PLAB 2 Hypertension Station: How to Approach, Mark Scheme & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Essential (primary) hypertension
  Over 90 percent of cases and the working diagnosis in this station - persistently raised blood pressure with no identifiable underlying cause, driven by age, weight, salt, alcohol, inactivity and family history. Confirmed on ambulatory or home readings, not a single clinic measurement.
• White-coat hypertension
  Clinic readings raised but ambulatory or home readings normal. This is exactly why NICE requires ABPM (or HBPM if ABPM is not tolerated) before diagnosing - and why you should explain to the patient what the 24-hour monitor was for.
• Renal secondary hypertension
  Chronic kidney disease or renal artery stenosis. Screen with urea and electrolytes, eGFR and a urine dip for protein and blood - abnormal renal function or an abrupt rise in a previously normal patient should make you pause before labelling it essential.
• Endocrine secondary hypertension
  Primary hyperaldosteronism (Conn's) is the commonest secondary cause - think of it with low potassium. Phaeochromocytoma gives episodic headache, sweating and palpitations; Cushing's gives the classic habitus. Suspect secondary causes in patients under 40 or with resistant hypertension.
• Drug-induced hypertension
  NSAIDs, the combined oral contraceptive pill, corticosteroids, decongestants, some antidepressants, and recreational stimulants such as cocaine. One direct question about medicines, over-the-counter remedies and supplements covers this block of marks.
• Accelerated (malignant) hypertension
  Blood pressure of 180/120 or higher with retinal haemorrhages, papilloedema or new end-organ symptoms - severe headache, visual disturbance, chest pain, confusion. This needs same-day specialist assessment and is the red flag the safety-critical items are watching for.
• Pregnancy-related hypertension
  In any woman of childbearing age, ask about pregnancy - gestational hypertension and pre-eclampsia follow a completely different pathway with urgent obstetric involvement, and ACE inhibitors are contraindicated.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Open the consultation and signpost

   The patient has come for results and expects answers early - tell them the plan for the conversation up front.

   • Wash hands, greet, introduce yourself with name and grade, confirm the patient's full name and date of birth.
   • Establish why they have come and what they already understand about the check-up and the monitor.
   • Signpost: "I have your results here. Before we go through them, may I ask a few questions so I can give you the full picture?"

2. 2. Confirm how the diagnosis was made

   NICE requires ambulatory (or home) readings to confirm hypertension - a single clinic reading is not a diagnosis, and saying so out loud shows the examiner you know it.

   • Acknowledge the 24-hour ambulatory monitor and its average reading in plain terms.
   • Explain why it was done: clinic readings can be falsely high from nerves, so the monitor confirms the pressure really is raised through a normal day.
   • Ask the examiner for today's observations and a repeat blood pressure - it is a weighted mark and grounds your explanation.

3. 3. Screen for symptoms and red flags

   Most newly diagnosed patients feel entirely well, but you must actively exclude accelerated hypertension and end-organ symptoms rather than assume.

   • Headaches, visual disturbance or blurring, dizziness.
   • Chest pain, breathlessness, palpitations, ankle swelling.
   • Any previous raised readings, and in a woman of childbearing age, whether she could be pregnant.
   • Severe headache or visual disturbance with a very high reading means same-day referral - never dismiss end-organ symptoms as stress.

4. 4. Sweep risk factors and the rest of the history

   This is the highest-yield data-gathering block - each lifestyle area is a separate mark, so ask about each one specifically.

   • Past medical history - diabetes, high cholesterol, heart disease, kidney disease specifically.
   • Medications including over-the-counter, herbal and supplements (NSAIDs and decongestants raise blood pressure), plus allergies.
   • Family history of hypertension, diabetes, heart disease, kidney disease, stroke or mini-stroke.
   • Smoking - amount and duration. Alcohol - quantify a typical week, including weekends.
   • Diet (salt, takeaways, fried food), physical activity, occupation and stress.
   • Previous hospital admissions and operations round out the history.

5. 5. Ideas, concerns and expectations

   This patient usually carries two things: a fear of what happens if it is not dealt with, and a wish to avoid tablets. Invite both before you explain anything.

