iCARDIOVASCULARCHAPTER 1 QUESTIONSGP ST: Stage 2 Practice Questions Third Edition vCONTENTSContributorsviiIntroductionviiiClinical Problem Solving QuestionsIntroduction to Clinical Problem Solving Questions21CardiovascularQuestions11Answers212Dermatology, ENT and EyeQuestions35Answers493Endocrinology and MetabolicQuestions65Answers754Gastroenterology and NutritionQuestions89Answers1015Infectious Diseases, Haematology, Immunology and Genetics Questions 115Answers1276MusculoskeletalQuestions 143Answers1557PaediatricsQuestions169Answers181viGP ST: STAGE 2 PRACTICE QUESTIONS8Pharmacology and TherapeuticsQuestions193Answers2039Psychiatry and NeurologyQuestions217Answers22910Renal and UrologyQuestions247Answers25911ReproductiveQuestions273Answers28712RespiratoryQuestions301Answers311Mock Exam 13Clinical Problem Solving Example Test PaperQuestions327Answers359Professional DilemmasIntroduction to Professional Dilemma Questions39714Professional Dilemmas Example QuestionsQuestions405Answers421Index434 1CHAPTER 1 QUESTIONSClinical Problem Solving Questions2INTRODUCTION TO CLINICAL PROBLEMSOLVING QUESTIONSThepurposeofGPtrainingistoprovidethetraineewiththenecessary competencestopractiseindependentlyasageneralpractitioner (http://www.rcgp-curriculum.org.uk),nottothrustknowledgeinto anindividual.However,acandidateisexpected,after56years asamedicalstudentand2yearsasafoundationdoctor,tohavea reasonablelevelofknowledgeandtobeabletoapplyittoclinical situations. This is what the frst part of Stage 2 assesses.The assessment consists of a 95-minute question paper. The questions are in the form of clinical scenarios that require candidates to exercise judgementandproblemsolvingskillstodeterminetheappropriate diagnosisandmanagementofpatients.Thelevelofdifcultyofthe questionswillbesuchthatayear2foundationprogrammedoctor could reasonably be expected to answer. Thus, none of the questions requires specifc knowledge about general practice. The questions are evenly distributed across specifc topic areas:CardiovascularDermatology/ENT/eyeEndocrinology/metabolicGastroenterology/nutritionInfectious disease/haematology/immunology/geneticsMusculoskeletalPaediatricsPharmacology/therapeuticsPsychiatry/neurologyRenal/urologyReproductive (male and female)Respiratory 3Questions will relate to:Disease factorsMaking a diagnosisInvestigationsManagementPrescribingEmergency careThequestionsmayappearinavarietyofformatsbuttwoformatsare commonlyused,ExtendingMatchingQuestionsandSingleBestAnswer Questions.Inbothformats,candidateshavetochoosethemostlikely ofthegivenpossibleresponsestoaquestion,accordingtotheirclinical judgement.Unlessotherwisestated,onlyoneanswerisrequired.Itwill often be an answer that could be found in a nationally approved guideline or the British National Formulary. Other answers may be plausible, but one will clearly be the most appropriate.A sample Extending Matching Question and Single Best Answer Question are given overleaf.INTRODUCTION TO CLINICAL PROBLEM SOLVING QUESTIONS 4EXTENDED MATCHING QUESTIONInExtendingMatchingQuestions,anumberofscenariosrelatingtoa themearematchedtothemostappropriatechoicefromalistof options. ExampleTHEME: FEBRILE CHILDRENAChickenpoxBErythema infectiosumCHand, foot and mouth diseaseDHerpanginaEHerpes simplexFRubellaGScarlet feverHVincent anginaFor each clinical scenario given below, select the single most likely diagnosis from the list above. Each option may be selected once, more than once or not at all.

1A 4-year-old boy is pyrexial and has a sore throat and an erythematous rash that spares the area around the mouth. The tongue is red with prominent papillae.

2A 5-year-old girl has been unwell for 2 days. She now has oedematous erythematous plaques on the cheeks.

3A 3-year-old girl has a sore mouth with difuse ulceration. She is dripping saliva and there are vesicles around her mouth.

