Cases/Allergy and Immunology

Tree Surgeon Given One Adrenaline Pen After A Wasp Sting — Free SCA Practice Case

Tree surgeon given one adrenaline pen after a wasp sting

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Initial Introduction

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•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

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Materials for Candidate

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Patient Profile

Full Name

Owain Pritchard

Age

44 years

Consultation Type

Video

Age

Situation

Video Consultation. Booked by the patient.

Reason for Encounter

"Seen in A&E last week after a wasp sting. Would like the adrenaline pen added to repeat prescriptions."

Medical Records

●PMH: Mechanical low back pain, 2023.
●Medications: None regular. Adrenaline 300 micrograms auto injector, one supplied by ED 5 days ago.
●Allergies: NKDA.
●Social: Self employed tree surgeon. Non smoker.

Recent Notes

●ED discharge summary, received yesterday: Wasp sting to neck, then lip swelling, throat tightness, hoarse voice, hives, faintness. BP 84/50; IM adrenaline 500 micrograms twice. Tryptase 25.2, then 19.6 micrograms/L. Observed overnight, one auto injector supplied.

Patient Script

For the friend playing the patient role

Character Overview: You are Owain Pritchard, a 44 year old self employed tree surgeon, 15 years in business, working on farms, estates and village gardens near the Welsh border. You live with your wife Nia, a dental nurse, and your daughter Megan, 11. Your nephew Cai, 20, works the ground on bigger jobs and has aerial rescue training, but on small jobs you go alone because you cannot justify paying him.

Six days ago, pruning an apple tree alone in a customer's garden, a wasp stung you on the right side of the neck. Your lips swelled, your throat tightened, your voice went croaky and you felt faint. You got down, lay on the lawn and the customer rang 999. The ambulance took about 25 minutes. You were kept in overnight and sent home with one adrenaline pen, which lives in the van glovebox. You went back to work yesterday and are taking this call in your van at lunch.

You think one pen is plenty because "one jab sorted me out", and assume you would just get down and get help if it happened again. You do not know the crew gave two injections. You are cheerful and jokey, a man who plays things down. Money matters: no sick pay, a mortgage, and you fear being told to stop climbing.

Underneath, you were badly frightened. On the lawn you thought you were going to die and kept thinking of Megan. You have not told Nia how bad it was. If the doctor gently asks how it felt or how you have been since, the joking stops and you go quieter and slower. You do not volunteer that you climb alone or that the pen stays in the van unless asked.

Opening Sentence: "Hiya, thanks for calling. I got stung by a wasp at work last week and had a bit of a funny do with it. Ended up in A&E overnight. They gave me one of those adrenaline pens and said to see you, so I just need it put on my repeat so I've got another when this one runs out."

History if Asked (Data Gathering Phase)

●What happened: "I was up an old apple tree in a lady's garden, only three or four metres up, taking some weight off it. There were wasps all over the windfalls. One got me on the side of the neck, just under my right ear."
●How quickly it came on: "Within minutes my lips swelled. Then my throat went tight, like swallowing round a golf ball, and my voice went croaky. I came out in big itchy lumps over my chest and arms, then went dizzy and sweaty, like I'd pass out."
●Breathing and collapse: "It wasn't wheezy, it was my throat. I couldn't get a proper breath in and could hardly talk." He did not black out, but could not have stood: "I just lay there on the grass."
●The ambulance and hospital: "They took about twenty five minutes. One of them jabbed something into my leg and I started coming round. It's a blur." If told the letter shows two injections: "Two? I didn't know that. I thought it was just the one." "A nurse showed me the pen in the morning, quickly."
●Since leaving hospital: "No problems at all. The swelling had gone by that evening and nothing came back. I went back to work yesterday."
●Stings before: "Loads as a kid, never anything. Last August one got me on the right forearm and my whole arm swelled to the elbow for three or four days. Hay fever tablets sorted it. Nothing like this, though."
●The insect: "Definitely a wasp, yellow and black, I swiped it off my neck. Loads on the apples this time of year." He has never knowingly been stung by a bee.

Ideas, Concerns, Expectations

Gating note: Owain does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks happened, what is worrying him, or what he was hoping for.

