Breathlessness and Acute Rash – OSCE Case

When did this first begin?

“About 2 minutes ago”

Did it come on suddenly or gradually?

“Suddenly”

Has it worsened or been getting better?

“It’s rapidly getting worse”

Were you doing anything prior to this?

“I just received my antibiotics and painkillers”

Does any particular position seem to make it worse or better?

“No”

• Palpitations: “I have a feeling that my heart is racing out of control”
• Chest pain: “No”
• Abdominal pain: “I have some pain over my surgical wounds”
• Cough: “No”
• Fever/chills: “No”
• Nausea/vomiting: “Nauseous, but no vomiting”
• Light-headedness: “I have been feeling faint and dizzy since the breathlessness began”
• Itch: “Yes, along the rash on my arms”

Any prior issues with breathing or any history of asthma?

“No”

Any history of allergy?

“None known to patient or staff”

Family history?

“There is no history of breathing difficulty or major surgeries in my family”

Any regular or over-the-counter medications?

“Only the oral contraceptive pill”

Smoking history?

“I have never been a smoker”

Any recent changes to your diet?

“No”

• General examination
• Basic observations
• Cardiovascular examination
• Respiratory examination

Examination findings

General examination:

• Erythematous urticarial rash on arms
• Swollen tongue and lips
• Periorbital swelling
• Facial flushing
• Appears distressed and anxious

Basic observations:

• SpO2 90% on room air
• BP 80/50 mmHg
• HR 150 bpm
• RR 30 breaths per minute
• Temperature 37^oC

Cardiovascular examination:

• Low-volume central pulses
• Thready peripheral pulses
• Tachycardia
• Hypotensive

Respiratory examination:

• Increased work of breathing
• Hoarseness in voice
• Diffuse wheeze auscultated bilaterally
• Low SpO2
• Tachypnoea

• Mast cell tryptase
• Chest X-ray
• ECG
• ABG
• Urea and electrolytes

• Anaphylaxis
• Haemorrhagic shock
• Pneumothorax
• Septic shock
• Asthma exacerbation
• Panic attack

Anaphylaxis

IM adrenaline and elevate the patient’s legs.

• When recognised, anaphylaxis should be immediately treated with intramuscular adrenaline
• Do not delay administering adrenaline to perform investigations or take a detailed history

Any acutely unwell patient should be assessed and managed by an ABCDE approach:

Airway

• Remove allergen
• Repeat IM adrenaline (0.5 mg or 0.5 mL 1:1000) after 5 minutes if signs of respiratory or circulatory collapse persist
• Consult specialists on administering IV adrenaline if still needed after 2 IM doses

Breathing

• Supplemental oxygen

Circulation

• Fluid resuscitation with IV crystalloids
• Provide CPR if cardiac arrest occurs

• Document the patient’s allergy
• Provide patient education
• Referral to an allergy clinic
• Provide with adrenaline auto-injector if other non-medication allergies are discovered on follow-up