CASE INFORMATION

Case ID: ALLERGY-2025-09
Case Name: James Reynolds
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A92 (Allergy/allergic reaction NOS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to assess allergic symptoms 1.3 Uses clear language to explain allergy mechanisms and triggers 1.5 Uses shared decision-making regarding avoidance strategies and treatment
2. Clinical Information Gathering and Interpretation	2.1 Conducts a thorough allergy history to identify possible triggers 2.3 Differentiates between allergic and non-allergic reactions (e.g., anaphylaxis vs urticaria)
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies key clinical features to diagnose an allergic reaction 3.4 Recognises when referral to an allergist is needed
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate first-line management for allergic reactions 4.5 Prescribes and educates on the use of antihistamines, adrenaline auto-injectors, and emergency plans
5. Preventive and Population Health	5.1 Advises on allergen avoidance and environmental modifications 5.3 Discusses the role of immunotherapy where applicable
6. Professionalism	6.1 Provides reassurance while addressing patient concerns
7. General Practice Systems and Regulatory Requirements	7.1 Documents allergic reactions accurately and ensures appropriate follow-up 7.2 Completes an anaphylaxis action plan if required
9. Managing Uncertainty	9.1 Addresses patient concerns about future allergic reactions and severity
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when an allergic reaction may progress to anaphylaxis and requires emergency care

CASE FEATURES

Young male presenting with generalised urticaria, itching, and mild facial swelling after eating a restaurant meal.
No prior history of known food or medication allergies.
No respiratory distress, hypotension, or other features of anaphylaxis.
Concerned about what caused the reaction and how to prevent future episodes.
Needs education on allergy testing, management, and emergency preparedness.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: James Reynolds
Age: 28
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known allergies

Medications

Nil regular medications

Past History

No previous history of allergic reactions or asthma

Social History

Works as a software engineer
No recent overseas travel
Eats a varied diet but no prior known food intolerances

Family History

No family history of atopy, asthma, or anaphylaxis

Smoking

Non-smoker

Alcohol

Drinks socially on weekends

Vaccination and Preventative Activities

Up to date with vaccinations

SCENARIO

James Reynolds, a 28-year-old male, presents to the clinic after experiencing generalised itching, urticaria (hives), and mild facial swelling about 30 minutes after eating a meal at a restaurant.

He did not experience difficulty breathing, wheezing, dizziness, or throat swelling. His symptoms resolved within two hours after taking an over-the-counter antihistamine.

James is concerned about what triggered the reaction and is worried about a more severe reaction in the future. He would like to know if he needs allergy testing and what steps he should take if this happens again.

On examination, James is well-appearing with no signs of ongoing allergic reaction.

EXAMINATION FINDINGS

General Appearance: Well, no respiratory distress
Vital Signs:

Temperature: 36.9°C
Heart Rate: 76 bpm
Blood Pressure: 118/74 mmHg
Respiratory Rate: 14 breaths per minute
Oxygen Saturation: 99% on room air

Skin Examination:

No active urticaria or rash
No angioedema

Respiratory & Cardiovascular Examination:

Normal air entry, no wheeze or stridor
No hypotension, normal heart sounds

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this patient’s allergic reaction?

Prompt: How do you differentiate between anaphylaxis and a mild allergic reaction?
Prompt: What potential allergens should be considered based on his history?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: How do you distinguish between IgE-mediated and non-IgE-mediated reactions?
Prompt: When would further investigations, such as allergy testing, be required?

Q3. How would you manage James’s allergic reaction and future risk?

Prompt: What medications and lifestyle modifications should be recommended?
Prompt: When would an adrenaline auto-injector (EpiPen) be indicated?

Q4. How would you counsel James on recognising and responding to allergic reactions?

Prompt: What symptoms would indicate a severe reaction requiring emergency care?
Prompt: How should he manage potential future exposures?

Q5. What follow-up plan would you implement?

Prompt: When should he return for review?
Prompt: When would referral to an allergist be appropriate?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this patient’s allergic reaction?

A structured history and focused examination are essential in determining the nature and severity of James’s allergic reaction.

1. History

Timing and onset:
- When did symptoms start in relation to food intake?
- How long did they last, and how quickly did they resolve?
Symptoms and severity:
- Skin: Urticaria, angioedema, flushing
- Respiratory: Wheezing, dyspnoea, stridor, throat swelling
- Cardiovascular: Dizziness, syncope, hypotension
- Gastrointestinal: Nausea, vomiting, abdominal pain
Potential triggers:
- Food allergies: Common allergens include peanuts, tree nuts, shellfish, dairy, and eggs.
- Medications: Any recent use of NSAIDs, antibiotics, or new medications?
- Insect stings: Any bites or stings before symptom onset?
- Other allergens: Latex, environmental factors (e.g., pollen, dust).
Personal and family history:
- Previous allergic reactions and their severity.
- History of asthma, eczema, allergic rhinitis.
- Family history of atopy or anaphylaxis.
Medication use and response:
- What treatments were taken? Did antihistamines provide relief?
- Was adrenaline (EpiPen) required?

2. Examination

General appearance: Well-looking or in distress?
Vital signs: Fever, hypotension, tachycardia, respiratory rate, oxygen saturation.
Skin: Active urticaria, angioedema.
Respiratory: Stridor, wheezing, use of accessory muscles.
Cardiovascular: Capillary refill time, heart sounds, blood pressure.

This structured assessment ensures an accurate diagnosis and appropriate risk stratification.

SUMMARY OF A COMPETENT ANSWER

Elicits a detailed history of symptom onset, severity, and triggers.
Distinguishes between anaphylaxis and a mild allergic reaction.
Identifies potential allergens (food, medications, insect stings).
Performs a focused examination, including vital signs and skin/respiratory findings.

PITFALLS

Failing to differentiate between anaphylaxis and a non-life-threatening allergic reaction.
Not considering medication or environmental triggers.
Overlooking personal or family history of atopy, which increases risk.
Not assessing response to treatment (e.g., antihistamines, adrenaline).

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough allergy history to identify possible triggers.
2.3 Differentiates between allergic and non-allergic reactions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD