Cases/Allergy and Immunology

Woman Requesting Adrenaline Auto-injector After Allergic Reaction On Holiday — Free SCA Practice Case

Woman requesting adrenaline auto-injector after allergic reaction on holiday

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•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

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Emma Fletcher

Age

34 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"I had a really scary allergic reaction on holiday and ended up in a hospital abroad. They told me I need one of those adrenaline pens. Can you just prescribe me one?"

Medical Records

●PMH: Mild asthma (well controlled), childhood eczema (resolved).
●Medications: Salbutamol inhaler PRN (uses rarely).
●Allergies: NKDA recorded — no drug allergies on file.
●Recent contact: No UK records for the episode described; the reaction occurred abroad ten days ago and she has no discharge paperwork with her.

Patient Script

For the friend playing the patient role

Character Overview: You are Emma, a 34-year-old primary school teaching assistant. You are usually easy-going but you were badly frightened by what happened on holiday and you have not felt fully settled since. You are not tearful, but there is an undercurrent of anxiety — you keep coming back to how quickly it happened. You want to be taken seriously and you want a plan.

Opening Sentence: "Hi Doctor. So, I was in Turkey last week and after a meal my whole face swelled up, my lips went huge, and I couldn't really catch my breath. They rushed me to a clinic and gave me an injection and I was okay after a few hours. They said I need to carry a pen from now on. I've been panicking a bit about it happening again."

History if Asked (Data Gathering Phase)

●What happened: "We'd been out for dinner. Within about ten, fifteen minutes of eating I felt my lips tingle, then my face puffed up, I came out in hives all over, and my throat felt tight — like I was breathing through a straw. I felt dizzy and a bit sick."
●The meal: "It was a seafood mezze thing — lots of dishes shared. There were prawns, some kind of fish, nuts on a couple of the salads. I honestly don't know which bit did it. I've eaten prawns before and been fine, I think."
●Treatment abroad: "They gave me an injection in my thigh — I assume adrenaline — and something through a drip, and a tablet. They watched me for a few hours and then let me go. They gave me a leaflet but it's in Turkish and I've lost it."
●Since then: "No, it hasn't happened again. But I've barely eaten out since. I read the labels on everything now and I'm scared to try anything new."
●Previous reactions: "I've had hay fever type stuff, and I got a bit of a rash off a plaster once, but never anything like this. Nothing that's ever affected my breathing before."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores the patient's perspective.

●Ideas: Emma thinks she is now "allergic to seafood" and that carrying a pen will make her safe. She is not sure whether one reaction means she will always react, or whether it could have been a one-off. "I've decided it must be shellfish, but part of me thinks — was it just a weird one-off? I don't really understand how this works."
●Concerns: Her real fear is dying from a reaction, particularly when she is on her own or when nobody around her knows what to do. She is also anxious about her job — she works with young children and eats in a shared staff room. "What scares me is if it happens when I'm on my own, or at work, and I can't get help in time. My mum keeps saying people die from this."
●Expectations: She wants a pen prescribed today and, ideally, to be told exactly what she is allergic to. "I just want the pen sorted, and honestly I'd love to know for certain what set it off so I can avoid it."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Asthma: "I've got mild asthma. I use a blue inhaler maybe once a month, if that. No steroid inhaler, no flare-ups for years."
●Eczema: "I had eczema as a kid but grew out of it."
●Medications: "Just the blue inhaler. Nothing regular. I don't take any tablets."
●Allergies to medicines: "Not that I know of."
●Family history: "My sister has a nut allergy, actually. And my dad has asthma."

Social History and Lifestyle Impact

Emma works as a teaching assistant in a primary school. She lives with her partner. She drives.

●Work: "I'm in a classroom all day with reception-age kids. We have snack time, birthdays, food comes in. And the staff room — people heat all sorts up. It's constantly on my mind now."
●Home: "My partner works shifts, so a lot of the time in the evenings it's just me at home. That's the bit that frightens me — if it happened at night when I was alone."
●Impact: "I've stopped going out for meals. I check every label. I'm exhausted from worrying about it, honestly."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about breathing during the reaction: "Yes — my throat felt tight and I was wheezy, worse than my asthma ever is."
●If asked about feeling faint or collapsing: "I felt really dizzy and light-headed, like I might pass out, but I didn't actually collapse."
●If asked about the rash: "Hives — raised, red, itchy, all over my arms and chest."
●If asked about tummy symptoms: "I felt sick and had a bit of tummy cramp, yeah."
●If asked about how long it lasted: "The worst of it was maybe half an hour before the injection kicked in."
●If asked about whether it has recurred: "No, nothing since."
●If asked about exercise, alcohol, or medication around the meal: "We'd had a couple of glasses of wine with dinner. Nothing else — no painkillers or anything."
●If asked about stings or new medicines: "No wasp stings, no new tablets. It was definitely after the food."

