Station 82
Daniel White
Age: 37 years old male
Full Case
Patient’s Data
Patient’s name: Daniel White
Age: 37-year-old male
Past medical history:
- None recorded
Drug and Allergy History
- Not currently on any medication
- No Known Drug Allergy
Alerts and QOF
- Smoker
- Smoking cessation advice needed
Recent notes/ consultation
Face-to-face consultation 3 weeks ago with Dr Daniel Stubbs (Clinical practitioner access role)
Presenting complaint: Patient booked appointment to request routine blood tests, particularly cholesterol because he did a quick, random home testing kit which indicated a raised cholesterol level.
Examination: BP 130/80mmHg, BMI: 31
Plan: Arrange full lipid profile and routine blood tests. Schedule follow-up consultation to review and discuss results once available.
Blood Test Results
| Test | Result | Normal Range |
|---|---|---|
| Total Cholesterol | 6.0 mmol/L | < 5.0 mmol/L |
| HDL Cholesterol | 1.1 mmol/L | > 1.0 mmol/L |
| LDL Cholesterol | 3.9 mmol/L | < 3.0 mmol/L |
| Triglycerides | 1.7 mmol/L | < 1.7 mmol/L |
| Total/HDL Ratio | 5.5 | < 4.0 |
| QRISK3 Score | 4% | – |
| HbA1c, U+Es, LFTs, TFTs, FBC | Normal | All within reference range |
Note: Patient booked follow-up consultation to discuss blood test results.
Patient's Story (Role player’s brief)
Patient’s Story
You are here today to discuss the results of your recent cholesterol blood test.
You did a quick home cholesterol test out of curiosity after your brother-in-law sadly died of a heart attack at the age of 40. The result suggested high cholesterol, which prompted you to contact the surgery to request for cholesterol tablets, but the GP advised me to formal lab tests, these have now been completed.
You’ve been feeling fine, with no chest pain, shortness of breath, or other symptoms.
Social History and Lifestyle: You don’t exercise much, and your job involves sitting most of the day (You work as a Web developer for a tech company). You smoke about 10 cigarettes per day, and you’ve been doing so for around 10 years. You don’t drink alcohol. You live with your wife. Your diet is unhealthy as you rely on processed and takeaway food
You were particularly worried after your brother-in-law, who is in his 40s, had a heart attack, and the family said it was because of his cholesterol. That’s what prompted you to check yours.
Family history: You were adopted as a baby, so you don’t know your biological family history.
Idea: You think your cholesterol is probably high because of diet — you eat quite a bit of processed and takeaway food.
Concerns: You’re worried about a heart attack, especially because of your brother-in-law
Expectations: You would like to be started on cholesterol tablets (statins)
Say NO to any other questions asked outside of the details already provided in the scenario.
Marking Scheme
Data Gathering and Diagnosis
- Clarify why the patient requested the cholesterol test (explore background and motivation)
- Ask about symptoms of cardiovascular disease: including chest pain, shortness of breath, palpitations, dizziness, headaches, and any weakness or numbness affecting one side of the body, which may indicate stroke or TIA.
- Ask about lifestyle factors including diet, exercise, and occupation (sedentary work increases CVD risk)
- Ask about smoking, alcohol, and substance use
- Ask about any personal or family history of cardiovascular disease (heart attacks, strokes, high blood pressure, diabetes)
- Explore understanding of cholesterol and its risks (identify misconceptions)
- Explore Ideas, Concerns, and Expectations, especially fear of heart attack and desire for statins.
- Give a diagnosis of raised cholesterol with low QRISK3 of 4%
Example of explanation to patient
Daniel, thanks for coming in today and for being proactive about your health.
I’ve reviewed your blood results, and they show that your total cholesterol is raised at 6.0, and your LDL cholesterol, which is the ‘bad cholesterol’, is also raised. These are important findings because raised cholesterol can increase the risk of heart and blood vessel problems over time.
To help us understand your overall risk, we use a tool called QRISK3. This takes into account your age, blood pressure, smoking status, cholesterol, and other factors to estimate your chance of having a heart attack or stroke over the next 10 years. Your score comes out at 4%, which we consider to be low risk. To put it in perspective, in a group of 100 people with the same risk factors as you, about 4 are likely to have a heart attack or stroke over the next 10 years.
That said, even with a low risk, there’s still benefit in reducing it further, and that’s where lifestyle changes come in. You mentioned earlier that your diet isn’t the healthiest, are there things you feel you could change?
Some practical steps include:
- Eating a healthy, balanced diet, including at least 5 portions of fruit and vegetables each day
- Cutting down on foods high in saturated fat like fried food, processed meats, and certain baked goods
- Checking food labels, aiming for foods with unsaturated fats like olive oil, nuts, and oily fish
You also mentioned that you don’t currently exercise much. Have you had any thoughts about how you could increase your activity levels?
