Pre-diabetes and Cardiovascular Risk After a Health Check — Free SCA Practice Case
South Asian man with pre-diabetes and cardiovascular risk after a health check
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
A live 12-minute consultation with an AI patient, marked. You see your verdict before we ask for anything.
Materials for Candidate
Please review before starting the consultation
Full Name
Tariq Miah
Age
45 years
Consultation Type
TelephoneAge
45
Situation
Telephone Consultation.
Reason for Encounter
"Patient booked a telephone appointment to discuss the results of his recent NHS Health Check / Cardiovascular Disease (CVD) screening bloods."
Medical Records
- ●PMH: None.
- ●Medications: None.
- ●Lifestyle: Ex-smoker (stopped 1 year ago, transitioned to e-cigarettes). BMI: 27.2 kg/m².
- ●Allergies: NKDA.
Recent Notes
- ●1 week ago (HCA Clinic): Blood pressure 144/92. Fasting bloods: HbA1c 45 mmol/mol (Non-Diabetic Hyperglycaemia / Pre-diabetes). Total Cholesterol 5.2 mmol/L. QRISK3 score: 11%.
Patient Script
For the friend playing the patient role
Character Overview: You are Tariq, a 45-year-old taxi driver. You work 10-to-12-hour shifts, sitting in your cab almost all day. Because you are always on the road, your diet consists heavily of quick, processed takeaways or large, late-night traditional family meals (heavy in ghee and white rice) when you get home at midnight. You feel absolutely fine. When the receptionist told you to book a call for "pre-diabetes," you felt relieved. To you, "pre-diabetes" means "not diabetes," so you believe you have dodged a bullet and don't need to change anything. Regarding your smoking, you are actually quite proud of yourself. You quit traditional cigarettes a year ago and now exclusively vape a disposable strawberry e-cigarette. You vape constantly in your cab and believe it is 100% harmless. You will not volunteer information about your sedentary job, your late-night eating habits, or your belief that vaping is completely safe unless the doctor specifically explores your daily routine, asks about your diet, or questions your understanding of the blood results.
ICE — Ideas, Concerns, Expectations:
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Ideas: You think "pre-diabetes" simply means you don't have diabetes — your dad has "proper diabetes" with insulin injections, and since you don't need any of that, your body must be handling things fine. You have no concept that pre-diabetes is an active metabolic warning or that your ethnicity places you at higher risk. If anything, you put the tiredness down to long hours, not to anything medical.
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Concerns: Your only real worry, buried beneath the reassurance, is your father. He developed type 2 diabetes in his fifties and now has problems with his eyes and feet. You don't want to end up like him — but you've convinced yourself that because you're not on medication, you're in a different category. If the doctor draws a direct line between pre-diabetes and your father's condition, this concern surfaces quickly. You are also quietly worried about your weight — you know you carry a belly — but you'd rather not bring it up yourself.
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Expectations: You are expecting a quick, reassuring phone call confirming there's nothing to worry about. Ideally, you'd like to hear "it's fine, just keep an eye on it." You are not expecting to be told you need to make significant lifestyle changes, and you are certainly not expecting to hear the word "obese" applied to you.
(ICE content surfaces only when the candidate directly explores the patient's perspective — not volunteered unprompted.)
Consultation Flow & Responses:
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The Opening:
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If the doctor asks an open question: "Hi Doctor. The receptionist said I needed to call to get my blood test results. She mentioned something about 'pre-diabetes', but I feel completely fine, so I assume there's nothing to worry about?"
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Data Gathering (The Layers):
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Layer 1: Exploring Baseline Understanding (The Misconception):
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If the doctor asks what you understand about pre-diabetes: "Well, it means I don't have diabetes, right? My dad has proper diabetes and he has to inject insulin. I don't have any of that, so I figure my body is handling things okay."
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Layer 2: Screening for Overt Symptoms:
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If asked about thirst, urination, or fatigue: "No, nothing like that. I get a bit tired, but I work long hours."
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Layer 3: Exploring the Sedentary Lifestyle & Diet:
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If asked about your job, exercise, or diet: "I'm a taxi driver, so I'm sitting down for about 12 hours a day. I don't really have time for the gym. Food-wise, I usually grab a burger or a pasty between fares, and then my wife leaves me a big plate of curry and rice for when I get home around midnight."
