base for reducing consumption in **hazardous drinkers** who are not yet dependent. - These techniques, often using the **FRAMES model**, focus on enhancing **self-efficacy** and personal responsibility, which is ideal for a patient already motivated to change. *Provision of written information leaflets about recommended alcohol limits* - **Written materials** alone are significantly less effective than **personalized counseling** or brief face-to-face discussions. - Leaflets are best used as an **adjunct** to a brief intervention rather than a standalone primary strategy. *Referral to community alcohol services for specialist counseling* - **Specialist referral** is generally reserved for patients with complex needs or **alcohol dependence**, rather than uncomplicated hazardous drinking. - Managing the patient in a **primary care setting** is more resource-efficient and appropriate for someone drinking 36 units without dependency signs. *Prescription of disulfiram to support abstinence attempts* - **Disulfiram** is an aversive agent indicated strictly for **alcohol dependence** to maintain abstinence, not for harm reduction in hazardous drinkers. - Given the patient lacks features of **dependence**, pharmacological treatment is contraindicated and carries unnecessary risks of **toxicity**. *Recommendation to attend Alcoholics Anonymous meetings* - **Alcoholics Anonymous (AA)** follows a 12-step model designed for **alcoholics** seeking lifelong sobriety, which may not align with this patient's goal to simply reduce drinking. - While helpful for some, the evidence for **AA** is most robust in populations with established **dependence** rather than non-dependent hazardous drinkers.

Question 55: A 59-year-old woman with type 2 diabetes attends for annual review. She has not attended diabetic eye screening for 3 years despite invitations. She explains she doesn't attend because she can see perfectly well and has no eye symptoms. Her HbA1c is 78 mmol/mol. What is the best approach to encourage screening attendance?

A. Explain that most sight-threatening diabetic retinopathy is asymptomatic until advanced (Correct Answer)
B. Arrange urgent optometry referral for comprehensive eye examination
C. Document her refusal and discharge her from the diabetic eye screening programme
D. Warn her that she may lose her driving licence if she doesn't attend screening
E. Reassure her that absence of symptoms means screening is less urgent

Explanation: ***Explain that most sight-threatening diabetic retinopathy is asymptomatic until advanced*** - Patient education must address the misconception that normal vision excludes pathology; **diabetic retinopathy** is notoriously **asymptomatic** in early stages. - Early detection through **digital photography screening** allows for timely intervention before permanent, irreversible visual loss occurs. *Arrange urgent optometry referral for comprehensive eye examination* - An urgent referral is not clinically indicated as the patient is currently **asymptomatic**, and specialized **diabetic eye screening programs** are the gold standard over routine optometry. - The primary goal at this stage is to fix the **screening gap** and address the patient's health beliefs rather than bypass systematic screening protocols. *Document her refusal and discharge her from the diabetic eye screening programme* - Discharging a patient from a necessary screening program due to a misunderstanding of risk is not **patient-centered care** and increases the risk of **preventable blindness**. - While **autonomy** and documentation are important, the clinician’s role is to ensure the patient makes an **informed decision** by explaining the risks of non-attendance. *Warn her that she may lose her driving licence if she doesn't attend screening* - This approach is coercive and factually incorrect; **DVLA requirements** are based on functional **visual acuity** and fields, not on participation in screening programs. - Using threats can damage the **doctor-patient relationship** and is less effective for long-term health behavior change than positive education. *Reassure her that absence of symptoms means screening is less urgent* - This is medically dangerous advice; her high **HbA1c (78 mmol/mol)** indicates poor glycemic control, which significantly increases the risk of **maculopathy** and proliferative changes. - Clinical urgency is actually increased in poorly controlled **Diabetes Mellitus**, as the risk of rapid **retinopathy progression** is much higher.

Question 56: A 46-year-old man attends for an NHS Health Check. He smokes 15 cigarettes daily, drinks 28 units of alcohol weekly, and has a BMI of 31 kg/m². Blood pressure is 138/86 mmHg. Fasting blood tests show: total cholesterol 6.2 mmol/L, HDL 0.9 mmol/L, non-HDL 5.3 mmol/L, HbA1c 41 mmol/mol, eGFR 78 ml/min. His QRISK3 score is 18%. Considering the hierarchy of intervention priorities, which lifestyle modification should be the primary focus?