4A 2-year-old boy develops crops of vesicles on an erythematous base on the head, body and arms. The crops appear in diferent stages. There are ulcers in the mouth. 5Answers1GScarlet fever2BErythema infectiosum3EHerpes simplex4AChickenpoxINTRODUCTION TO CLINICAL PROBLEM SOLVING QUESTIONS 6SINGLE BEST ANSWER QUESTIONSingle Best Answer Questions consist of a statement followed by a number of items, one of which is correct.Example1A 34-year-old woman returns 7 days after receiving chloramphenicol eye drops for apparent conjunctivitis. Her eyes feel gritty and water. There is difuse injection of the sclera.Select the single most likely diagnosis from the list below.

ABacterial conjunctivitis

BEpiscleritis

CIritis

DKeratitis

EViral conjunctivitisAnswerEViral conjunctivitisOccasionally, more than one answer may be required (Multiple Best Answer Question) so it is important to read each question carefully. Beside clinical scenarios, results of investigations may also be presented. Photographs or electrocardiograms may also be included.Eachcorrectanswerisawardedonemarkandthetotalscoreequalsthe number of correct answers. The score required to proceed to Stage 3 varies from year to year and depends on many factors, not least of which is how hard the paper is thought to be. This implies that a few hard questions can beexpected.Thepurposeofthetestistodistinguishbetweenhighand low achieving candidates and if all the questions are easy that task will be much more difcult. A few of the examples in this book are in the difcult category for the same reason. 7Thereisnonegativemarkinginthistest(iethelossofamarkwhenan incorrect answer is given). This removes the fear factor. Candidates should pace themselves carefully and not run out of time. Where an answer is not known an intelligent guess should be made. No questions should be left unanswered as this may artifcially lower the mark.Alotofthoughtisgiventothewordingofthequestionstotrytomake themasunambiguousaspossible.Allquestionsshouldbetakenatface value.Theansweristhemostlikelyonefromtheinformationgiven. However, it is important that candidates understand the meaning of certain conventionaltermswhichfrequentlyappearinthepaper.Thesewillbe providedwiththepaperandcanbefoundontheNationalRecruitment Ofcewebsite.Theyarereproducedbelowandmayappearinsomeof the questions in this book.Pathognomonic, diagnostic, characteristic and in the vast majority imply that a feature would occur in at least 90% of cases.Typically, frequently, significantly, commonly and in a substantial majority imply that a feature would occur in at least 60% of cases.In the majority implies that a feature occurs in greater than 50% of cases.In the minority implies that a feature occurs in less than 50% of cases.Low chance and in a substantial minority imply that a feature may occur in up to 30% of cases.Has been shown, recognised and reported all refer to evidence that can be found in authoritative medical texts. None of these terms make any implication about the frequency with which the feature occurs.Candidateswhodonotalreadydososhouldstartreadingthoroughly. Reviewarticlesandeditorialsinmajorjournalsareuseful.Weaknessesin theminorspecialtiescanbecoveredbyreadingbookssuchastheABC ofDermatologyandtheABCofEyes(bothpublishedbyBMJPublishing Group).Itisusefultobeawareofthemainconclusionspresentedin thediferentsectionsofClinicalEvidence(BMJPublishingGroup;www.clinicalevidence.com). It is useful to study the more important guidelines INTRODUCTION TO CLINICAL PROBLEM SOLVING QUESTIONS 8GP ST: STAGE 2 PRACTICE QUESTIONSthatafectGeneralPractice,particularlythosepublishedbytheNational InstituteforClinicalExcellence(NICE).Agoodworkingknowledgeofthe British National Formulary will be invaluable. Preparation for this test should form a sound foundation for the later Applied Knowledge Test (AKT) in the MRCGPexam.Lastly,thereisnosubstituteforseeingplentyofpatients andrefectingonthediagnosticandmanagementissuespresented,and the efect of the illness on a patients