CCE-CBD-174

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess the severity of Michael’s reaction and determine if urgent treatment is required?

• Prompt: Describe your approach to history and examination.
• Prompt: What signs would indicate anaphylaxis?
• Prompt: How would you manage mild systemic symptoms in a rural setting?

Q2. What is your differential diagnosis and immediate management plan for this patient?

• Prompt: What conditions must you rule out?
• Prompt: What treatments would you initiate today?
• Prompt: What observations and monitoring would you implement?

Q3. How would you provide education on prevention and management of future insect bites or stings?

• Prompt: Discuss strategies for preventing insect stings on the farm.
• Prompt: What emergency plan would you recommend?
• Prompt: What would you teach about recognising signs of anaphylaxis?

Q4. What follow-up and referral would you recommend in this case?

• Prompt: When should he return for review?
• Prompt: Would you recommend specialist referral or allergy testing?
• Prompt: How would you coordinate care in a rural setting with limited access to emergency services?

Q5. How would you manage potential complications such as secondary infection or recurrent reactions?

• Prompt: Discuss indications for long-term management, including an EpiPen prescription.
• Prompt: What red flags would indicate complications?
• Prompt: When would antibiotics be necessary?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess the severity of Michael’s reaction and determine if urgent treatment is required?

Answer:

To assess the severity of Michael’s reaction, a systematic approach is required, focusing on identifying signs of anaphylaxis and evaluating local/systemic effects.

History-taking:

• Timing of onset: Symptoms began within 12 hours of the sting.
• Systemic symptoms: Assess for difficulty breathing, wheezing, hoarseness, stridor, chest tightness, hypotension, collapse, or altered consciousness.
• Progression: Has the swelling continued to increase? Has he developed any rash (urticaria), vomiting, or diarrhoea?
• Previous reactions: Any prior history of anaphylaxis or allergy to insect bites/stings.

Examination:

• Airway: Look for signs of obstruction, hoarseness.
• Breathing: Assess for respiratory distress, wheeze, use of accessory muscles, oxygen saturation.
• Circulation: Pulse rate, BP, capillary refill time. Monitor for hypotension or tachycardia.
• Skin: Generalised rash, urticaria, angioedema.
• Neurological: Conscious state and orientation.

Red flags indicating anaphylaxis:

• Hypotension (systolic BP <90 mmHg)
• Airway compromise (stridor, hoarseness)
• Severe bronchospasm/wheezing
• Cardiovascular collapse

In Michael’s case, no signs of anaphylaxis are currently present. However, he reports feeling dizzy and has tachycardia (98 bpm). Given the rural setting and delayed access to emergency care, a low threshold for intervention is warranted.

Management in rural setting:

• Observation for at least 4-6 hours in a monitored setting.
• Administer oral antihistamines for symptomatic relief.
• Consider oral corticosteroids (e.g., prednisone 50mg) to reduce inflammation.
• Educate on anaphylaxis signs and emergency action plan.
• Prepare to administer IM adrenaline (0.5mg) if condition worsens.

Follow ASCIA Anaphylaxis Guidelines (2022).

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Q2: What is your differential diagnosis and immediate management plan for this patient?

Answer:

Differential diagnoses:

1. Large local reaction to insect sting (most likely)
2. Cellulitis secondary to insect bite
3. Early anaphylaxis
4. Toxic reaction due to multiple stings (less likely)

Immediate management:

• Reassurance and education to address anxiety.
• Mark the area of swelling to monitor progression.
• Administer:
  • Oral antihistamine (e.g., loratadine 10mg)
  • Oral corticosteroid (e.g., prednisone 50mg stat dose)
  • Paracetamol for pain relief
• Cold compresses on the site to reduce swelling.
• Assess for infection:
  • Empirical antibiotics (e.g., flucloxacillin 500mg QID) if signs of cellulitis (warmth, erythema, systemic signs) are present.
• Monitor vitals every 15-30 minutes initially.

