IM injection post pic

Breathlessness and Acute Rash – OSCE Case

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Introduction

A 20-year-old woman develops shortness of breath on the ward following a laparoscopic appendicectomy. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

  • Acute rash
  • Breathlessness
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History

Presenting complaint

“I really can’t catch my breath and I’ve got a rash on my arms.”

History of presenting complaint

When did this first begin?

β€œAbout 2 minutes ago”

Did it come on suddenly or gradually?

β€œSuddenly”

Has it worsened or been getting better?

β€œIt’s rapidly getting worse”

Were you doing anything prior to this?

β€œI just received my antibiotics and painkillers”

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

β€œNo”

Other parts of the history

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

Any prior issues with breathing or any history of asthma?

β€œNo”

Any history of allergy?

“None known to patient or staff”

Family history?

β€œThere 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?

β€œI have never been a smoker”

Any recent changes to your diet?

β€œNo”


Clinical 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 37oC

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

Investigations


Diagnosis


Management

IM adrenaline and elevate the patient’s legs.

  • When recognised, anaphylaxis should beΒ 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

Circulation

  • 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


Editor

Dr Jess Speller


References

  1. Heilman J. Allergic angioedema. License: [CC BY-SA 3.0]
  2. Resuscitation Council UK. Emergency Treatment of Anaphylactic reactions: Guidelines for healthcare providers. Published in 2021. Available from: [LINK]
  3. Tidy C, Knott L. Anaphylaxis. Patient.info. Edited in 2020. Available from: [LINK]

 

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