High BMI with High QRISK score

Casebank Counselling
1

Where you are
You are an FY2 in GP Surgery

Who the patient is
Mrs Lena Brown 55 year old lady has come to the practice for her well-woman follow up. Blood tests were taken and examination was done.

Other information you have about the patient
FBC, LFT, TFT and U&E are Normal
BMI is 28
Cholesterol on two occasions: 6.2
Q score: 14%
She has been planned to be started on statins

What you must do
Explain exam findings and discuss management plan with the patient

QRISK is a prediction algorithm for cardiovascular disease. A QRISK score over 10 (10% risk of CVD event over the next ten years) indicates that primary prevention with lipid lowering therapy (such as statins) should be considered.

Patient information:

  • You are Mrs Lena Brown, a 55-year-old lady.
  • Today you have come for a well woman clinic follow up
  • The doctors last time had done some blood tests, checked your weight and
    height
  • You don’t know what Body Mass index (BMI) is
  • You do not smoke
  • You drink wine a glass a day
  • You like eating outside, mainly fish and chips
  • You hang out with friends
  • You do not like exercising but play golf with your husband
  • You walk around with golf course with your husband
  • The doctors are planning to start you on statin
  • You are retired

Questions:

  • If the doctors says he will start you on statin, ask him/her; Does statin have
    any side effects?
  • So how can I reduce the BMI?
  • Will I be on statin for the rest of my life?
  • Doctor, am I obese?

Approach

  • GRIPS: Paraphrase
  • Explain the blood test results and examinations
    • Explains BMI
      BMI is a ratio between the body weight and the height
      • Normal 18.5 – 24.9 kg/m2
      • Overweight 25 – 29.9 kg/m2
      • Obesity I 30 – 34.5 kg/m2
      • Obesity II 35 – 39.9 kg/m2
      • Obesity III 40 kg/m2
    • Explain the high cholesterol
      • explain that she needs to be put on statins, atorvastatin
      • side effects of statins: muscle aches, drowsiness, stomach upsets, headaches
    • Explain the QRISK score which is a score that tells us the risk of developing cardiovascular disease (heart attack or stroke) in the next 10 years, ideally this score should be less than 10%, it is classified as;
      • Low risk < 10 %
      • Moderate risk 10 – 20 %
      • High risk > 20 %
    • We calculate it by taking many factors into consideration for example cholesterol levels, medical conditions (such as high blood pressure and high blood sugar), age, sex, ethnicity, weight.
    • Explain that she has a slight increase in the risk of developing heart problems or
      stroke
  • PMAFTOSA
  • Have you been diagnosed with any medical condition?
  • Are you on any regular medication?
  • Anyone in the family had …
  • What is your occupation?
  • Is it stressful?
  • Diet
  • Can you describe me what is your normal diet?
  • Ask in details
  • Do you exercise?
  • How often do you do?
  • How many hours of exercise do you do?
  • What kind of exercise do you do?
  • Alcohol
    • Do you drink alcohol?
    • What sort of alcohol do you drink?
    • How often do you drink?
    • How much do you drink?
  • Smoking
    • Do you smoke?
    • How long have you been smoking?
    • How many cigarettes do you smoke?
    • Do you have any hobbies?
  • Take history of other risk factors:
    • Diabetes
    • Hypertension
    • Cholesterol
    • AF
    • Exercise
    • Diet
    • Heart problems
    • Previous stroke
    • Alcohol

Management:

  • For high cholesterol start on atorvastatin
  • Making some changes in your lifestyle you can further reduce the cholesterol and the QRISK
  • Advices about weight loss, by doing exercise and diet.

Expectations:

  • Will I be on statin for the rest of my life?
    It is hard to say it now but when the cholesterol is well controlled and if there is no high risk of other medical conditions we can maintain a healthy diet then we may discontinue
  • Doctor, am I obese?
    You are falling in the category of overweight
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