Station 69

Queen Roberts

Age: 34 years old female

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis 

  • Ask about the onset of the rash
  • Ask about the location of the rash and whether it has spread or changed over time
  • Ask the patient to describe the rash — whether it’s raised, bumpy, flat, or blistering
  • Ask if the rash is getting worse, staying the same, or improving over time
  • Ask whether the rash is itchy, painful, or both
  • Ask about any possible triggers, such as food, stress, new fabrics, insect bites, or medications
  • Ask if there has been any recent change in environment, such as a new home, job, skincare product, or laundry detergent  
  • Ask if she has experienced a similar rash before
  • Ask if she has started any new medications recently, including over-the-counter or supplements
  • Ask about any known allergies
  • Ask about any family history of allergic skin conditions (e.g. eczema, urticaria, hay fever, asthma)
  • Screen for red flag features of anaphylaxis, including lip or tongue swelling, difficulty breathing, or wheeze
  • Ask about smoking, alcohol use, and the impact of the rash on daily life and wellbeing
  • Give a working diagnosis of urticaria

Example of explanation to patient​

Queen, thanks for explaining everything so clearly. From what you’ve described, a red, raised, itchy rash that comes and goes, usually settling within a few days, this sounds like something called urticaria, or what people sometimes call hives. It’s a common allergic skin reaction that can be triggered by many different things, like certain foods, stress, changes in temperature, or even just irritation from fabrics or products.

The tricky part is that the trigger isn’t always obvious, especially when the rash only appears now and again. What I would suggest is that you keep a symptom diary for the next couple of weeks, just a note of when the rash appears, how long it lasts, anything you ate, any new products you’ve used, or anything else that stood out that day. This can help us spot patterns over time. Is this something you are happy doing? 

Because the rash isn’t active right now, there’s no need for you to come into the surgery, but if it happens again, it would be really helpful if you could take a clear photo and send it to us. That way, we can see exactly what it looks like and guide you better.

If you don’t spot any clear triggers in your diary and the rash keeps coming back, we can then look at doing some simple blood tests to rule out other causes.

Just so you know, urticaria is usually harmless, but if you ever notice more serious symptoms like tongue swelling, difficulty breathing, or feeling faint, that could be a sign of a more serious allergic reaction called anaphylaxis, and you should seek urgent medical help straight away by dialling 999.

Does all of that make sense so far? Would you like me to go over any part again?

Management

Management

  • No need for a face-to-face assessment at present as the patient is not currently experiencing the rash
  • Advise the patient to send a photo of the rash if she has one from a previous episode, or to take and send a photo if the rash occurs again
  • Recommend keeping a symptom diary for 2–4 weeks to help identify potential triggers such as food, stress, environmental factors, or skincare products
  • Arrange a follow-up in 2–4 weeks to review symptom patterns and the impact of any self-care strategies
  • If no clear triggers are identified and symptoms persist, consider offering blood tests and further investigations to explore other causes. 
  • Advise the patient that if the rash comes back, she can take cetirizine again, as it helped settle the symptoms last time.
  • Safety-net: advise the patient to seek urgent medical attention if she experiences signs of anaphylaxis, such as swelling of the lips or tongue, difficulty breathing, wheezing, or feeling faint

Learning point from this station: ​

Urticaria is a superficial swelling of the skin involving the epidermis and mucous membranes, typically presenting as a red, raised, itchy rash. It is usually self-limiting, resolving within hours to a few days, and is often triggered by allergens, infections, temperature changes, or stress.

Angioedema is a deeper form of urticaria affecting the dermis and subcutaneous or submucosal tissues, presenting as swelling of the lips, eyelids, hands, feet, or genitalia.

Anaphylaxis is a medical emergency and presents with airway, breathing or circulatory compromise — including tongue swelling, stridor, wheeze, or breathlessness. 

NOTE: While tongue swelling can occur in both angioedema and anaphylaxis, it is more commonly associated with anaphylaxis. Therefore, any patient presenting with tongue swelling should be referred to hospital via 999 urgently, as this may indicate early anaphylaxis.

Investigations are not routinely required for acute urticaria. However, if the rash persists for longer than 6 weeks (chronic urticaria) or no clear trigger is identified after a symptom diary, further investigations may be appropriate to rule out underlying causes.

Referral to dermatology should be considered in the following scenarios:

  • Acute severe urticaria thought to be related to food or latex allergy
  • Persistent, painful urticaria (consider vasculitic urticaria)
  • Urticaria not well controlled on antihistamine treatment. Note: Off-label use of non-sedating antihistamines up to 4 times the standard dose is considered safe in urticaria and should be trialled before referral to dermatology. If symptoms remain uncontrolled at this dose, refer to dermatology for further input.
Further reading