●Ideas: A one off: the wasp got him on the neck, near a vein, so the venom went straight in. "Freak thing. One jab sorted me out, so one pen should do me, shouldn't it?" If it happened again he would come down and go to hospital.
●Concerns: On the surface, money and work. "If I'm not up a tree I'm not getting paid, and I've got a mortgage." If the doctor explores further, or asks how it felt, the joking stops: "Honestly? Lying on that grass, I thought that was it. All I could think about was Megan. I haven't told Nia it was that bad. And now every time a wasp comes near me up there, I'm jumping out of my skin."
●Expectations: The pen on repeat and to carry on working as normal. "I'm not after a load of hospital appointments."

If Asked: Medical History and Medications

Gating note: Owain answers each of these plainly when the doctor asks about it.

●Health and medicines: Nothing much; his back is fine now. No asthma, wheeze or heart problems, and blood pressure was fine two years ago. No blood pressure or heart tablets. Ibuprofen about once a month. No food or medicine allergies. Mum has hay fever; nobody else has had anything like this.
●The pen: "I think you jab it in your leg. I haven't read the leaflet or looked at the expiry date." It lives in the glovebox. "If I'm at the back of a big garden or across a field it might be a couple of hundred yards away." He does not carry it: "I'm in a harness with a saw and ropes, nowhere to put it."
●Video demonstration: If offered a demonstration on the video, he declines politely: "I'd rather someone showed me properly, face to face. Could I pop in to the nurse?"

Social History and Lifestyle Impact

●Work: On big jobs Cai is with him. "On the little ones it's just me. I know you're meant to have someone on the ground, but I can't justify paying him for a bit of pruning." Next week he is taking down a big dead oak smothered in ivy. "You often find wasps' nests in the ivy, this time of year especially."
●Distance from help: "The nearest A&E is about forty minutes away and the phone signal's rubbish in some woods."
●Home: He lives with Nia and Megan in a village. Nia came to the hospital that evening and has been on at him to see the doctor. "I don't want Nia worrying more than she is already." He agrees to tell her and Cai if the doctor explains that they need to know so they can help.
●Lifestyle impact: "I'm fine, really, just a bit twitchy when I see a wasp now." Three or four pints at the weekend. Never smoked.

If Asked: Associated Symptoms

Gating note: Owain answers these only when the doctor asks about them directly.

●During the reaction: No wheeze, all in his throat. His heart was "going like the clappers", with no pain. A bit sick, no tummy pain, no loss of bladder control.
●Negatives, grouped: no swelling, rash or breathing problems since discharge; no further stings; no flushing, itchy rashes, tummy upsets or dizzy turns out of the blue; no reactions to foods or medicines; sleeping fine, a bit on edge at work.

Responses to Management (The Negotiation Phase)