Observation and monitoring:

• Keep under observation for 4-6 hours.
• If systemic symptoms develop, prepare to administer IM adrenaline immediately.
• Have IV access ready in case of deterioration.

Safety-netting includes:

• Immediate emergency response if new symptoms arise.
• Provide ASCIA Action Plan and EpiPen prescription if risk factors warrant.

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Q3: How would you provide education on prevention and management of future insect bites or stings?

Answer:

Prevention strategies:

• Wear long sleeves, gloves, and insect repellent (containing DEET) while working outdoors.
• Inspect clothing and bedding for insects before use.
• Avoid perfumed products that attract insects.
• Take care around hives or nests.

Emergency preparedness:

• Educate on recognising anaphylaxis: difficulty breathing, wheezing, dizziness, swelling of the face/tongue.
• Provide an ASCIA Action Plan for anaphylaxis.
• Demonstrate correct use of EpiPen (IM adrenaline auto-injector).
• Advise carrying an EpiPen at all times if indicated.

Follow-up:

• Recommend allergy testing for insect venom if recurrent stings occur.
• First aid training for family members.

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Q4: What follow-up and referral would you recommend in this case?

Answer:

Follow-up:

• Review in 48 hours to assess swelling and systemic symptoms.
• Earlier review if redness, swelling, or fever worsens.

Referral considerations:

• Referral to an allergist/immunologist if:
  • Recurrent stings with systemic reactions
  • Positive allergy testing for insect venom
  • For consideration of venom immunotherapy

Rural coordination:

• Arrange telehealth consultation with an allergist if in-person services are limited.
• Ensure Michael knows how to contact emergency services.
• Educate about emergency evacuation plans if future anaphylaxis risk is high.

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Q5: How would you manage potential complications such as secondary infection or recurrent reactions?

Answer:

Red flags for complications:

• Increased pain, redness, or heat
• Fever, rigors
• Pus formation
• Rapid worsening of swelling despite treatment

Antibiotics:

• Indicated if signs of cellulitis present.
• Empirical flucloxacillin 500mg QID for 5-7 days.
• Alternative in penicillin allergy: cephalexin or clindamycin.

Recurrent reactions:

• Allergy assessment and possible venom immunotherapy.
• Provide and educate on EpiPen use.
• Update ASCIA Action Plan.

Long-term management:

• Educate about early signs of allergic reactions.
• Emphasise personal protective equipment in high-risk environments.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive assessment of severity, focusing on anaphylaxis signs.
• Clear differential diagnosis and rational management plan.
• Emphasis on education, prevention, and anaphylaxis action plans.
• Referral to allergist where indicated, including rural considerations.
• Safety-netting with follow-up and awareness of potential complications.

PITFALLS

• Failure to recognise early anaphylaxis signs.
• Delaying administration of adrenaline when indicated.
• Inadequate patient education on prevention and EpiPen use.
• Not considering rural limitations in emergency care access.
• Omitting antibiotics when cellulitis is suspected.

REFERENCES

• Australian Society of Clinical Immunology and Allergy (ASCIA)
• RACGP Red Book Guidelines for Preventive Activities in General Practice
• Therapeutic Guidelines on Antibiotic
• ASCIA Action Plans for Anaphylaxis

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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 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about the patient’s presenting problem.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises a differential diagnosis.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements an appropriate management plan.
4.2 Provides therapeutic interventions based on the best available evidence.

5. Preventive and Population Health

5.1 Provides health promotion and disease prevention activities relevant to the consultation.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Demonstrates appropriate prescribing and documentation practices.

8. Procedural Skills

8.1 Demonstrates appropriate procedural skills.

9. Managing Uncertainty

9.1 Manages uncertainty effectively in clinical practice.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and responds to serious or life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Provides care appropriate to rural and remote communities.

Competency at Fellowship Level

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