The question
Work it with the BNF open before you show the answer. At exam pace this item has 1 min 12 s.
A 48-year-old man of white British family origin attends to discuss blood pressure readings taken at home.
PMH: nil of note; non-smoker.
DH: no regular medication; no allergies.
On examination: BMI 27 kg/m². Stage 2 hypertension confirmed on ambulatory monitoring (average 152/96 mmHg). No end-organ signs.
Investigations: Na 140 mmol/L (135–145), K 4.3 mmol/L (3.5–5.0), creatinine 84 µmol/L (60–110), eGFR >90 mL/min/1.73m², urine ACR normal, HbA1c 38 mmol/mol.
- amlodipine
- atenolol
- bendroflumethiazide
- doxazosin
- ramipril
Answer and marking
ramipril
Marks2
ExplanationFor a patient aged under 55 and not of African or Caribbean family origin, NICE recommends an ACE inhibitor (or ARB) first-line. Ramipril is therefore most appropriate; a calcium-channel blocker such as amlodipine would be first-line if he were 55 or over, or of African/Caribbean origin.
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How to approach a planning management item
The repeatable method from the Planning Management section guide.
- Identify the problemDiagnosis or clinical state in one phrase: severe hypercalcaemia, new atrial fibrillation, stage 2 hypertension.
- Decide the urgencyIs the patient unstable? Stabilisation and reversal come before definitive treatment.
- Find the first-line pathwaySearch the condition. The treatment summary lists steps in order.
- Apply the modifiersAge under or over 55, family origin, eGFR, pregnancy, asthma: each moves the answer within the pathway.
- Check it is the next stepNot a later correct step. Not a second-line agent. The one thing that should happen now.
Before you submit
- Have I named the problem and its urgency?
- Is this the treatment summary's first-line step, not a later one?
- Have I applied every modifier the case gives me?
- Is anything needed before this step?
- Is the option contraindicated for this patient?
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