life. 9CARDIOVASCULARCHAPTER 1 QUESTIONSChapter 1 Cardiovascular 11CHAPTER 1 QUESTIONSQUESTIONSTHEME: CHEST PAINOptionsACoronary artery spasmBDissection of thoracic aortaCGastro-oesophageal reflux diseaseDMesotheliomaEMetastatic lung depositsFOesophageal spasmGPericarditisHPneumoniaIPneumothoraxJPulmonary embolismKTietze diseaseLUnstable anginaFrom each of the case scenarios given below, select the single most appropriate diagnosis from the above list of options. Each option may be used once, more than once or not at all. 1.1A 25-year-old man has central chest pain, tachycardia and sweating. He has taken cocaine. 1.2A 63-year-old male smoker has long-term hypertension. He has severe chest pain radiating to his back. 1.3A 37-year-old woman has severe left-sided pain, which is worse on inspiration. She has antiphospholipid syndrome and a swollen left ankle.12GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 QUESTIONS 1.4A 42-year-old man has central chest pain. Movement exacerbates the pain and the anterior chest wall is tender. 1.5A 67-year-old male industrial worker has left-sided chest pain and long-term pleural plaques. 1.6An obese 42-year-old woman has central chest pain going through to her back, and this is worse in bed. 13CARDIOVASCULARCHAPTER 1 QUESTIONSTHEME: BASIC LIFE SUPPORT MANAGEMENTOptionsACheck airwayBCheck pulseCContinue cardiopulmonary resuscitation (CPR) until exhaustedDGive rescue breathsELeave patientFNo actionGPlace in recovery positionHStart chest compressionsFor each of the patients below, choose the single most appropriate treatment from the list of options above. Each option may be used once, more than once or not at all. 1.7A 6-year-old has stopped breathing in the supermarket. You have given mouth-to-mouth ventilation. What do you do next? 1.8A 73-year-old male visitor collapses in the hospital shop. You are the only other person in the shop. You open his airway and fnd he is not breathing. 1.9A 43-year-old man collapses in the street. After you open his airway he starts groaning. 1.10You rescue a 17-year-old boy from under the water in a canal. He is in cardiac arrest. You perform cardiopulmonary resuscitation alone for 1 minute and stop to assess your next action. The patient is unresponsive and cold. 1.11There has been a bomb blast at a London underground train station and the man in the seat next to you has stopped breathing. The train is full of black smoke and you can see a fre.14GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 QUESTIONSTHEME: DRUGS USED IN CARDIOLOGYOptionsAAmlodipineBAtenololCAtorvastatinDClopidogrelEDigoxinFDipyridamoleGFurosemideHLisinoprilILosartanJSpironolactoneKWarfarinForeachpatientdescribedbelow,choosethesinglemostappropriate treatment from the above list of options. Each option may be used once, more than once or not at all. 1.12A 70-year-old man has stable angina and hypertension. His medication consists of aspirin, ramipril and simvastatin. He develops a weakness in his left arm and leg that resolves within 24 hours. His blood pressure is 135/85 and his pulse 78 and regular. 1.13 A 75-year-old woman has a troublesome cough six weeks after discharge from hospital where her heart failure was treated. Her medication includes bisoprolol, and ramipril. 1.14 The same womans cough settles but she remains moderately dyspnoeic. There is no obvious evidence of fuid retention and her pulse is 88 and regular. 1.15 A 50-year-old woman has had two visits to the Emergency Department because she had atrial fbrillation. On both occasions she reverted to sinus rhythm but would like to try to prevent further attacks. 1.16 An 80-year-old man has symptoms of angina on exertion but has declined invasive investigations. There has been some symptom improvement with oral and sub-lingual nitrates and atenolol but he still fnds the angina troublesome. 