PLAB 1 & UKMLA Clinical Scenario: Mastering Hypertension Management (November 2025 Recall)
Topic: General Practice / Cardiology GMC MLA Content Map: Chronic Conditions (Hypertension)
One of the most common themes in the PLAB 1 and UKMLA exams is the management of chronic conditions according to NICE guidelines. Hypertension is a staple of the syllabus. It appears in almost every exam because it tests your ability to follow a logical, stepwise algorithm. Remember, since August 2024, both the PLAB and the MLA AKT exam are based on the same MLA content map and are conducted by the GMC UK. Check out reviews from recent exam candidates
Below, we break down a high-yield question based on the November 2025 PLAB 1 exam.
The Clinical Scenario
A 62-year-old man attends his GP for a routine hypertension review. He was diagnosed 5 years ago and reports being fully adherent to his medication.
Current Medication:
Ramipril 10 mg ONCE daily
Amlodipine 10 mg ONCE daily
Vitals & Labs:
Clinic Blood Pressure: 154/92 mmHg
Home Blood Pressure (Diary): Average 148/90 mmHg (over two weeks)
Potassium: 4.3 mmol/L
eGFR: 78 mL/min/1.73m²
Co-morbidities: None
Which is the most appropriate additional medication to prescribe?
A. Bisoprolol
B. Dapagliflozin
C. Doxazosin
D. Indapamide
E. Spironolactone
The Correct Answer & Explanation
✅ Correct Answer: D. Indapamide
Why is this the correct answer? This patient has uncontrolled hypertension despite being on maximum doses of two agents: an ACE inhibitor (Ramipril) and a Calcium Channel Blocker (Amlodipine).
According to NICE Guideline [NG136], hypertension management follows a strict stepwise approach. To answer this correctly, you need to identify which "Step" the patient is currently on.
The NICE Hypertension Algorithm (The "A+C+D" Rule)
Step 1: Start with an ACE inhibitor (A) or ARB.
This patient is already taking Ramipril (A).
Step 2: Add a Calcium Channel Blocker (C) OR a Thiazide-like diuretic (D).
This patient is taking Ramipril + Amlodipine (A + C).
Step 3: If BP remains uncontrolled, use the combination of A + C + D.
This patient needs the "D" added to his regimen.
Indapamide is a thiazide-like diuretic and is the preferred agent for Step 3. Therefore, adding Indapamide to his current regimen is the definitive management step.
Why Are the Other Answers Wrong? (Distractor Analysis)
Understanding why an answer is wrong is just as important as knowing the right one. Here is how the examiners try to trick you:
A. Bisoprolol (Beta-Blocker): Beta-blockers are no longer routine 3rd-line agents for uncomplicated hypertension. They are usually reserved for patients with specific indications like heart failure, angina, or post-MI. In the absence of these, they are considered a Step 4 option only if other drugs are contraindicated.
B. Dapagliflozin (SGLT2 Inhibitor): While excellent for heart failure and CKD, SGLT2 inhibitors are not part of the standard NICE hypertension algorithm for a patient with normal kidneys (eGFR 78) and no heart failure.
C. Doxazosin (Alpha-Blocker): This is a Step 4 agent. You would only consider this (or Spironolactone) after the patient is already taking the A+C+D combination and their BP is still not controlled.
E. Spironolactone (Aldosterone Antagonist): Like Doxazosin, this is a Step 4 drug. It is the preferred Step 4 agent if the patient’s potassium is <4.5 mmol/L. However, you cannot jump to Step 4 without completing Step 3 (adding the diuretic) first.
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Exam Tip: "Clinic" vs. "Home" BP Readings
Did you notice the question gave you two BP readings?
Clinic BP: 154/92 mmHg
Home BP Average: 148/90 mmHg
In the UKMLA/PLAB, always look at the Home Blood Pressure Monitoring (HBPM) or Ambulatory (ABPM) average to confirm the diagnosis or control. The target for treated patients over 80 years old is <150/90 mmHg, but for a 62-year-old, the target is generally <135/85 mmHg (home/ambulatory) or <140/90 mmHg (clinic). Since his home average is 148/90, he is definitely above target and requires an escalation in therapy.
Ace the UKMLA or the PLAB exam with MedRevisions
Questions like this are exactly what you will face on exam day. They don't just test recall; they test your ability to apply specific UK guidelines to a patient scenario.
At MedRevisions, our question bank is built on the GMC MLA Content Map. We constantly update our scenarios to reflect the latest NICE NG136 guidelines, ensuring you never study outdated medicine.
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