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Layer 4: Exploring Vaping Habits:
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If asked about smoking/vaping: "I haven't touched a cigarette in a year! I just use those disposable vapes now. I puff on it all day in the cab to keep me awake. It's just water vapor and flavoring, isn't it?"
If Asked — Medical History and Medications:
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If asked about past medical history: "No, I've never really been to the doctor for anything. I've always been healthy — no tablets, no hospital visits, nothing like that."
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If asked about the recent blood pressure reading: "They did check my blood pressure at the health check, yeah. The nurse didn't seem too worried — she just said it was a little bit on the high side and that the doctor would go through everything on the phone."
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If asked about the cholesterol result: "She mentioned cholesterol as well, I think. I can't remember the number. Is it bad? I thought cholesterol was more of an older person's thing."
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If asked about the QRISK score or cardiovascular risk: "I don't know what that is. Nobody explained it to me. Is that something from the blood test?"
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If asked about family history of diabetes: "My dad — he got diabetes when he was about 55. He's on insulin now and he's had trouble with his eyes and his feet. My mum doesn't have it, but my uncle on my dad's side does too."
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If asked about family history of heart disease: "Not that I know of. My dad has high blood pressure as well, but nobody's had a heart attack or anything like that."
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If asked about allergies: "No, no allergies to anything."
Social History and Lifestyle Impact:
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Occupation and daily life context: You work as a self-employed private hire taxi driver, typically doing 10-to-12-hour shifts, six days a week. Your working day is entirely sedentary — you sit in the cab from early morning until late evening. You eat on the go between fares and rarely have a structured break. When you get home around midnight, your wife has left you a large traditional meal, which you eat before going straight to bed. You have two children (ages 8 and 12) and see them mostly at weekends.
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Lifestyle impact of the condition: Because you feel completely well, there is currently no perceived disruption to your daily life from the pre-diabetes diagnosis. However, if the doctor explains the risks clearly, you should show dawning recognition that your entire working pattern — the sedentary hours, the grab-and-go eating, the late-night heavy meals, the constant vaping — is the problem. You might say: "I suppose the whole way I work makes it hard to be healthy. I'm in the cab all day, I eat rubbish between fares, and then I have a massive dinner at midnight and go straight to sleep. I don't really see when I'd fit in exercise or cooking something different." This is volunteered naturally when the doctor explores your routine — not delivered as a monologue.
If Asked — Associated Symptoms:
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If asked about unexplained weight loss: "No, if anything I've probably put on a bit of weight this last year since I stopped smoking."
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If asked about blurred vision or visual changes: "No, my eyes are fine. I had them tested last year for my taxi licence — no problems."
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If asked about tingling, numbness, or pins and needles in hands or feet: "No, nothing like that."
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If asked about skin changes, dark patches on the neck or armpits (acanthosis nigricans): "Actually, now you mention it, I have noticed the skin on the back of my neck has gone a bit darker and thicker. I thought it was just from rubbing on my shirt collar. Is that something?"
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If asked about wounds or cuts that are slow to heal: "No, I haven't noticed anything like that."
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If asked about recurrent infections or thrush: "No, nothing like that."
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If asked about chest pain, palpitations, or shortness of breath: "No, nothing at all. I feel fit as a fiddle, honestly."
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If asked about erectile dysfunction: "Well... actually, things haven't been great in that department for a few months now. I just put it down to being tired and stressed from work. I didn't think it was medical."
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If asked about alcohol intake: "I don't drink much at all. Maybe a beer at a family thing, but that's it. Once a month at most."
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If asked about stress or mood: "I'm alright, just tired. The hours are long but I need the money, so I just get on with it."
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If asked about sleep or snoring: "My wife says I snore like a train and sometimes I stop breathing in my sleep. She's been on at me about it for ages. I do feel knackered during the day, but I thought that was just the long shifts."
Negotiation & Collaborative Management Plan:
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If the Doctor tells you your BMI is fine because it's only 27:
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Reaction: "Oh, good. I know I carry a little bit of a belly, but I didn't think I was obese." (Note: Candidate critically fails population health knowledge; a BMI of 27 in a South Asian male is classified as obese and carries high metabolic risk).