15CARDIOVASCULARCHAPTER 1 QUESTIONSTHEME: PREVENTION OF CARDIOVASCULAR DISEASEOptionsAACE inhibitorBAspirinC-blockerDCalcium channel blockerEEzetimbeFFibrateGLifestyle advice onlyHNo treatment neededIStatinFor each patient below, choose the single most suitable option from the above list for cardiovascular disease prevention. Each option may be used once, more than once or not at all. 1.17 A 48-year-old woman has recently been diagnosed with type 2 diabetes and is found to have a fasting total cholesterol level of 4.9mmol/l and triglyceride of 2.0mmol/l. 1.18 A 50-year-old man has an average blood pressure of 165/100 after serial measurements. His cholesterol is 4.0mmol/l and random blood sugar 5.0mmol/l. He is a non-smoker and has no family history of cardiovascular disease. 1.19 A 52-year-old man takes ramipril to control his blood pressure. The current measurement is 130/80. 1.20 A 70-year-old man has had an exercise ECG that is suggestive of coronary heart disease and is awaiting further investigations. His current medication includes aspirin, atenolol, bendrofumethiazide, and simvastatin. His last three blood pressure readings averaged 150/95. 1.21 An otherwise healthy 40-year-old woman smokes 10 cigarettes per day. Her blood pressure is 120/80, total cholesterol 4.2mmol/l, LDL cholesterol 2.0mmol/l and random blood sugar 5.5mmol/l. Her cardiovascular disease risk is estimated at less than 10% over the next 10 years.16GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 QUESTIONSTHEME: CLINICAL SIGNS OF STRUCTURAL HEART ABNORMALITIESOptions AAtrial septal defectBAortic incompetenceCAortic sclerosisDAortic stenosisEHypertrophic cardiomyopathyFLeft ventricular aneurysmGMitral incompetenceHMitral stenosisIMitral valve prolapseJPatent ductus arteriosusKPulmonary stenosisLTricuspid regurgitationMTricuspid stenosisNVentricular septal defect (VSD)For each description of clinical signs below, choose the single most likely diagnosis from the list of options above. Each option may be used once, more than once or not at all. 1.22There is a harsh pan-systolic murmur, loudest at the lower left sternal edge and inaudible at the apex. The apex is not displaced. 1.23There is a soft late systolic murmur at the apex, radiating to the axilla. 1.24The pulse is slow rising and the apex, which is not displaced, is heaving in character. There is an ejection systolic murmur heard best at the right second interspace that does not radiate. 1.25The pulse is regular and jerky in character. The cardiac impulse is hyperdynamic and not displaced. There is a mid-systolic murmur, with no ejection click, loudest at the left sternal edge. 1.26There is a constant machinery-like murmur throughout systole and diastole. 17CARDIOVASCULARCHAPTER 1 QUESTIONSTHEME: HYPERTENSION TREATMENTOptionsA AmlodipineB AtenololC BendroflumethiazideD DoxazosinE LisinoprilF LosartanG Methyl dopaH MoxonidineFor each of the hypertensive patients below, choose the single most suitable antihypertensive medication from the list of options above. Each option may be used once, more than once or not at all. 1.27A 60-year-old man has diabetes and is already taking an angiotensin-converting enzyme (ACE) inhibitor. 1.28 A 42-year-old African Caribbean woman has hypertension which is not controlled by bendrofumethiazide. 1.29 A 72-year-old man has poorly controlled hypertension and has recently developed angina. 1.30 A 35-year-old pregnant womans blood pressure is 170/110 mmHg in the mid-trimester.18GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 QUESTIONS1.31A 60-year-old man has crushing central chest pain of one hour duration.Select from the list below the single measure that would not be appropriate prior to recording an ECG. A Aspirin 300mg chewed B Cyclizine intra venous 50mg C Glyceryl trinitrate sublingually D Diamorphine intravenous 5mg E Tenecteplase intravenous 50mg1.32A 72-year-old man has heart failure and chronic obstructive pulmonary disease (COPD). He has come for his medication to be reviewed. His current medications are aspirin, lisinopril, simvastatin and inhalers for his COPD.Which one other medication would he most beneft from?

