top of page

PLAB 2 Case Scenario Summary: Allergic Rhinitis (Hay Fever)

Updated: Mar 19



Summary:

This case focuses on a 40-year-old patient, John Davis, presenting with symptoms suggestive of allergic rhinitis. The scenario tests the candidate's ability to gather relevant clinical information, rule out serious conditions, and efficiently transition to diagnosis and management. Effective time management and structured consultation are crucial for success.


Key Points

Data Gathering:

  • History-taking technique:

    • Use SOCRATES for symptom evaluation.

    • Ask 40-PARA questions (Past, Onset, Characteristics, Radiation, Alleviating/Aggravating factors, etc.).

  • Important Symptoms to Elicit:

    • Duration of symptoms (e.g., sneezing, nasal congestion, postnasal drip).

    • Seasonal variation, exposure to allergens (outdoor vs. indoor triggers).

    • Presence of associated symptoms:

      • Red flags: Hemoptysis, unexplained weight loss, persistent headaches.

      • Signs of sinusitis: Facial pain, headaches, nasal obstruction.

      • Signs of nasal polyps: Anosmia, recurrent infections.

      • Sleep disturbances (possible Obstructive Sleep Apnea).

  • Examinations to Perform:

    • General examination: Check vitals.

    • ENT examination:

      • Throat: Look for erythema, tonsillar hypertrophy.

      • Nasal Examination: Anterior rhinoscopy to assess for nasal polyps.

      • Respiratory exam: Rule out asthma or chronic respiratory disease.

Diagnostic Approach:

  • Working diagnosis: Allergic rhinitis based on:

    • Symptoms occurring with allergen exposure.

    • Lack of systemic signs like fever or weight loss.

    • Normal anterior rhinoscopy and ENT exam findings.

  • Differentials to Rule Out:

    • Chronic Sinusitis: Headache, facial pain, postnasal drip.

    • Nasal Polyps: Persistent nasal obstruction, anosmia.

    • Neoplasm: Persistent unilateral symptoms, epistaxis, weight loss.

  • Confirmatory Investigations:

    • Skin Prick Test or Serum IgE levels for allergen identification.

    • Nasal endoscopy if polyps suspected.

    • CT scan of sinuses in persistent or severe cases.

Management Plan:

Non-Pharmacological:

  • Avoid allergens: Keep windows closed, use air purifiers, avoid outdoor exposure during pollen season.

  • Lifestyle modifications: Shower after outdoor exposure, use saline nasal irrigation.

Pharmacological:

  1. Antihistamines (e.g., Loratadine, Cetirizine) – First-line treatment

  2. Intranasal corticosteroids (e.g., Fluticasone, Mometasone) – For moderate/severe cases

  3. Leukotriene receptor antagonists (Montelukast) – If symptoms persist

  4. Nasal decongestants (short-term use only)

Follow-up and Safety Netting:

  • Monitor response to treatment.

  • Red flag symptoms: If new onset of unilateral symptoms, persistent nasal obstruction, unexplained weight loss, or recurrent epistaxis—refer for urgent ENT review.

  • Provide patient education leaflet on allergic rhinitis.

Communication Skills & Ethical Considerations:

  • Empathy and reassurance: Acknowledge impact on daily life (e.g., work performance, social embarrassment).

  • Avoid alarming language: Do not prematurely mention cancer unless highly suspected.

  • Structured explanation: Clearly communicate the diagnosis and treatment plan using patient-friendly language.

  • Consent for examination and investigations.

Time Management Strategy for the Exam:

  • Data Gathering: 4 minutes

    • Quick history (40-PARA), relevant differentials.

  • Examination & Diagnosis: 2 minutes

    • Focused ENT exam, working diagnosis explanation.

  • Management: 2 minutes

    • Treatment, safety netting, follow-up advice.

By following this structured approach, candidates can ensure they efficiently address all key components of the PLAB 2 consultation station while maximizing their score.

Comments

bottom of page