Screening & Prevention

Screening & Prevention UK Medical PG Question 1: A 76-year-old woman with dementia (MMSE 18/30), Parkinson's disease, type 2 diabetes, and recurrent falls is brought by her daughter for medication review. Current medications include: co-careldopa 25/100 three times daily, ropinirole 8mg three times daily, quetiapine 25mg twice daily, metformin 500mg twice daily, gliclazide 40mg twice daily, alendronic acid 70mg weekly, calcium/vitamin D, and PRN paracetamol. She has had three falls in the past two months. Her daughter reports increasing confusion and hallucinations. Blood glucose monitoring shows values between 4.8-8.2 mmol/L. Which medication intervention should be prioritised?

• A. Reduce co-careldopa dose as dopaminergic medications contribute to hallucinations and falls
• B. Stop quetiapine immediately as antipsychotics worsen Parkinson's disease motor symptoms
• C. Review and rationalise diabetes medications given risk of hypoglycaemia contributing to falls
• D. Stop alendronic acid as bisphosphonates increase fall risk in elderly patients
• E. Reduce ropinirole as dopamine agonists cause hallucinations and should be withdrawn first (Correct Answer)

Screening & Prevention Explanation: ***Reduce ropinirole as dopamine agonists cause hallucinations and should be withdrawn first*** - **Dopamine agonists** like ropinirole carry a much higher risk of inducing **visual hallucinations** and confusion compared to levodopa, especially in patients with cognitive impairment. - Management guidelines for Parkinson’s psychosis prioritize the **gradual withdrawal** of dopamine agonists before altering levodopa therapy to minimize neuropsychiatric side effects while preserving motor function. *Reduce co-careldopa dose as dopaminergic medications contribute to hallucinations and falls* - While levodopa can contribute to hallucinations, it is the **gold standard** for motor control and is less frequently the primary cause of psychosis than dopamine agonists. - Reducing **co-careldopa** before reducing ropinirole might severely compromise the patient's mobility and increase the risk of **motor fluctuations**. *Stop quetiapine immediately as antipsychotics worsen Parkinson's disease motor symptoms* - **Quetiapine** is one of the few antipsychotics used in Parkinson's because it has a low affinity for **D2 receptors**, making it less likely to worsen motor symptoms. - Abruptly stopping it may cause a rebound of psychiatric symptoms; the priority is to remove the **precipitating factor** (ropinirole) rather than the treatment for the symptoms. *Review and rationalise diabetes medications given risk of hypoglycaemia contributing to falls* - The patient's blood glucose readings (4.8-8.2 mmol/L) indicate **tight control**, but she is not currently experiencing clinical **hypoglycemia** that would explain acute hallucinations. - While preventing hypoglycemia is important for fall prevention, it does not address the primary complaint of **visual hallucinations** and increasing confusion. *Stop alendronic acid as bisphosphonates increase fall risk in elderly patients* - **Alendronic acid** is used to prevent fractures and does not have a known association with an increased **risk of falls** or hallucinations. - It is generally continued in elderly patients with high fracture risk unless there are specific contraindications like **esophageal disorders** or severe renal impairment.

Screening & Prevention UK Medical PG Question 2: A 72-year-old man with chronic kidney disease stage 4 (eGFR 24 ml/min/1.73m²), type 2 diabetes, hypertension, and gout presents for medication review. His current medications include: metformin 1g twice daily, gliclazide 80mg twice daily, ramipril 10mg once daily, amlodipine 10mg once daily, aspirin 75mg once daily, atorvastatin 80mg once daily, allopurinol 100mg once daily, and omeprazole 20mg once daily. His HbA1c is 58 mmol/mol, and he reports intermittent episodes of feeling 'shaky and sweaty'. Which medication requires MOST urgent modification?

• A. Allopurinol should be increased to 300mg daily for adequate urate control
• B. Metformin should be stopped immediately due to risk of lactic acidosis (Correct Answer)
• C. Ramipril should be reduced due to advanced chronic kidney disease
• D. Gliclazide should be reviewed and reduced due to hypoglycaemia risk
• E. Aspirin should be stopped as cardiovascular protection is inadequate at this dose