AAmlodipine

BBisoprolol

CDigoxin

DLosartan

ERamipril 19CARDIOVASCULARCHAPTER 1 QUESTIONS1.33A 63-year-old woman with hypertension and recently diagnosed thyrotoxicosis complains of recent-onset palpitations. She is worried that the new medication she is taking for her thyrotoxicosis is causing these symptoms.Which one of the following is the single most likely diagnosis in this patient?

AAtrial fibrillation

BHeart block

CHeart failure

DSide-effect of carbimazole

EVentricular ectopics1.34A patient is newly diagnosed with atrial fbrillation. Select the single feature from the list below that would make the decision to prescribe aspirin rather than warfarin more appropriate. A Age > 75 years B Age < 65 years C Aortic stenosis D Heart failure E Previous transient ischaemic attack20GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 QUESTIONS1.35A 78-year-old woman presents with dyspnoea. Her pulse is regular but there are alternating weak and strong beats.Select from the list below the single condition that this type of pulse is characteristic of. A Aortic regurgitation B Aortic stenosis C Cardiac tamponade D Severe left ventricular failure E Takayasus arteritis1.36 A 6-year-old girl has fever and earache. She looks well but is febrile and has otitis media. Also she has a quiet systolic murmur localised to the left sternal edge. Otherwise cardiac examination is normal.Select from the list below the single most appropriate management option. A Admit to a paediatric unit B Arrange a chest X-ray and electrocardiogram C Follow-up appointment D Ignore the finding E Routine outpatient appointment 21CHAPTER 1 ANSWERSANSWERSTHEME: CHEST PAIN1.1ACoronary artery spasmCocainecausesagitation,tachycardia,hypertension,arrhythmiasand coronaryarteryspasm.Coronaryarteryspasmmayleadtoangina-type chest pain and even myocardial infarction.1.2BDissection of thoracic aortaDissectionoftheaortawithinthechestcausesseverecentralpain,that usually radiates to the back between the scapulae. Dissection of the aorta is associated with hypertension and collagen disorders (Marfan syndrome, pseudoxanthomaelasticum).Late-stagesyphilisisalsoassociatedwith dissection.1.3JPulmonary embolismAclothasembolisedfromthisladyslegandherlungisinfarcted. Antiphospholipidantibodysyndromeisanautoimmunedisorderthat predisposestorecurrentthromboses.Theclinicalpresentationof pulmonaryembolismrangesfrommildpleuriticchestpaintocardiac arrest.Patientsareoftenmildlyshortofbreathandhypoxiconarterial bloodgastestingandD-dimertestingwillbepositive.ChestX-raysare oftennormal.Diagnosisisbyventilation/perfusionscanningorspiral computed tomographic pulmonary angiography.1.4KTietze diseaseThis disorder is caused by infammation around the costosternal junctions. Itmaybebilateralorunilateralandthechestwallisverytenderover the afected area. Reassurance and non-steroidal anti-infammatory drugs (NSAIDs) are the mainstays of treatment.22GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 ANSWERS1.5DMesotheliomaThispatienthaslong-standingpleuralplaques,asignofmajorprevious asbestosexposure.Asbestoshasmanyadverseefectsonthelung, includingpleuralthickening(plaques),pleuralefusions,fbrosisand mesothelioma.Itisalsoassociatedwithcarcinomaofthebronchus.No medicaltreatmentisknowntoaltertheprogressofasbestos-related disease.1.6CGastro-oesophageal reflux diseaseThiswomanhasrefuxofgastriccontentsintotheoesophagus,theacid natureofwhichisirritatingtheoesophagealmucosaandcausingpain. This is often an indigestion-type pain, which may be relieved by antacids or proton pump inhibitors. Obesity, fatty foods, alcohol, cigarette smoking andlargemealsareassociatedwithsymptomaticdisease.Complications include oesophageal stricture and Barrett oesophagus.THEME: BASIC LIFE SUPPORT MANAGEMENT1.7BCheck pulseInacardiacarrestinachild,therecommendationisfrsttoopenthe airway, then to check breathing. If the child is not breathing, fve efective rescuebreathsaregiven.Afterthis,acentralpulseshouldbechecked.If this is absent then external cardiac massage is started. Alternate between cardiacmassageandbreathsataratioof15:2fortwotrainedpersonnel, or 30:2 for lone rescuer. Continue for 1 minute. After this obtain access to advanced life support. You may be able to carry the child to a telephone if no one else has summoned help. In reality, in a supermarket help will be on its way. In this case you continue CPR until help arrives or you become exhausted.1 23CARDIOVASCULAR ANSWERSCHAPTER 1 ANSWERS1.8ELeave patientThemostlikelycauseofarespiratoryarrestinthisadultpatientisa cardiacarrest.Thebestchanceofasuccessfuloutcomeisifthepatient is