●
If the doctor says he needs two pens, or points out that the ambulance crew gave two injections or how long help took:
- ●Reaction: Unconvinced at first. "Two? One did the job last time, didn't it? And I've got one in the van." Then, quiet: "Two. I didn't know that. So one pen might not have been enough. Right, fair enough, I'll have two."
●
If the doctor says the pens must be on him, or asks what he would do if stung high up a big tree:
- ●Reaction: "On me? I'm in a harness with a chainsaw. Where am I meant to put them? They'll get smashed." He accepts a practical suggestion such as a pouch on his harness or a zipped chest pocket. On the tree question the jokiness drops: "I've been trying not to think about that. If I'd been up the oak, I don't know how I'd have got down." He engages if helped to make a plan.
●
If the doctor advises against climbing alone, or suggests he stops tree work or signs him off:
- ●Reaction: "I can't afford Cai every day. Can't I just be careful?" He accepts if the doctor explains why and works out how, for example Cai with him until he has seen the allergy team. If told to stop climbing: "It's my living. There must be a way of doing it safely."
●
If the doctor explains when to use the pen, lying down afterwards, or an antihistamine:
- ●Reaction: "So I do it the second my throat goes, even if I'm not sure? And I still ring 999 after?" On lying down: "And what if I'm still up the tree?" He settles with a clear plan. If offered a bracelet: "Not up a tree, it'll catch on something. Could I have a tag on my harness, or a card in my wallet?"
●
If the doctor mentions an allergy referral, injections to reduce the allergy, or the chance of another reaction:
- ●Reaction: "What would they do? I'm not keen on loads of trips to hospital." On a course of injections: "For how long? Every week?" Once explained: "If I could do the weekly bit over the winter, when it's quieter, I could manage that. Could I stop carrying the pens after?" On risk: "Be straight with me. Could it be worse next time?" He settles with an honest answer and a plan.
●
If the doctor gives vague safety netting, or offers a written plan:
- ●Reaction: To "come back if there are problems": "What sort of problems? If I get stung again, what do I actually do?" To a written plan: "Can I have a copy for the van, and one for Cai?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Owain asks for a repeat prescription, but he has just had anaphylaxis to a wasp sting. The skill is reading the discharge summary closely, hearing that one pen sits in a van while he climbs alone, and turning a request for a repeat into a safe plan without frightening him away from his livelihood.
●Model plan: confirm anaphylaxis; explain the real chance of another reaction; prescribe a second auto injector, both on repeat; get both onto his body; teach when and how to use them, with 999; arrange face to face device training; agree a plan for working at height with a trained person on the ground; give a written plan and wearable identification; record the allergy; refer for venom testing and immunotherapy assessment; follow up and safety net.
●Also acceptable: two adrenaline nasal sprays where the formulary includes them; a different device type with retraining; a second pen after 5 to 15 minutes; a lower threshold for using a pen for any symptoms away from the sting; a baseline tryptase taken in primary care.

Recognising Venom Anaphylaxis and the Chance of Recurrence

●NICE NG258 (Anaphylaxis: assessment and referral after emergency treatment, 2026, replacing CG134) lists the acute features as rapidly developing airway, breathing or circulation problems, usually with skin and mucosal changes. Owain had throat tightness with a hoarse voice (airway) and blood pressure 84/50 (circulation) within minutes, with hives and lip swelling. That is anaphylaxis, and in the British Society for Allergy and Clinical Immunology (BSACI) venom guideline a severe systemic reaction.
●Venom reactions often present with low blood pressure and collapse, sometimes without skin features. A raised tryptase soon after the reaction supports the diagnosis; NG258 advises one sample as soon as possible and a second ideally within 1 to 2 hours of onset.
●The neck site does not explain the severity. His history shows escalation: harmless childhood stings, a large local reaction last August, then anaphylaxis.
●NICE CKS (insect bites and stings) puts recurrence at 4 to 10% after a large local reaction, 14 to 20% after a mild systemic reaction and up to 70% after anaphylaxis; BSACI quotes 40 to 60% after a systemic reaction. Exact figures are not needed, but honesty is. Severity next time cannot be predicted; stings cause about a quarter of UK anaphylaxis deaths with an identified cause.

Two Adrenaline Devices, Always

●NG258, the MHRA (2023) and BSACI primary care guidance (2024) say everyone discharged after anaphylaxis should have two in date auto injectors and carry both at all times, unless the trigger is an easily avoided drug. Reasons: a reaction may need more than one dose before help arrives, devices can fail or misfire, and pens get dropped or lost. Owain needed two doses from the ambulance crew and waited 25 minutes.
●The adult auto injector dose is 300 micrograms (British National Formulary, BNF). One brand's 500 and 300 microgram devices were recalled in 2023, so anyone still holding them needs a replacement.
●The BNF lists an adrenaline nasal spray (2 mg, roughly equal to 300 micrograms intramuscularly) for adults of 30 kg or more; two are needed in the same way, subject to local formularies.
●Prescribe the device he was trained on where possible, with two on repeat so they are replaced together. An emergency department supplying one pen leaves a gap for primary care to close.

When and How to Use It

●Use it without delay at the first signs, such as throat or tongue swelling, a hoarse voice, breathing difficulty or feeling faint, even if unsure; delay is riskier than an unnecessary dose (MHRA).
●Inject into the outer thigh, through clothing if needed, and hold for the time the device instructions give (3 or 10 seconds for the two UK auto injectors).
●Call 999 at once and say "anaphylaxis", even if he improves. Lie flat with legs raised, or sit up if breathing is difficult; never stand or walk.
●Use the second device if no better after 5 minutes (MHRA and BNF; NICE CKS gives 5 to 15 minutes, which is also acceptable).
●Antihistamines treat itching and hives only and never replace adrenaline; a non sedating one suits someone working at height.