Screening & Prevention Explanation: ***Metformin should be stopped immediately due to risk of lactic acidosis***- **Metformin** is primarily cleared by the kidneys and is **contraindicated** when the **eGFR falls below 30 ml/min/1.73m²** (CKD Stage 4). The patient's eGFR is 24.- Continued use in this setting significantly increases the risk of **metformin-associated lactic acidosis (MALA)**, a severe and life-threatening metabolic emergency requiring urgent discontinuation.*Allopurinol should be increased to 300mg daily for adequate urate control*- Increasing **allopurinol** to 300mg in a patient with an **eGFR of 24 ml/min/1.73m²** is inappropriate and risky, as it can lead to severe toxicity, including **allopurinol hypersensitivity syndrome**.- The current dose of **100mg daily** is generally considered the maximum safe dose for patients with this level of **renal impairment**.*Ramipril should be reduced due to advanced chronic kidney disease*- **ACE inhibitors** like **ramipril** are often beneficial in CKD for **renoprotection** and blood pressure control, provided there is no acute kidney injury or severe hyperkalemia.- While renal function and electrolytes require close monitoring, discontinuing metformin due to the immediate and severe risk of **lactic acidosis** takes precedence.*Gliclazide should be reviewed and reduced due to hypoglycaemia risk*- The patient's symptoms of feeling "shaky and sweaty" are classic for **hypoglycaemia**, likely exacerbated by **gliclazide** accumulation due to reduced renal clearance.- While adjusting **gliclazide** is crucial to prevent further hypoglycaemic episodes, the immediate risk of **metformin-associated lactic acidosis** is a higher priority.*Aspirin should be stopped as cardiovascular protection is inadequate at this dose*- **Aspirin 75mg daily** is the standard and effective dose for **secondary prevention** of cardiovascular events, especially in patients with multiple risk factors like this gentleman.- There is no clinical indication to stop aspirin based on its efficacy at this dose, and doing so would remove a crucial component of his cardiovascular protection.

Screening & Prevention UK Medical PG Question 3: Understanding the concept of 'diagnostic uncertainty' in managing undifferentiated symptoms in primary care involves recognizing that certain presentations cannot be immediately diagnosed. Which of the following statements best describes the evidence-based approach to managing diagnostic uncertainty?

• A. Immediate referral to secondary care is always appropriate when a diagnosis cannot be made in primary care to ensure patient safety
• B. Safety-netting with clear instructions for re-consultation if symptoms persist, worsen, or new features develop is an essential component of managing uncertainty (Correct Answer)
• C. Extensive investigation should be undertaken immediately to exclude all possible serious diagnoses before adopting a watch-and-wait approach
• D. Patients should be reassured that the absence of abnormal findings on initial tests means serious pathology is excluded and no follow-up is needed
• E. Empirical treatment should be started for the most likely diagnosis to avoid delays in management

Screening & Prevention Explanation: ***Safety-netting with clear instructions for re-consultation if symptoms persist, worsen, or new features develop is an essential component of managing uncertainty***- **Safety-netting** is an evidence-based strategy that allows for the management of **undifferentiated symptoms** by providing patients with clear, specific **red-flag symptoms** and a planned follow-up.- This approach maintains **patient safety** and utilizes the clinical tool of **time as a diagnostic test**, permitting the natural history of a condition to reveal itself without unnecessary harm.*Immediate referral to secondary care is always appropriate when a diagnosis cannot be made in primary care to ensure patient safety*- Primary care clinicians frequently manage **low-prevalence conditions** where immediate referral would lead to **over-medicalization** and unnecessary patient anxiety.- Most undifferentiated symptoms in primary care are **self-limiting** or benign, making immediate specialist referral an inefficient and potentially harmful use of resources.*Extensive investigation should be undertaken immediately to exclude all possible serious diagnoses before adopting a watch-and-wait approach*- Over-investigation increases the risk of **false positives** and **incidentalomas**, which may lead to invasive procedures that cause more harm than the original symptom.- A **judicious use of investigations** is preferred to avoid the cascades of care that arise from testing without sufficient clinical suspicion.*Patients should be reassured that the absence of abnormal findings on initial tests means serious pathology is excluded and no follow-up is needed*- Many serious conditions can present with **normal initial tests** because some pathologies only become detectable as the disease progresses over time.- Providing false reassurance without a plan for **re-evaluation** violates the principles of safety-netting and may lead to **delayed diagnoses** if symptoms evolve.*Empirical treatment should be started for the most likely diagnosis to avoid delays in management*- Initiating treatment without a diagnosis can **mask symptoms**, making it significantly more difficult to reach a definitive diagnosis later.- This approach exposes patients to potential **adverse drug reactions** and side effects that are unnecessary if the underlying cause is a self-limiting viral illness.

Screening & Prevention UK Medical PG Question 4: A 67-year-old woman with multimorbidity attends for a comprehensive medication review. She has six chronic conditions: heart failure, atrial fibrillation, type 2 diabetes, hypothyroidism, osteoporosis, and depression. She takes 11 regular medications. According to NICE guidance on multimorbidity (NG56), which approach is MOST important when prioritising her care during this consultation?