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If the Doctor bluntly tells you to "stop eating curry and rice":
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Reaction: Defensive. "That's what my family eats. I'm not going to sit in the corner eating a salad while my wife and kids eat dinner." (Candidate fails for lacking cultural humility in dietary advice).
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If the Doctor explains the ethnic risk factors and what pre-diabetes actually means:
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Reaction: Surprised and slightly worried. "Wait, so because of my background, my body struggles with sugar even if I'm not massively overweight? And this is a warning sign that the diabetes is actually starting? I didn't realize that."
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If the Doctor brings up active transport / dietary changes (Planetary/Population Health):
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Reaction: "I suppose I could park the cab further away when I take my breaks and walk to the shop instead of driving drive-thru to drive-thru. And maybe swap some of the red meat for lentils or vegetables."
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If the Doctor addresses the vaping:
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Reaction: "I didn't realize it still kept my blood pressure up. I guess I swapped one addiction for another. Do you have any programs to help me quit the vapes?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Population Health: Ethnicity-Adjusted BMI Thresholds
- ●In people of South Asian, Chinese, Black African, and African-Caribbean origin, visceral fat accumulates at lower body weights, driving insulin resistance and cardiovascular risk at BMIs that would be considered safe in Caucasian populations.
- ●NICE and NICE CKS recommend lower diagnostic thresholds for these groups:
- ●BMI 23.0–27.4 kg/m² = Overweight
- ●BMI ≥27.5 kg/m² = Obese
- ●Tariq's BMI of 27.2 kg/m² sits at the threshold of clinical obesity by these criteria — not simply "overweight." Applying the standard Caucasian chart and offering false reassurance is a clear fail in the SCA.
- ●South Asian ethnicity is independently associated with a higher risk of Type 2 diabetes and CVD at any given BMI, partly due to a higher proportion of visceral and ectopic fat relative to total body weight. South Asian adults also develop T2DM on average 10 years earlier than Caucasian populations.
- ●Frame this with the patient as a biological vulnerability, not a personal failing — it contextualises why his results demand action even though he feels well.
Non-Diabetic Hyperglycaemia (NDH) — What It Is and Why It Matters
- ●An HbA1c of 42–47 mmol/mol defines NDH, often called pre-diabetes. A fasting plasma glucose of 6.1–6.9 mmol/L is the other route into the same category and is specifically called impaired fasting glycaemia. Tariq's HbA1c of 45 mmol/mol sits in the upper half of this range.
- ●NDH is not a benign or static label — it reflects active insulin resistance and carries a meaningful annual risk of progression to Type 2 diabetes. Without intervention, approximately 5–10% of people with NDH progress to T2DM per year.
- ●NDH is also an independent cardiovascular risk factor — microvascular and macrovascular damage begins before the diabetic threshold is crossed.
- ●Acanthosis nigricans — darkened, velvety thickening of the skin, typically on the neck or axillae — is a visible cutaneous marker of insulin resistance. Always ask about skin changes in pre-diabetes consultations; Tariq reports this on the back of his neck. Its presence reinforces the clinical significance of the HbA1c result and should not be dismissed as a skin condition.
- ●Family history significantly amplifies risk: Tariq's father and paternal uncle both have T2DM, and his father has established complications (retinopathy, peripheral neuropathy). A first-degree family history of T2DM approximately doubles lifetime risk — this is a powerful motivational hook as well as a genuine risk modifier.
- ●The reversibility of NDH is the critical message: structured lifestyle intervention can normalise HbA1c and substantially reduce progression risk. This framing — "your body is warning you and you still have time to change course" — is more motivationally effective than catastrophising.
The NHS Diabetes Prevention Programme (NDPP)
- ●The Healthier You: NHS Diabetes Prevention Programme is the NICE-recommended, evidence-based structured intervention for adults with NDH. It is a 9-to-12-month group-based behavioural programme focusing on diet, physical activity, and weight management.
- ●NDPP participation reduces progression to T2DM by approximately 26–31% compared to standard care — far superior to brief GP advice alone.
- ●Referral to the NDPP is a positive indicator in the marking scheme. Advising "eat better and exercise" without offering the formal programme is a fail.
- ●The programme is available both in-person and digitally — the digital pathway is particularly relevant for Tariq given his shift pattern and limited free time during standard hours.