in ventricular fbrillation and is electrically defbrillated. In this situation youshouldleavethepatienttosummonhelpbeforestartingbasiclife support.11.9GPlace in recovery positionGroaningimpliesreturnofspontaneousbreathing,andalsoadequate circulation.However,themanhasareducedlevelofconsciousness.Ifhe is lying on his back there is a danger of the tongue blocking the airway so he should be placed in the recovery position.1.10ELeave patientRescue from drowning is an indication to start CPR rather than leaving the patient to summon help and a defbrillator. If there has been no response toinitialCPR,leavethepatienttogethelp.Inanadultwhomayhave sustainedtraumaorwhoseconditionindicatesdrowningasthecause ofcardiacarrest,thefrstactionisalsotogive1minuteofCPRpriorto leaving to summon help.11.11ELeave patientYour own safety is at risk. There is no merit in becoming another victim.24GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 ANSWERSTHEME: DRUGS USED IN CARDIOLOGY1.12FDipyridamoleNICErecommends2thatacombinationofmodifed-releasedipyridamole andaspirinbeusedtopreventocclusivevasculareventsinthosewho have had a transient ischaemic attack (as with this patient) or an ischaemic stroke.Thecombinationshouldbeusedfor2yearsafterthelastevent and the low dose aspirin continued thereafter. Warfarin is likely to be used instead if this patient had atrial fbrillation.1.13ILosartanLosartan(anangiotensinIIreceptorantagonist)shouldbesubstituted fortheACEinhibitorramipril.Troublesomedrycoughisacommonside efect with ACE inhibitors. Unfortunately losartan can also produce cough. -blockers can cause wheezing and that can make patients cough.1.14JSpironolactoneCurrentguidelines3recommendthatpatientsalreadyonoptimaldoses ofa-blockerandACEinhibitorshouldhaveanaldosteroneantagonist, spironolactoneaddedtotheirtherapy.Furosemideisusedtocontrol congestive symptoms and fuid retention. Digoxin can be used if she remains symptomatic in spite of the above therapy or if she has atrial fbrillation.1.15BAtenololGuidelines4 suggest that people with paroxysmal atrial fbrillation should frsthavetheirstroke/thromboembolicriskdeterminedtodecideifthey needaspirinorwarfarin.Forprevention,astandard-blockersuchas atenololshouldthenbetried.Suitablepatientsmayjustchoosetotake treatment when they have attacks. If this fails, and there is no coronary artery diseaseorleftventriculardysfunction,sotaloloraclassIcantiarrythmic agent(suchasfecainideorpropafenone)maybeused.Sotalolcanalso beusedinthepresenceofcoronaryheartdisease.Amiodaronemaybe used if there is left ventricular dysfunction. 25CARDIOVASCULAR ANSWERSCHAPTER 1 ANSWERS1.16AAmlodipineFor symptom control in angina the addition of a calcium channel blocker is the next step. Nicorandil, a potassium channel activator might also help. He should take aspirin if tolerated and any risk factors should be managed appropriately. He should have as full a clinical assessment as he will permit and exacerbating factors such as anaemia should be excluded.THEME: PREVENTION OF CARDIOVASCULAR DISEASEThesequestionsandanswersarebasedontheJointBritish Societies guidelines on the prevention of cardiovascular disease in clinical practice.51.17IStatin Cholesterol lowering therapy (statins) should be prescribed for all people withtype1or2diabeteswhoareovertheageof40years.Younger patientswithotherriskfactors,poordiabeticcontrol,complicationsora cholesterol level > 6.0mmol/l should also be given a statin.1.18AACE inhibitorHealthypeopleshouldreceivelifestyleadviceanddrugtherapyifthe bloodpressureissustainedatlevelsof160/100orgreaterregardlessof the absolute level of cardiovascular risk. Treatment targets are to produce levelsof140/85orless.AnACEinhibitoristherecommendedtreatment for a patient under the age of 55 years.61.19BAspirinAspirin75mgdailyshouldbeprescribedforhypertensivepatientsover the age of 50 years whose blood pressure is controlled to a level of 150/90 or less.26GP ST: STAGE 2 PRACTICE QUESTIONSCHAPTER 1 ANSWERS1.20AACE inhibitorACE inhibitors are recommended for patients with ischaemic heart disease particularlyifthereisreducedleftventricularfunction.Theyshouldalso beconsideredforpatientswithnormalleftventricularfunctionifthe blood pressure targets have not been achieved (< 130/80 in patients with ischaemicheartdisease).Otherriskfactorsneedattentionandthestatin dosemayneedadjustment.Aspirinanda-blocker,bothbenefcial,are already being taken.1.21GLifestyle advice only Cardiovascularriskestimationchartsusetheriskfactors:gender, cholesterol:HDLcholesterolratio,diabetes,smokingandsystolicblood pressure.Healthyindividualswithacardiovasculardiseaseriskof