Mock 1 · Cholesterol result

Candidates: do not open until you have consulted.

Persona and manner

• Elaine Marsh, 49, a self-employed nutrition and wellness coach; articulate, confident, well-informed on your own terms; you see this as a debate you have prepared for; slightly condescending about “the pharmaceutical model”.
• Underneath: frightened by your father's heart attack and by the number. You do not want to be told what to do, and you are genuinely open to numbers.

Opening line (verbatim)

• “The nurse basically tried to hand me a statin prescription. I'm not against medicine, but I've read a lot about statins — the diabetes, the memory problems, the muscle damage — and I'd rather manage this naturally. I'd like to hear your honest view rather than the pathway.”

The story

• “I eat better than anyone I know. I run three times a week. No sugar.”
• “Red yeast rice is basically a natural statin anyway.”
• “My dad's on five different tablets since his stents and he's never been the same.”
• If asked about the family: your father had the heart attack at 58, stents, alive but “diminished”; your uncle died at 52; your grandmother “heart” at 70. No one has been tested for an inherited cause; no one has lumps on their tendons that you know of. Your cholesterol “has always been high”: 6.8 five years ago.
• No chest pain; no breathlessness; no leg pain walking; no symptoms.
• Alcohol: wine four nights a week, a glass or two, about 12 units. Sleep fine. Stress: a business to run.
• If asked about the red yeast rice: two capsules a day for a year; you do not know what it contains.
• If asked what you have read: statins cause diabetes in one in three, dementia, and “everyone gets muscle pain”. Two clients “couldn't walk on them”.
• If asked what would change your mind: “If the numbers were compelling and it was my decision.” You would also accept “a proper test for the family thing”.
• Perimenopausal: hot flushes, not on HRT; “I manage it”.

Ideas, concerns and expectations

• Idea: “Diet and exercise will fix it. Statins are over-prescribed.”
• Concern: Your father's decline; dementia and diabetes from statins; being on tablets for life at 49.
• Expectation: An honest discussion, a natural plan, and to be respected.

Impact

• Work: your business is built on managing health naturally; a statin feels like a contradiction you would have to explain.
• Home: your father's five tablets and his decline are in front of you every Sunday.
• Money and driving: no concern.

Red flags

• Present: A total cholesterol of 7.4 with a first-degree relative with premature coronary disease and a second relative who died at 52: the pattern that raises an inherited cause; an unregulated statin-like supplement taken daily.
• Absent: No symptoms of coronary or peripheral disease; no tendon lumps reported; no diabetes; a blood pressure below the treatment threshold.

Hidden facts and their triggers

• That red yeast rice contains a statin-like compound — released only you do not know this; it is for the doctor to tell you, and it changes your view if told without triumph
• The uncle's death at 52 and the grandmother — released only if asked about the wider family, not only your father
• The cholesterol of 6.8 five years ago — released only if asked whether it has been high before, or if the doctor reads it from the record
• What your father's decline means to you — released only if asked what “never been the same” looks like
• That you would accept a test for the family thing — released only if an inherited cause is raised as a question rather than a verdict

Behaviour

• Minute 1: “Rather than the pathway.”
• Minute 4, about your father: “He's never been the same.”
• Minute 8: “If the numbers were compelling…”
• If the doctor explores your beliefs and your father's story first, takes a family history that raises an inherited cause and offers a proper assessment for it, explains your risk in numbers you can use (14 in 100 over ten years; a statin roughly a quarter to a third fewer events, three or four people in a hundred helped), answers each belief with the evidence, tells you plainly that red yeast rice is an unregulated statin, and offers a genuine choice with a review date: pause. “So the red yeast rice is a statin?” Choose the inherited-cause assessment with a trial of the statin, “on my terms”.
• If the doctor says the guideline says over 10% you should have a statin: “That's exactly what the nurse said.” Disengage.
• If the doctor agrees to natural management without the family test or the numbers: pleased.
• If the doctor argues: argue back, once, then withdraw.

Examination findings, if the candidate states what they would examine and why

• Video: no examination today. If the candidate states what they would examine and why: no yellow deposits around the eyes that you can see; no lumps on the backs of your hands or your heels that you know of; the nurse's blood pressure was 134/84; your pulse at the gym is 64.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Quoting the guideline as an instruction, so that she says “That's exactly what the nurse said” and disengages (statement R4)
• Taking the family history no further than her father, so that the inherited cause is never considered (statement D1)
• Agreeing to natural management without the numbers, the family assessment or a review, to avoid the argument (statement C5)