A. Alcohol reduction to within recommended limits
B. Smoking cessation with pharmacological support (Correct Answer)
C. Weight loss through dietary modification and exercise
D. Dietary changes to reduce cholesterol levels
E. Blood pressure reduction through salt restriction

Explanation: ***Smoking cessation with pharmacological support*** - Smoking cessation is considered the **highest priority** intervention because it offers the largest and most immediate **absolute risk reduction** for cardiovascular events compared to other lifestyle factors. - NICE guidelines emphasize that for high-risk patients (QRISK3 >10%), **combination therapy** (NRT or Varenicline) should be proactively offered to maximize the chances of successful quitting. *Alcohol reduction to within recommended limits* - While the patient consumes **28 units/week** (double the recommended 14 units), the direct impact on **QRISK3 reduction** is less significant than stopping smoking. - Excessive alcohol contributes to **hypertension** and weight gain, but it is not ranked as the primary modifiable contributor to cardiovascular mortality in this hierarchy. *Weight loss through dietary modification and exercise* - A BMI of **31 kg/m²** indicates obesity, but weight loss interventions typically result in slower, more modest reductions in **CV risk** compared to the immediate benefits of cessation. - While essential for long-term health and preventing **Type 2 Diabetes** (HbA1c is currently 41), it remains secondary to smoking in urgent risk management. *Dietary changes to reduce cholesterol levels* - Although the **non-HDL cholesterol (5.3 mmol/L)** is elevated, the QRISK3 score of 18% suggests that pharmacological intervention (Statins) alongside diet is likely needed. - Dietary change alone typically reduces cholesterol by only **10–15%**, which is insufficient to match the risk reduction achieved by **stopping smoking**. *Blood pressure reduction through salt restriction* - The blood pressure of **138/86 mmHg** is high-normal/Grade 1 hypertension, but salt restriction provides a relatively minor drop in systolic pressure. - Managing hypertension is crucial, but addressing the **highly pro-thrombotic** and atherosclerotic nature of smoking takes clinical precedence.

Question 57: A 34-year-old woman attends with her cervical screening result showing hrHPV positive with normal cytology. She is anxious and asks what this means. She is in a long-term monogamous relationship and has had the same partner for 8 years. What is the most appropriate explanation and management?

A. She needs immediate treatment with topical imiquimod cream
B. She should have annual cervical screening for the next 5 years
C. She has precancerous changes requiring urgent colposcopy referral
D. The test indicates recent HPV acquisition suggesting partner infidelity
E. She should be retested at 12 months with hrHPV testing and cytology (Correct Answer)

Explanation: ***She should be retested at 12 months with hrHPV testing and cytology*** - In the primary HPV screening program, a result of **hrHPV positive but normal cytology** mandates a repeat test in **12 months** to allow for natural viral clearance. - Most HPV infections are **transient** and cleared by the immune system; colposcopy is only indicated at this stage if hrHPV persists for two consecutive 12-month repeats or if cytology becomes abnormal. *She needs immediate treatment with topical imiquimod cream* - **Imiquimod** is used for the treatment of **anogenital warts**, not for subclinical cervical hrHPV infection or cervical dysplasia. - Normal cytology indicates there are no visible cellular changes to treat, and the virus itself has no specific medical "cure" other than **immune clearance**. *She should have annual cervical screening for the next 5 years* - This management plan does not align with national screening protocols; the current pathway uses **12-month intervals** for HPV persistence monitoring. - If hrHPV is negative at the 12-month repeat, the patient generally returns to **routine recall** (3 or 5 years depending on age) rather than annual testing. *She has precancerous changes requiring urgent colposcopy referral* - **Normal cytology** specifically indicates that there are currently **no precancerous cells** (dyskaryosis) detected in the sample. - Urgent colposcopy is reserved for clinical suspicion of cancer or high-grade dyskaryosis; HPV positivity alone with normal cells is **low risk** for immediate malignancy. *The test indicates recent HPV acquisition suggesting partner infidelity* - HPV can remain **latent or dormant** for many years or even decades before becoming detectable on a screening test. - A positive result often represents a **reactivation** of an old infection rather than a new acquisition, making it an unreliable indicator of a partner's recent sexual activity.

Question 58: A 57-year-old woman attends for her NHS breast screening mammogram. She has been taking combined HRT (oestrogen and progestogen) for 4 years for menopausal symptoms. She asks whether her HRT use affects the accuracy of mammography. Which statement best explains the effect of HRT on breast screening?