• A. Focus on achieving optimal disease-specific targets for each individual condition
• B. Establish the patient's priorities for treatment and quality of life outcomes (Correct Answer)
• C. Systematically review medications starting with those prescribed most recently
• D. Concentrate on reducing the total number of medications to fewer than 10
• E. Prioritise management of conditions with the highest mortality risk first

Screening & Prevention Explanation: ***Establish the patient's priorities for treatment and quality of life outcomes***- According to **NICE NG56**, the core of multimorbidity management is a **patient-centered approach** that identifies personal goals, values, and desired outcomes.- Shared decision-making ensures that care focuses on improving **quality of life** and reducing **treatment burden**, rather than just following clinical guidelines.*Focus on achieving optimal disease-specific targets for each individual condition*- Managing multiple conditions solely through **single-disease guidelines** often leads to **polypharmacy** and increased risk of adverse drug interactions.- Strict adherence to multiple guidelines may ignore the patient's overall wellbeing and can be practically unfeasible for those with many comorbidities.*Systematically review medications starting with those prescribed most recently*- Medication reviews should focus on assessing **clinical benefit**, **safety**, and **adherence** rather than being dictated by the chronological order of prescription.- The goal is to identify medications that are no longer effective or are causing harm, which may include long-standing prescriptions.*Concentrate on reducing the total number of medications to fewer than 10*- While **deprescribing** is a key goal, there is no evidence-based **arbitrary threshold** (like fewer than 10) for what constitutes an appropriate number of drugs.- Focus should be on the **appropriateness of polypharmacy** and ensuring each medication provides more benefit than harm for that specific patient.*Prioritise management of conditions with the highest mortality risk first*- Focusing only on **mortality risk** (like heart failure) can overlook conditions that significantly impact **functional status** and daily life, such as depression or osteoporosis.- A holistic approach balances survival with the patient's own concerns regarding **symptom control** and daily living activities.

Screening & Prevention UK Medical PG Question 5: A 43-year-old woman presents asking about strategies to reduce her breast cancer risk. Her mother was diagnosed with breast cancer at age 48 and her maternal aunt at age 52. She has no personal history of breast disease. Clinical examination is normal. She takes the combined oral contraceptive pill and drinks 10 units of alcohol weekly. Her BMI is 26 kg/m². After appropriate genetic assessment, she is found not to carry BRCA mutations. Which lifestyle modification would provide the greatest reduction in her breast cancer risk?

• A. Stopping the combined oral contraceptive pill
• B. Reducing alcohol intake to below 5 units per week (Correct Answer)
• C. Achieving and maintaining BMI <25 kg/m² through weight loss
• D. Undertaking regular vigorous physical activity 150 minutes weekly
• E. Adopting a plant-based Mediterranean diet low in processed foods

Screening & Prevention Explanation: ***Reducing alcohol intake to below 5 units per week*** - There is a well-established **dose-response relationship** between alcohol consumption and breast cancer risk, where each unit consumed per day increases risk by approximately **7-10%**. - Reducing consumption from 10 units to below 5 units per week represents a significant risk reduction that is more impactful than other lifestyle changes in a **pre-menopausal** woman with a modest BMI and moderate alcohol intake. *Stopping the combined oral contraceptive pill* - While the **combined oral contraceptive pill (COCP)** is associated with a small relative risk increase (RR ~1.2), this risk is transient and **returns to baseline** 10 years after cessation. - The absolute risk reduction from stopping the pill in a 43-year-old is generally lower than that achieved through significant **alcohol modification**. *Achieving and maintaining BMI <25 kg/m² through weight loss* - Elevated **BMI** is primarily a significant risk factor for **post-menopausal** breast cancer due to peripheral aromatization of androgens in adipose tissue. - In **pre-menopausal** women like this patient, the association between obesity and breast cancer is less pronounced, and her current BMI of 26 kg/m² is only **borderline overweight**. *Undertaking regular vigorous physical activity 150 minutes weekly* - **Physical activity** provides a modest reduction in risk (approx. 10-20%), largely mediated through secondary effects like **weight management** and hormonal regulation. - While beneficial for overall health, the magnitude of specific breast cancer risk reduction is typically less than that achieved by **halving alcohol intake**. *Adopting a plant-based Mediterranean diet low in processed foods* - Although a **Mediterranean diet** is associated with lower overall cancer mortality and improved cardiovascular health, its specific impact on breast cancer risk is less clinically proven than **alcohol restriction**. - Dietary changes are often recommended as part of a holistic approach but do not show the same **linear correlation** with risk reduction as limiting alcohol.

Screening & Prevention Flashcard 1 of 5

Question: Screen patient's blood pressure every _____ if high-risk (e.g. diabetes, family history, smokers, obesity)

Answer: 1 year

Screening & Prevention Flashcard 2 of 5

Question: If cervical cancer screening (smear test) is +ve for hrHPV & there is evidence of cytological abnormalities then _____

Answer: refer to colposcopy

Screening & Prevention Flashcard 3 of 5

Question: What is the formula used to calculate Positive Predictive Value: _____

Answer: TP / (TP + FP)

Screening & Prevention Flashcard 4 of 5

Question: In a Contigency Table what does FN mean? _____ Where the Disease is Present and the test is Negative

Answer: False Negative

Screening & Prevention Flashcard 5 of 5

Question: What is the formula used to calculate Specificity: _____

Answer: TN / (TN+FP)