What the examiner is listening for in the last four minutes

By 8:00 the assessment should have been stated: a 10-year risk of 14% with a possible inherited hypercholesterolaemia that changes the question, and a supplement that is an unregulated statin. The examiner is listening for: the inherited-cause assessment and referral if met; the statin offered as a genuine choice with the three-month check and the alternatives; each belief answered with the evidence; the red yeast rice stopped with the reason; the lifestyle plan with a review date; the decision aid; and her own words on what she has decided and the numbers that made it.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Offer atorvastatin 20 mg for the primary prevention of cardiovascular disease to people with a 10-year QRISK3 risk of 10% or more; do not rule out treatment for people below 10% who would like it after an informed discussion; use the patient decision aid; aim for a reduction of more than 40% in non-HDL cholesterol at three months. NICE — NG238 Cardiovascular disease: risk assessment and reduction, including lipid modification, section 1.5, statins for primary prevention, December 2023, checked 10 Oct 2026
2. Suspect familial hypercholesterolaemia in adults with a total cholesterol above 7.5 mmol/L or an LDL above 4.9 mmol/L, particularly with a personal or family history of premature coronary heart disease (an event before 60 in a first-degree relative); assess with the Simon Broome or Dutch Lipid Clinic Network criteria and refer to a specialist for confirmation and cascade testing. NICE — CG71 Familial hypercholesterolaemia: identification and management, section 1.1, identification and assessment, 2008, last updated October 2019, checked 10 Oct 2026
3. In randomised trials statins increase the risk of new-onset diabetes modestly (about one additional case per 100 people treated over five years, mainly in those already at risk), do not cause dementia or cognitive impairment, and cause muscle symptoms in blinded comparisons no more often than placebo; most muscle symptoms attributed to statins are a nocebo effect. NICE — NG238 Cardiovascular disease: risk assessment and reduction, including lipid modification, section 1.5, statins: advice and monitoring; rationale and impact, December 2023, checked 10 Oct 2026
4. Red yeast rice products contain monacolin K, which is chemically identical to lovastatin, at variable and unlabelled doses; the UK and EU authorities advise that such products are not a safe or regulated alternative to a prescribed statin and may carry the same adverse effects. MHRA — Red yeast rice products: safety advice, 2023, checked 10 Oct 2026
5. The NICE patient decision aid for statins presents the 10-year risk and the benefit of a statin as numbers out of 100 people like the person, in both directions, and supports a shared decision; shared decision-making means the person's values and preferences shape the choice. NICE — NG197 Shared decision making, section 1.2, putting shared decision making into practice; patient decision aids, June 2021, checked 10 Oct 2026
6. If a statin is not tolerated, offer a lower dose or an alternative statin; if statins are contraindicated or not tolerated, consider ezetimibe; bempedoic acid with ezetimibe is an option where statins are not tolerated; the person is not left untreated because of intolerance. NICE — NG238 Cardiovascular disease: risk assessment and reduction, including lipid modification, section 1.7, intolerance and alternatives, December 2023, checked 10 Oct 2026
7. Cardiovascular risk rises after the menopause; HRT is not prescribed for cardiovascular prevention, and the perimenopause is an opportunity to review blood pressure, lipids and weight as part of the risk conversation. NICE — NG23 Menopause: identification and management, section 1.6, long-term benefits and risks of HRT: cardiovascular disease, 2015, last updated April 2026, checked 10 Oct 2026
8. The ESC/EAS dyslipidaemia guideline (2019) classes a markedly raised single risk factor, including an LDL cholesterol above 4.9 mmol/L or a total cholesterol above 8 mmol/L, as high risk irrespective of the risk score, and familial hypercholesterolaemia without other major risk factors as high risk. The LDL goal in high risk is below 1.8 mmol/L with at least a 50 per cent reduction from baseline; in very high risk below 1.4; in moderate risk below 2.6. A high-intensity statin is first line, then ezetimibe, then a PCSK9 inhibitor. ESC — 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk, cardiovascular risk categories; treatment targets for LDL cholesterol; pharmacological strategy, 2019, checked 10 Oct 2026
9. The AHA/ACC cholesterol guideline (2018) gives a high-intensity statin, without a risk calculation, to adults aged 20 to 75 with an LDL cholesterol of 4.9 mmol/L (190 mg/dL) or more. For primary prevention at 40 to 75 with a lower LDL, a ten-year atherosclerotic risk of 7.5 per cent or more supports a moderate-intensity statin after a risk discussion; risk-enhancing factors include a family history of premature atherosclerotic disease (men under 55, women under 65), a persistent LDL of 4.1 mmol/L or more and the metabolic syndrome. AHA/ACC — 2018 AHA/ACC multisociety guideline on the management of blood cholesterol, primary prevention in adults aged 40 to 75; LDL-C 190 mg/dL or higher; risk-enhancing factors; coronary artery calcium, 2018, checked 10 Oct 2026
10. Simon Broome criteria: definite familial hypercholesterolaemia is a total cholesterol above 7.5 mmol/L or an LDL above 4.9, with tendon xanthomata in the person or a relative; possible is the same cholesterol with a family history of myocardial infarction before 50 in a second-degree relative or before 60 in a first-degree relative, or of a cholesterol above 7.5 in a relative. CG71 says not to use a cardiovascular risk tool in familial hypercholesterolaemia, to aim for an LDL reduction above 50 per cent, and to arrange cascade testing. NICE — CG71 Familial hypercholesterolaemia: identification and management, section 1.1, identification: the Simon Broome criteria; section 1.3, management with statins; cascade testing, 2008, last updated October 2019, checked 10 Oct 2026
11. The AAC statin intolerance pathway: with muscle symptoms, measure creatine kinase; above four times the upper limit of normal, stop the statin and investigate; otherwise stop for a washout to see whether symptoms resolve, then rechallenge with the same statin at a lower dose or an alternative statin, including alternate-day dosing. Intolerance is accepted only when two different statins, one at the lowest licensed dose, have not been tolerated; the next steps are ezetimibe, then bempedoic acid with ezetimibe, inclisiran or a PCSK9 inhibitor per NICE technology appraisals. NHS England — Statin intolerance pathway (Accelerated Access Collaborative), muscle symptoms: creatine kinase, washout and rechallenge; definition of statin intolerance; next steps, 2022, checked 10 Oct 2026
12. The Cardiovascular health Topic Guide expects the GP to estimate cardiovascular risk with a validated tool and explain it in absolute terms, to offer lipid-lowering treatment as a shared decision supported by a decision aid, to recognise familial hypercholesterolaemia from the lipid profile and family history and refer for specialist assessment and cascade testing, to ask about over-the-counter and herbal products, and to arrange lipid monitoring. RCGP — GP curriculum: Cardiovascular health, Topic Guide: cardiovascular risk assessment and primary prevention; lipid disorders including familial hypercholesterolaemia, 2025 curriculum (Being a GP), checked 10 Oct 2026

Working references for this station

12 statements, 757 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-MOCK-1