Responses to Management (The Negotiation Phase)

●If the Doctor prescribes only one auto-injector: "Just the one? The nurse abroad mentioned carrying two. Is one enough?" (The tested point is whether the candidate knows two devices should be prescribed and carried at all times.)
●If the Doctor explains they cannot confirm the exact trigger today: "So you can't just tell me it's shellfish? How am I supposed to avoid it if I don't know what it is?"
●If the Doctor recommends allergy clinic referral: "Do I really need to see a specialist? Can't you just sort it here? How long will that take?"
●If the Doctor explains how and when to use the pen: "What if I use it and I'm wrong, and it wasn't actually a reaction? Will it hurt me?"
●If the Doctor mentions calling 999 after using it: "Even if I feel better after the pen? Do I still have to go to hospital?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Recognising Anaphylaxis

●Anaphylaxis is a severe, potentially life-threatening, generalised hypersensitivity reaction. It is characterised by rapidly developing airway, breathing, or circulation problems, usually with skin and mucosal changes (flushing, urticaria, angioedema).
●Skin changes alone (hives, itching, lip swelling) without airway, breathing, or circulatory compromise are not anaphylaxis — but they can be the prelude to it.
●Onset is typically minutes after exposure to the trigger. Rapid progression is a hallmark.
●In this case, throat tightness and wheeze (breathing) plus dizziness and near-collapse (circulation), alongside widespread urticaria, confirm anaphylaxis rather than an isolated skin reaction.

Common Triggers and the Problem of the Shared Meal

●Common food triggers include peanuts, tree nuts, shellfish, fish, milk, egg, and sesame.
●When several allergens are eaten together — as in a shared seafood and salad meal — the specific culprit cannot be identified reliably from history alone. Confirming it requires specialist testing.
●Co-factors can lower the threshold for a reaction or amplify its severity: alcohol, exercise, NSAIDs, acute infection, and menstruation. Alcohol with the meal is relevant here.

Adrenaline Auto-Injectors — What and How Much

●Prescribe an adrenaline auto-injector (AAI) to anyone who has had anaphylaxis and remains at risk of recurrence, and to those judged at high risk.
●Adult dose (over 30 kg): 300 micrograms of adrenaline. Available devices in the UK include EpiPen, Jext, and Emerade (Emerade also offers a 500 microgram device).
●Always prescribe two devices and advise the patient to carry both at all times: a second dose is required in a substantial proportion of reactions, and devices can misfire or be used incorrectly under stress.

How and When to Use an Auto-Injector

●When: at the first sign of a serious reaction — throat tightness, difficulty breathing, wheeze, faintness, or collapse. When in doubt, give it: adrenaline is safe and delay is the main cause of avoidable death.
●How: inject into the outer mid-thigh, through clothing if necessary, and hold in place for the time specified by the device (varies by brand).
●After giving it: call 999 immediately and say "anaphylaxis." Attend hospital even if symptoms settle, because of the risk of a biphasic reaction (recurrence hours later).
●Positioning: lie flat with legs raised to support the circulation; sit up only if breathing is difficult; do not stand suddenly.
●Second dose: if there is no improvement after 5 minutes, give the second device.
●Offer a trainer pen and demonstrate technique; check the patient can describe the steps back.

Referral to a Specialist Allergy Service

●NICE CG134 recommends that everyone who has had a suspected anaphylactic reaction is referred to a specialist allergy service after emergency treatment.
●The clinic identifies the allergen (specific IgE blood testing and/or skin-prick testing), provides a personalised written emergency management plan, arranges AAI training, and advises on avoidance.
●History alone cannot confirm the trigger in a mixed-allergen exposure — this is precisely why specialist assessment matters and should be explained to the patient.

Interim Management While Awaiting the Clinic

●Advise avoidance of all foods eaten during the reaction (here, shellfish, fish, and nuts) until testing clarifies the trigger.
●Teach label reading, informing restaurant and catering staff of allergies, and vigilance for hidden ingredients and cross-contamination.
●Consider a medical alert identifier (bracelet or equivalent) and discuss telling trusted people who can act in an emergency.

Co-existing Asthma

●Poorly controlled asthma is a recognised risk factor for severe and fatal anaphylaxis. Review and optimise asthma control and inhaler technique in any patient prescribed an AAI.
●The respiratory component of anaphylaxis can be more severe and harder to treat in people with asthma.

Safety-Netting and Follow-Up

●Give specific, actionable safety-netting: use the pen and call 999 for breathing difficulty, throat tightness, or faintness; do not wait to "see how it goes."
●Arrange follow-up to confirm the patient can use the device, to review the allergy clinic outcome, and to renew AAIs before expiry (devices expire and need replacing).

Common Candidate Mistakes in This Case

●Refusing to prescribe because the trigger is unconfirmed: a patient who has had anaphylaxis needs an auto-injector now; the trigger is confirmed later at the clinic.
●Prescribing only one device: two should always be prescribed and carried.
●Omitting the 999-and-hospital step: failing to explain that the patient must attend hospital after using the pen, even if better, misses the biphasic reaction risk.
●Not referring to allergy services: leaving the diagnosis and allergen unconfirmed and the patient without a written plan.
●Missing the anxiety agenda: treating this as a simple prescription request and never addressing the fear of dying alone, which is what actually brought her in.

Free MRCGP SCA practice case for GP registrars covering Woman Requesting Adrenaline Auto-injector After Allergic Reaction On Holiday — Allergy and Immunology. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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