A. HRT increases breast density which may reduce mammographic sensitivity (Correct Answer)
B. HRT increases the false positive rate but does not affect cancer detection
C. HRT should be stopped 6 months before mammography to ensure accuracy
D. HRT has no effect on mammographic breast density or screening accuracy
E. HRT reduces breast density making abnormalities more easily detectable

Explanation: ***HRT increases breast density which may reduce mammographic sensitivity*** - Combined **HRT (estrogen and progestogen)** stimulates glandular tissue, leading to an increase in **mammographic breast density** in about 25-30% of women. - High breast density reduces **mammographic sensitivity** because both dense fibroglandular tissue and potential tumors appear **white (radiopaque)**, potentially masking underlying malignancies. *HRT increases the false positive rate but does not affect cancer detection* - While HRT can increase the **false positive rate** due to benign changes, it definitely impacts **cancer detection** by lowering the sensitivity of the test. - Increased density makes it harder to distinguish between **normal tissue** and a **carcinoma**, leading to more missed diagnoses (false negatives). *HRT should be stopped 6 months before mammography to ensure accuracy* - There is no clinical guideline recommending that HRT be **stopped or paused** prior to routine breast screening mammograms. - Clinical practice focuses on maintaining **symptom control** for the patient while acknowledging the slight reduction in screening accuracy as a known factor. *HRT has no effect on mammographic breast density or screening accuracy* - This is incorrect as **hormonal replacement** has a well-documented physiological effect on the proliferation of **breast epithelium**. - Studies consistently show that **combined HRT** significantly alters the radiographic appearance of the breast, unlike estrogen-only therapy which has a lesser effect. *HRT reduces breast density making abnormalities more easily detectable* - HRT actually has the opposite effect; **estrogen and progesterone** increase the ratio of glandular to fatty tissue, thereby **increasing density**. - **Fatty involution** (decreased density) typically occurs naturally after menopause without HRT, which usually makes mammograms **easier to interpret**.

Question 59: What is the screening interval for cervical screening in women aged 50-64 years in the NHS Cervical Screening Programme in England?

A. Annually
B. Every 3 years
C. Every 5 years (Correct Answer)
D. Every 10 years
E. No routine screening required

Explanation: ***Every 5 years*** - In the **NHS Cervical Screening Programme** in England, women aged **50 to 64** are invited for routine screening every **5 years**. - This extended interval, compared to younger age groups, reflects the slower progression of **HPV-related cervical changes** and a lower risk of rapidly developing high-grade lesions in this demographic. *Annually* - **Annual screening** is not the routine interval for any age group within the NHS Cervical Screening Programme in England. - It is typically reserved for specific **follow-up management** after abnormal results or for individuals with certain high-risk factors. *Every 3 years* - This is the standard screening interval for women aged **25 to 49** within the NHS Cervical Screening Programme. - A shorter interval is used for younger women due to a higher prevalence of **HPV infection** and potentially faster progression of cervical abnormalities. *Every 10 years* - A **10-year interval** is not currently utilized as a routine screening frequency in the NHS Cervical Screening Programme. - Such a long interval would significantly increase the risk of undetected **cervical cancer** development between screens. *No routine screening required* - Routine screening is still **required** for women aged 50-64 years in England to detect cervical abnormalities early. - Screening typically stops at age **65** only if a woman has had adequate negative screening results (e.g., two negative HPV tests after age 50 or three consecutive negative cytology results).

Question 60: A 62-year-old woman attends for discussion of her NHS bowel cancer screening result. Her FIT result is 95 micrograms Hb/g faeces. She has no symptoms and examination is unremarkable. She is on clopidogrel following a TIA 18 months ago. Which of the following factors is most likely to have contributed to her positive FIT result?

A. Daily consumption of red meat
B. Concurrent use of clopidogrel (Correct Answer)
C. Haemorrhoids noted on previous examination
D. Recent upper respiratory tract infection
E. Menstruation at the time of sample collection

Explanation: ***Concurrent use of clopidogrel***- **Clopidogrel** is an **antiplatelet agent** that inhibits platelet aggregation and can increase the risk of **occult gastrointestinal bleeding**.- This increased bleeding risk can lead to the presence of **human haemoglobin** in the faeces, resulting in a positive **Faecal Immunochemical Test (FIT)** result.*Daily consumption of red meat*- The **Faecal Immunochemical Test (FIT)** uses antibodies specific to **human haemoglobin**, making it unaffected by dietary sources of haemoglobin like **red meat**.- This is a key advantage over older **guaiac-based tests**, which required dietary restrictions to avoid false positives.*Haemorrhoids noted on previous examination*- While **haemorrhoids** can cause bleeding, patients are usually advised to defer **FIT sample collection** if they are actively bleeding from haemorrhoids.- The patient is described as having **no symptoms**, making active haemorrhoidal bleeding a less likely explanation for a high FIT result compared to medication-induced occult bleeding.*Recent upper respiratory tract infection*- An **upper respiratory tract infection (URTI)** is localized to the respiratory system and has no physiological mechanism to cause **gastrointestinal bleeding**.- Therefore, an URTI cannot contribute to the presence of **human haemoglobin** in the stool, which is detected by the FIT.*Menstruation at the time of sample collection*- The patient is **62 years old**, indicating she is almost certainly **post-menopausal**.- Consequently, **menstruation** is an improbable cause for a positive FIT result in this age group.

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