The general recommendation is to aim for at least 150 minutes of moderate activity per week, that could be something like brisk walking, cycling, or swimming. Even walking briskly each day so that your heart rate increases a bit is a great place to start.
You also told me that you smoke, have you considered cutting down or stopping? The reason I ask is, smoking not only raises your cholesterol but also significantly increases your risk of heart attacks, strokes, and certain cancers. We have excellent stop-smoking support services, and I’d be happy to refer you if you’re open to it.
All of these changes, diet, exercise, stopping smoking, not only help improve your cholesterol but also support your general health. They may also help with weight management, and I noticed from your records that your weight is a bit on the higher side.
If patient still wishes to start cholesterol tablets:
Since you’re keen to start cholesterol tablets, we can certainly talk through that. The type of medication we’d offer is called a statin, and it works by lowering the level of cholesterol your body makes. It’s effective at reducing the risk of heart problems in the long term.
Like all medications, statins can have side effects. Some people experience muscle aches, tummy upset, or effects on the liver, but not everyone gets these, and for many people the benefits outweigh the risks.
If you’re happy to go ahead, we can prescribe the statin today. We’ll then repeat your blood tests in about 3 months to see how well it’s working and to monitor for any side effects. If at any point you have concerns, you can let us know and we can review things together.
Management
Management
- Reassure that although cholesterol is raised, QRISK3 score is low (4%), so no current indication for statin per NICE guidelines
- Explain that the patient’s QRISK3 score is 4%, meaning their estimated risk of having a heart attack or stroke over the next 10 years is 4%. In simple terms, this means that out of 100 people with similar risk factors, 4 may go on to develop cardiovascular disease within the next decade. While this is considered a low risk, it’s still important to explore ways to lower it further through lifestyle changes such as improving diet, increasing physical activity, and stopping smoking.
- Offer lifestyle advice: smoking cessation referral/support (key modifiable risk), heart-healthy diet advice (leaflet or referral to dietitian if available), encourage regular aerobic exercise (30 mins, 5x/week)
- If the patient still wishes to proceed with statin treatment, take time to explain what statins are, their potential benefits in lowering cholesterol and reducing cardiovascular risk, as well as the possible side effects, such as muscle aches, tummy upset, or effects on the liver.
- If, after a balanced discussion, the patient is well-informed and happy to go ahead, then it would be reasonable to offer statin therapy.
- According to NICE guidelines, even when the QRISK3 score is below 10%, statin treatment can still be considered if lifestyle change alone is ineffective or inappropriate (e.g. due to comorbidities or clinical judgement), or if the patient expresses an informed preference to start treatment, or where there is concern that the calculated risk may underestimate their true cardiovascular risk.
- Arrange a repeat lipid profile in 3 months, regardless of whether the patient starts statin therapy or opts for lifestyle changes alone. If statins are not started, the repeat test will help assess the effectiveness of lifestyle interventions. If statins are prescribed, the test will monitor response to treatment and check for any changes that might guide ongoing management.
- Offer referral to Health and Wellbeing Coach or lifestyle support services if patient wishes
- Provide written materials or links to trusted lifestyle and CVD risk resources (For example NHS website or British Heart Foundation)
- Safety-net: advise to seek urgent medical help if he develops symptoms (e.g. chest pain, breathlessness, palpitations, weakness or numbness affecting one side of the body)
- Offer follow-up appointment in 3 months to review progress.
Learning point from this station:
Learning Point from This Station
This station explores the management of mildly raised cholesterol in a low-risk patient and highlights the importance of shared decision-making in primary prevention of cardiovascular disease (CVD).
NICE recommends offering statin therapy for primary prevention to the following groups:
- People with a 10-year QRISK3 score of 10% or more, including those with type 2 diabetes
- People with type 1 diabetes, chronic kidney disease (CKD), or familial hypercholesterolaemia
- People aged 85 years and older, where benefits may still be seen in reducing non-fatal myocardial infarction
However, NICE also makes it clear that if the QRISK3 score is below 10%, clinicians should not automatically rule out statin therapy. Statins may still be considered if:
- The patient has an informed preference for treatment after a discussion of risks and benefits,
- Or there is concern that the QRISK3 score underestimates true risk (e.g., due to comorbidities or unrecorded risk factors such as strong family history in adopted individuals or smoking in younger patients).
This case also reinforces the importance of supporting lifestyle changes, including diet, physical activity, smoking cessation, and weight management, as the first-line approach in low-risk individuals.
Regardless of whether a statin is prescribed, it is essential to arrange a repeat lipid profile after 3 months. This helps evaluate the effectiveness of lifestyle interventions or response to medication and informs decisions about ongoing care.