EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Sarah’s skin rash?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features suggest anaphylaxis or systemic illness?
• Prompt: What initial investigations would you consider if symptoms were persistent or atypical?

Q3. How would you manage Sarah’s condition?

• Prompt: What pharmacological and non-pharmacological treatments would you recommend?
• Prompt: When would you consider specialist referral?

Q4. Sarah is concerned about potential allergies and wants testing. How would you counsel her?

• Prompt: Does she need immediate allergy testing?
• Prompt: How can she identify and avoid potential triggers?

Q5. What preventive strategies can Sarah implement to reduce the likelihood of future urticaria episodes?

• Prompt: What role do lifestyle modifications and stress management play?
• Prompt: When should she seek further medical attention?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Sarah’s skin rash?

Sarah’s most likely diagnosis is acute urticaria, given the pruritic, transient, blanching wheals appearing in different locations without systemic symptoms.

Key Differential Diagnoses:

1. Acute Urticaria (Most Likely) – Episodic pruritic wheals lasting <24 hours, triggered by food, infections, or stress.
2. Chronic Urticaria – Recurrent urticaria lasting >6 weeks, often idiopathic or autoimmune.
3. Angioedema – Deeper swelling of the face, lips, or tongue, may occur with or without urticaria.
4. Allergic Contact Dermatitis – Localised, itchy erythema, often with a clear allergen exposure.
5. Erythema Multiforme (EM) – Fixed target-like lesions associated with viral or drug exposure.

Further history, particularly potential triggers and duration, will clarify the diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral:

• Airway involvement (stridor, difficulty swallowing, voice changes) – Consider anaphylaxis or severe angioedema.
• Hypotension, tachycardia, or syncope – Suggests anaphylactic shock.
• Persistent urticaria >6 weeks – Consider chronic autoimmune urticaria or systemic disease.
• Associated systemic symptoms (fever, weight loss, joint pain) – Consider vasculitis or malignancy.

Recommended Investigations (if red flags present):

• Serum tryptase – If concern for anaphylaxis or mast cell disorder.
• Full blood count, CRP, autoimmune screen – If chronic or systemic involvement suspected.
• Allergy testing (skin prick or serum IgE) – If clear allergen trigger identified.

Sarah has no immediate red flags, so empirical management is appropriate.

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Q3: How would you manage Sarah’s condition?

1. First-Line Management:

• Second-generation antihistamines (e.g., cetirizine or loratadine 10mg daily) – First-line therapy.
• Avoid identified triggers – Food, stress, heat, NSAIDs.

2. If Symptoms Persist or Severe:

• Increase antihistamine dose (up to 4x daily if needed).
• Short course of oral prednisolone (25–50mg daily for 3–5 days) if severe flare.

3. If Anaphylaxis Occurs:

• IM adrenaline (0.5mg) and urgent hospital transfer.
• Prescribe an EpiPen if future risk of anaphylaxis.

4. Follow-Up and Specialist Referral:

• If symptoms persist >6 weeks, refer to an immunologist for chronic urticaria evaluation.
• Review in 1–2 weeks to assess symptom resolution and triggers.

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Q4: Sarah is concerned about potential allergies and wants testing. How would you counsel her?

1. Explain the Likely Cause
   • “Most cases of acute urticaria are not due to true allergies, but rather viral infections, stress, or unknown triggers.”
2. Discuss When Allergy Testing is Useful
   • “Allergy testing is only helpful if a clear, repeatable trigger is suspected.”
   • “If you develop immediate swelling, breathing issues, or anaphylaxis, allergy testing is warranted.”
3. Practical Advice for Identifying Triggers
   • “Keeping a symptom diary can help identify patterns related to food, medications, or environmental exposures.”
4. Reassure About Prognosis
   • “Acute urticaria usually resolves within days to weeks and does not require long-term treatment.”

Providing clear explanations prevents unnecessary testing and anxiety.

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Q5: What preventive strategies can Sarah implement to reduce the likelihood of future urticaria episodes?

1. Avoid Known Triggers:
   • If specific foods, stress, or heat trigger episodes, reduce exposure.
   • Avoid NSAIDs or aspirin if they worsen symptoms.
2. Lifestyle Modifications:
   • Manage stress with relaxation techniques, exercise, and mindfulness.
   • Maintain a healthy diet and sleep routine.
3. Medication and Long-Term Management:
   • Keep antihistamines on hand to take at the first sign of urticaria.
   • If recurrent or severe, discuss long-term antihistamine use with GP.
4. When to Seek Medical Attention:
   • If symptoms persist >6 weeks, consider chronic urticaria assessment.
   • If angioedema or systemic symptoms occur, seek urgent medical review.

Preventing recurrences involves trigger avoidance, early antihistamine use, and stress management.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing acute urticaria from allergic reactions, erythema multiforme, and chronic urticaria.
• Identification of red flags, ensuring escalation if needed.
• Structured evidence-based management plan, including antihistamines, trigger avoidance, and escalation to steroids if necessary.
• Clear patient-centred counselling, addressing concerns about allergies and unnecessary testing.
• Preventive strategies, including lifestyle modifications, stress reduction, and medication optimisation.

PITFALLS

• Failing to assess for anaphylaxis, missing a life-threatening emergency.
• Overprescribing steroids unnecessarily, when antihistamines suffice.
• Not addressing lifestyle factors, such as stress, diet, and medication triggers.
• Ordering unnecessary allergy testing, when trigger avoidance is more practical.
• Lack of structured follow-up, missing progression to chronic urticaria.

REFERENCES

• RACGP – RACGP Guidelines for Acute and Chronic Urticaria
• GP Exams – Urticaria

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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

1. Communication and Consultation Skills

1.1 Takes a structured allergy history, including triggers and symptom impact.
1.2 Provides clear explanations about the diagnosis, management, and prognosis.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic skin examination and evaluates for signs of anaphylaxis.
2.2 Differentiates between acute and chronic urticaria.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses urticaria based on clinical presentation.
3.2 Determines when further investigations (e.g., allergy testing, autoimmune screen) or hospital referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate treatment plan, including pharmacological and lifestyle modifications.
4.2 Provides safety-netting and follow-up for potential complications.

5. Preventive and Population Health

5.1 Educates on avoidance of triggers and lifestyle measures to reduce recurrence.

6. Professionalism

6.1 Provides empathetic care and acknowledges the impact of symptoms on daily life.

Competency at Fellowship Level

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