Carrying, Storing, Training

●Both devices go on his body, not in a van a field away: a pouch on the harness or belt, or a zipped pocket, checked after each job. A summer van cab can exceed the 25 °C storage limit and they must not be frozen.
●BSACI advises repeating training with a trainer pen at each new prescription; a practice nurse or community pharmacist can do it, and it cannot be checked over video. It also advises carrying a charged phone, which matters in woods with poor signal.
●Teach Nia and Cai too, and check expiry dates using the manufacturer's reminder service. A bystander may lawfully give an auto injector in a life threatening emergency.

Specialist Allergy Referral and Venom Immunotherapy

●NG258 recommends offering every adult referral to a specialist allergy service after emergency treatment, and CKS and BSACI say anyone with a systemic sting reaction should be referred, including for venom immunotherapy (VIT). Pens are not a substitute. Include the discharge summary and tryptase results.
●The clinic tests wasp and honeybee venom specific IgE and measures baseline tryptase, which BSACI recommends after any systemic sting reaction; some laboratories allow primary care to request it.
●VIT is gradually increasing doses of purified venom under the skin in a specialist clinic, then maintenance doses. BSACI recommends it for all severe systemic reactions, with occupational exposure and remoteness from help weighing in favour. It prevents systemic reactions in about 95% of people with wasp allergy and 80% with bee allergy.
●Conventional up dosing takes at least 12 weeks of weekly injections, cluster schedules about 7; maintenance follows every 4 to 8 weeks, usually for 3 years in the UK. Starting over winter fits a seasonal job. NICE TA246 has been withdrawn because its product lost its UK licence; VIT continues with other extracts.
●BSACI advises continuing to carry pens after VIT for people with continuing occupational exposure, giving a gardener as its example. That applies to Owain.

Medicines and Conditions That Matter

●Beta blockers can worsen anaphylaxis and blunt the response to adrenaline, and ACE inhibitors are a reported risk for severe sting reactions. Record the venom allergy prominently so future prescribers avoid them where possible.
●Poorly controlled asthma raises the risk of a fatal reaction. Owain has none of these.

Working Safely at Height and the Written Plan

●Health and Safety Executive guidance on aerial tree work says at least two people must be present, one of the ground team equipped to do an aerial rescue without delay. That is the most useful single change for him.
●A plan agreed with him: check trees for nests, sleeves down and collar closed, come down at once after any sting, use a pen where he is if symptoms begin, and the ground worker calls 999 with the exact location and does the rescue. CKS adds: avoid scented products and bright or floral clothing, and take care with opaque drinks containers.
●Give a personalised written action plan (BSACI publishes adult plans) with copies for the van and Cai. A medical alert tag on the harness or a card suits him better than a bracelet; Anaphylaxis UK and Allergy UK offer support.

Follow Up and Safety Netting

●Arrange a defined check that he has two pens, training, the written plan and an allergy appointment.
●Swelling only around a sting, even if large, can be managed with a cold compress and an antihistamine. Hives or swelling away from the sting are systemic: take an antihistamine, do not stay alone, keep a pen in hand, and use it at once for any throat, breathing or faint symptoms.
●After any use of a pen: 999, hospital assessment, replacement devices and a message to the allergy team.

Common Mistakes in This Station

●Adding one pen to repeat as asked without checking how many he has, where he keeps it or whether he can use it.
●Accepting the pen staying in the van, or not asking what he would do if stung at height.
●Offering an antihistamine as treatment for a reaction involving the throat or circulation, or advising him to drive to hospital.
●Forgetting the allergy referral, or referring without explaining venom immunotherapy and why it matters for his job.
●Telling him to give up tree work instead of agreeing how to work more safely, and missing the fear behind his jokes.
●Safety netting limited to come back if there are any problems.

Mapped to the RCGP curriculum topic: Allergy and Immunology.

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