Code Status case · Intermediate · Premium
Rash in a 19-year-old woman
“I thought it was just a rash but now my throat feels tight.”
“About twenty minutes after dinner, she developed widespread hives, lip swelling, and wheezing. Her voice sounds different now.”
Your challenge
Twenty minutes after dinner, Anika broke out in hives. Now her lips are swelling, she is wheezing, and the nurse says her voice sounds different. Several conditions can cause swelling or breathing trouble, but the combination of symptoms matters. So does the first drug you reach for. Getting her through the first hour is not the end of the case.
After the case, Attending’s Notes explains the decisions that mattered, backed by 10 sources.
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Spoiler: the diagnosis and what this case teaches
Diagnosis
Anaphylaxis
Lesson 1
Recognize Anaphylaxis Even Without Hives
Sudden breathing or circulation problems after an allergen can be enough.
- Hives, wheeze, vomiting after food fit anaphylaxis
- Anaphylaxis can occur without skin findings
- Hives alone do not mean anaphylaxis
- Normal BP does not exclude severe anaphylaxis
Lesson 2
Epinephrine Comes First
Epinephrine reverses breathing and circulation problems that antihistamines cannot treat.
- Inject epinephrine into the outer thigh muscle
- Repeat IM epinephrine if symptoms persist or recur
- Antihistamines and steroids cannot replace epinephrine
- Routine IV epinephrine boluses risk serious harm
Lesson 3
Escalate for a Threatened Airway or Persistent Shock
Continue epinephrine while preparing airway support or a monitored infusion.
- Hoarseness needs epinephrine & airway check
- Progressive throat swelling needs airway experts early
- Use a monitored epinephrine infusion for persistent shock
- Consider glucagon if beta-blocked shock persists
Lesson 4
Longer Observation After Severe Reactions
Observation should match the severity of the reaction, not one fixed clock for everyone.
- Rapid complete response may shorten observation
- Observe longer for severe reactions or repeat doses
- A biphasic reaction returns after apparent recovery
- Provide autoinjectors and an action plan at discharge
In the app, every line above opens into the detail behind it: doses, pitfalls and the evidence, with 10 sources linked to the originals.
Anika is a fictional patient. Code Status is for training only and is not intended for real-world patient care, diagnosis, treatment, or clinical decision-making.