   • "What is your biggest worry about this result?" - often a spouse's concern brought them in; acknowledge it.
   • "How would you feel about taking medication if we needed it?" - surfacing the reluctance early lets you build the plan around it.

6. 6. Explain the diagnosis, the risks and the numbers in plain English

   Translate every figure. The interpersonal-skills domain rewards lay language and checking understanding, and the clinical domain rewards explaining consequences without scaremongering.

   • "Your average blood pressure over 24 hours was higher than we would like - this is called high blood pressure, or hypertension."
   • Explain the why-it-matters honestly: untreated, it quietly strains the heart, brain, kidneys and blood vessels, raising the risk of heart attack, stroke and kidney damage.
   • If a QRISK score is given, explain it as "your chance of a heart attack or stroke over the next ten years" - and stress it is modifiable.
   • If BMI is given, explain in plain terms that they are overweight and that losing weight lowers the pressure directly.
   • Pause and check understanding before moving to the plan.

7. 7. Counsel on lifestyle - five specific areas

   Vague advice to "live healthily" scores nothing. Each area below is a separate mark, and several are weighted.

   • Diet - cut salt and saturated fat, more fruit and vegetables; be concrete about their actual habits (the takeaways, the fried food).
   • Exercise - around 150 minutes of moderate activity a week; suggest something that fits their life, such as brisk walking.
   • Weight - link weight loss explicitly to lowering both blood pressure and cardiovascular risk.
   • Smoking - the single biggest modifiable risk; offer the cessation service, nicotine replacement and medication options. Omitting this is a safety-critical fail in some stations.
   • Alcohol - bring intake within 14 units a week spread over several days.
   • Offer written information and referral to a dietitian or smoking-cessation service - a one-line offer scores the mark.

8. 8. Outline drug treatment, investigations and follow-up

   Respect a preference for lifestyle first where the guideline allows it, but be honest about when tablets are needed - then close with an explicit monitoring plan.

   • Explain the staged approach in lay terms: at his level of blood pressure and risk, medication is usually recommended alongside lifestyle change, not instead of it.
   • Know the NICE first-line logic: under 55 and not of Black African or African-Caribbean origin, an ACE inhibitor or ARB; aged 55 or over, or of Black African or African-Caribbean origin, a calcium channel blocker. Explain your chosen tablet as "one tablet a day that relaxes the blood vessels".
   • Acknowledge baseline tests already done (ECG, bloods, cholesterol, kidney function, urine dip) and say you would review anything outstanding - these screen for causes and for organ strain.
   • Say you will discuss the prescription with your senior - a safe, expected line for an FY2.
   • Arrange review in two to four weeks with repeat readings, and offer home blood pressure monitoring.
   • Safety-net explicitly: "If you get a severe headache, problems with your vision or chest pain, seek help the same day." Summarise, invite questions, thank the patient.

Common pitfalls

• Diving into the results before taking any history - the mark scheme rewards a focused history first, and signposting buys you the time to take it.
• Failing to ask specifically about headaches, dizziness and visual disturbance - each is a separate data-gathering mark, and together they are your accelerated-hypertension screen.
• Giving lifestyle advice as one vague sentence. Diet, exercise, weight, smoking and alcohol are marked as five separate items - cover each one specifically.
• Overlooking smoking cessation in a 20-a-day smoker - it is his biggest modifiable risk and a weighted, sometimes safety-critical, item.
• Dismissing the raised blood pressure as harmless because the patient feels well - this is a safety-critical fail. Feeling well is the norm in hypertension; say so and explain why it still matters.
• Steamrolling the patient's wish to try lifestyle change first. Acknowledge it, explain what the readings and risk score mean, and build a shared plan - dictating loses interpersonal marks.
• Forgetting to ask the examiner for today's observations and an examination - the repeat blood pressure is a weighted clinical-management mark.
• Closing without a follow-up plan. An unmonitored new diagnosis of hypertension is a safety-critical fail; always book the review and offer home monitoring.

Frequently asked questions