- ●Explain what the programme involves so the patient can make an informed decision: regular sessions over 9–12 months, structured meal planning, supported activity goals, and peer group contact.
Raised Blood Pressure — Confirmation Before Treatment
- ●A clinic blood pressure of 144/92 mmHg is above the NICE clinic threshold of 140/90 mmHg, so hypertension is suspected but not yet diagnosed. NICE NG136 defines Stage 1 hypertension as a clinic BP of 140/90 to 159/99 mmHg and an ABPM daytime or home average of 135/85 to 149/94 mmHg.
- ●NICE NG136 requires ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to confirm the diagnosis before initiating antihypertensive medication. Do not prescribe on a single clinic reading.
- ●While confirmation is pending, address lifestyle contributors: nicotine (vaping), physical inactivity, dietary sodium, excess weight, and OSA.
- ●If ABPM/HBPM confirms Stage 1 hypertension and cardiovascular risk is ≥10% (as it is here), NICE NG136 recommends offering antihypertensive drug treatment in addition to lifestyle advice. For a South Asian patient aged under 55, an ACE inhibitor (e.g. ramipril) or ARB (e.g. losartan) is the preferred first-line agent per NICE NG136 — the calcium channel blocker preference applies to patients of Black African or Caribbean origin or those aged 55 and over.
- ●The blood pressure result must not be ignored — it contributes directly to the QRISK3 score and to the overall cardiometabolic risk picture.
Cardiovascular Risk: Cholesterol, QRISK3, and Statin Therapy
- ●Tariq's QRISK3 score of 11% represents his 10-year risk of a first cardiovascular event. South Asian ethnicity is built into the QRISK3 algorithm as a multiplier.
- ●NICE NG238 (Cardiovascular disease: risk assessment and reduction, 2023) recommends offering a statin for primary CVD prevention when the QRISK3 10-year risk is ≥10% in adults aged 25–84. Tariq meets this threshold.
- ●First-line agent for primary prevention: atorvastatin 20 mg once daily (can be taken at any time of day — atorvastatin has a long half-life and is not time-dependent, unlike simvastatin).
- ●The threshold to offer a statin discussion is met on the QRISK3 score alone; the total cholesterol of 5.2 mmol/L and the presence of NDH, elevated BP, South Asian ethnicity, and heavy vaping further strengthen the clinical case.
- ●This should be a shared decision-making conversation, not a unilateral prescription. Explain the risk, the benefit, common side effects (muscle aches are a commonly reported side effect, with severe myopathy being uncommon at standard doses), and the option to revisit after a period of structured lifestyle change.
- ●Failing to link the QRISK3 score to a discussion about primary prevention is a clear negative indicator.
Vaping: Harm Reduction Without False Reassurance
- ●E-cigarettes are the UK's most widely used cessation aid. UKHSA estimates they are substantially less harmful than combustible tobacco, primarily because they do not produce tar or carbon monoxide. The evidence base continues to evolve — vaping is best described as significantly less harmful than smoking, rather than harmless.
- ●However, heavy, continuous nicotine delivery — particularly via modern high-nicotine disposable vapes — maintains significant nicotine addiction. Nicotine is a potent sympathomimetic: it acutely raises heart rate and blood pressure, causes endothelial dysfunction, and independently contributes to cardiovascular risk.
- ●In a patient with NDH, a raised blood pressure, and a QRISK3 of 11%, this matters clinically.
- ●The balanced GP position: Acknowledge and affirm stopping combustible tobacco — a genuine harm reduction achievement — then gently and honestly explain that vaping is not neutral for his blood pressure and cardiovascular risk, and offer referral to NHS stop-smoking services (which now support vaping cessation).
- ●Avoid two common errors: telling the patient vaping is completely harmless (medically inaccurate and clinically unsafe given his BP and QRISK3), or equating it directly to smoking (overstates risk and negates genuine progress).
Obstructive Sleep Apnoea (OSA) in the Cardiometabolic Context
- ●Tariq reports loud snoring and witnessed apnoeas, along with significant daytime sleepiness. This is sufficient to raise clinical suspicion for obstructive sleep apnoea.
- ●OSA is clinically significant in this case for two reasons: it independently worsens insulin resistance and contributes to sustained hypertension through overnight sympathetic activation and intermittent hypoxaemia.
- ●OSA is also a relevant occupational and safety consideration. The DVLA requires that drivers with excessive daytime sleepiness must not drive until symptoms are adequately treated and controlled — this applies to both Group 1 (ordinary car and private hire taxi) and Group 2 (HGV/bus) licence holders, though Group 2 standards are stricter. Tariq should be advised not to drive if excessively sleepy.
- ●Investigation: Arrange an overnight oximetry study (available via primary care in many areas) or refer to a respiratory/sleep clinic for formal assessment if clinical suspicion is high.
- ●Do not attribute daytime fatigue entirely to long shifts without screening for OSA in a patient with this clinical profile.
Erectile Dysfunction as an Early Vascular Marker
- ●New-onset erectile dysfunction (ED) in a 45-year-old male with NDH, elevated blood pressure, heavy nicotine use, and a QRISK3 of 11% is not simply psychogenic or fatigue-related — it is a potential early marker of endothelial dysfunction and subclinical cardiovascular disease.
- ●The penile vasculature is among the smallest in the body and is often the first to show the effects of vascular damage. ED frequently precedes clinically overt CVD by 2–5 years.
- ●In this context, ED raises the clinical urgency of cardiovascular risk management — it should be acknowledged, framed sensitively within the vascular picture, and followed up with a dedicated review. Basic assessment includes: fasting glucose (to exclude overt T2DM), lipid profile, testosterone, and blood pressure.
- ●Do not dismiss or ignore this disclosure. Responding with clinical curiosity and sensitivity is a positive indicator in Domain 3.
Pragmatic, Culturally Informed Lifestyle Advice
- ●Lifestyle advice that ignores occupational and cultural reality is clinically useless and a fail in the SCA.
- ●For a taxi driver on 12-hour shifts: practical physical activity suggestions include parking further from the destination during breaks and walking, using waiting time between fares for short walks, and taking stairs when possible. The NHS recommends ≥150 minutes of moderate-intensity activity per week — this can be accumulated in 10-minute bouts.
- ●Dietary advice must be culturally informed and collaborative: explore what the patient actually eats before prescribing a dietary model. For Tariq, realistic adaptations include reducing portion size of the late-night meal (or shifting eating earlier in the evening), switching to wholegrain basmati rice, increasing dal and vegetables, reducing ghee, and replacing processed snacks between fares with lower-GI alternatives (e.g., nuts, fruit, wholegrain options).
- ●Never advise a patient to "stop eating curry." This is culturally illiterate and triggers defensive disengagement. Adapt traditional foods rather than replace them.
- ●The late-night, large high-GI meal is a modifiable contributor to poor glycaemic control and excess calorie intake in this case — address it directly and collaboratively, focusing on portion size and meal composition rather than requiring wholesale dietary change.
Safety Netting and Structured Follow-Up
- ●A single vague follow-up ("see you in a year") is a fail. This case has multiple active clinical threads, each requiring its own timeline.
- ●HbA1c: Repeat at 12 months to assess response to lifestyle changes and NDPP. If HbA1c rises to ≥48 mmol/mol on repeat testing, this meets the threshold for a T2DM diagnosis.
- ●Blood pressure: Arrange ABPM or HBPM within 4–8 weeks to confirm Stage 1 hypertension before any prescribing decision.
- ●Lipids: If statin therapy is initiated, recheck lipids at 3 months to assess response per NICE CG181.
- ●OSA: If Epworth Sleepiness Scale score is elevated or clinical suspicion is high, refer to a sleep clinic for formal sleep studies. Given this patient holds a vocational licence, advise him of his DVLA obligation to report symptoms of OSA.
- ●ED: Arrange a dedicated follow-up appointment with appropriate baseline blood tests.
- ●Safety-net symptoms: Advise the patient to return sooner if he develops symptoms of overt T2DM — increased thirst, frequent urination, unexplained weight loss, or blurred vision. These would require an urgent repeat HbA1c to exclude diabetes above threshold.
Further reading
From the PCCS Academy, the Primary Care Cardiovascular Society’s learning modules for primary care.
Free for practising healthcare professionals. You need a PCCS account to open these. Join the PCCS
Mapped to the RCGP curriculum topic: Population and Planetary Health.
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