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Been Medical Video Lectures Dr. Monday, November 22, A yr-old child has intermittent symptoms of mild asthma. The most appropriate treatment option is:. Inhaled 2-agonist as needed for symptoms Explanation: For mild intermittent symptoms of asthma, recommended treatment is with a short-acting inhaled 2- agonist as needed for symptoms.
The intensity of treatment depends on the severity of exacerbations. The need for short-acting inhaled 2-agonist use more than two times a week may indicate the need to initiate long-term-control therapy. The child described in Question 30 experiences worsening of symptoms, which are now persistent and of moderate severity.
Daily inhaled corticosteroid and a long-acting inhaled 2-agonist Explanation: For moderate persistent symptoms of asthma, recommended treatment is with a daily-inhaled corticosteroid and a long-acting inhaled 2-agonist. Alternatives to the inhaled 2-agonist are sustained-release theophylline and a leukotriene receptor antagonist. In addition, for moderate persistent symptoms of asthma, a short-acting 2-agonist is also used as needed for quick relief of symptoms. Daily inhaled corticosteroid, a long-acting inhaled 2- agonist, and oral theophylline.
A yr-old asthmatic boy has developed an asthma exacerbation in the past few days. Asthma symptoms have continued to progress despite frequent albuterol use at home. He comes to the emergency department with chest tightness, dyspnea, and wheezing, and in moderate respiratory distress.
In this setting, management should include all of the following except:. Inhaled ipratropium may be added to the - agonist treatment if no significant response is seen with the first inhaled -agonist treatment.
If a child responds poorly to intensive therapy with nebulized albuterol, ipratropium, and parenteral glucocorticoids, then adding intravenous theophylline could be considered. A 7-yr-old girl has had intermittent asthma symptoms over the past 5 yr.
Her asthma symptoms have been treated with inhaled albuterol as needed. She mostly has exercise-induced asthma symptoms, which happens on most school days except when she uses her albuterol inhaler before going to recess and physical education classes.
In the past year, she has had two asthma exacerbations with viral upper respiratory tract infections, and she has used a total of 5 albuterol metered-dose inhalers. The most appropriate management for this asthmatic girl is:. Begin daily inhaled glucocorticoid in a low dose, increasing the dose monthly until good control is obtained.
Administer daily oral glucocorticoid treatment for one week, with concurrent daily inhaled glucocorticoid. Components of the U. Asthma pharmacotherapy, especially the use of anti- inflammatory controller medications. Features characteristically associated with atopic dermatitis include all of the following except:. Lymphopenia Explanation: Most patients with atopic dermatitis have peripheral blood eosinophilia and elevated serum IgE level.
Major features of atopic dermatitis in children include all of the following except:. Angioedema Explanation: Angioedema is similar to urticaria but has deeper tissue involvement.
Urticaria and angioedema are not characteristic features of atopic dermatitis. A 2-yr-old is diagnosed with atopic dermatitis. Which of the following environmental modifications is recommended?
Use of a liquid rather than powder laundry detergent, and adding a second rinse cycle Explanation: Using a liquid rather than a powder laundry detergent and adding a second rinse cycle will facilitate removal of the detergent. Soaps should have minimal defatting activity and a neutral pHChapter The most appropriate prognosis to convey to the parents of the 2-yr-old with atopic dermatitis described in Question 37 is:.
Symptoms will gradually worsen during childhood and persist stably through adulthood. Symptoms will exhibit a remittent but progressively worsening course through adulthood. With control of trigger factors and appropriate local treatment, reasonable but not complete resolution of symptoms is usually possible. Periods of remission appear more frequently as the child grows older.
Pruritus Explanation: All patients with atopic dermatitis have pruritus. However, not all patients with atopic dermatitis have other allergic symptoms, elevated IgE levels, or S. A 5-yr-old boy with severe atopic dermatitis develops illness with dozens of vesicles primarily covering areas of skin previously affected by atopic dermatitis. The distribution crosses many dermatomes. Findings include fever and lymphadenopathy. Kaposi varicelliform eruption Explanation: Kaposi varicelliform eruption, or eczema herpeticum, results from herpes simplex virus infection of skin with altered immunity, usually from atopic dermatitis.
Kaposi varicelliform eruption is clinically distinguished from zoster by its random distribution, which may involve many dermatomes. Additionally, lesions of eczema herpeticum are often isolated and are not grouped, as are the vesicles of zoster.
Similar eruptions have been described in association with vaccinia virus smallpox vaccination and coxsackievirus infections. A yr-old presents with acute-onset urticaria that has gradually worsened over the past 10 days. Detailed history reveals no clues to the possible etiology. Findings on physical examination are normal except for urticaria. Which of the following diagnostic options is recommended? Allergy skin testing Explanation: No laboratory test confirms or excludes the diagnosis of urticaria.
Allergy skin testing can be helpful in sorting out causes of acute urticaria, especially when supported by historical evidence. Drugs and foods are the most common causes of acute urticaria. A skin biopsy is indicated only if urticarial vasculitis is suspected. Which of the following treatment options is recommended for the patient described in Question 42?
Oral antihistamine Explanation: Antihistamines are usually effective for treatment of urticaria. Diphenhydramine and hydroxyzine are effective but also cause sedation. A nonsedating antihistamine e. Which of the following laboratory tests is most likely to give abnormal results in a patient with chronic urticaria? Assay for antibodies to thyroglobulin Explanation: There is an increased association of chronic urticaria with Hashimoto thyroiditis. Such patients generally have antibodies to thyroglobulin, or a microsomal-derived antigen peroxidate even if they are euthyroid.
Patients with chronic urticaria usually have normal IgE levels. A yr-old girl with repeated episodes of streptococcal pharyngitis experiences another episode of sore throat.
The rapid strep test result is positive, and oral amoxicillin is started, with the first dose given in the office. One hour later, she experiences a "funny feeling" and a tingling sensation around her mouth. Next she becomes apprehensive, has difficulty swallowing, and develops a hoarse voice. The most appropriate therapy is administration of:. Epinephrine Explanation: Intramuscular epinephrine is the treatment of choice.
If the blood pressure does not respond, lactated Ringer's solution should be administered. Benadryl, cimetidine, and prednisone are second-line therapeutic agents to be administered after epinephrine and fluids. Anaphylaxis Explanation: Anaphylaxis to penicillin usually occurs within min of administration of this drug.
Anaphylactic shock is often missed as a diagnosis unless a complete history is obtained and there is a high index of suspicion. The mother of an 8-yr-old boy with acute streptococcal tonsillitis calls to report that now, within 15 min after the first dose of oral penicillin V that you prescribed, he is complaining of itching and has developed hives.
Which of the following should you recommend? A dose of oral Benadryl, with instructions to call again if he has not improved within 30 min. Immediate return to your office or the nearest emergency department Explanation: The urticarial reaction described in the question may develop into anaphylaxis; the latter requires emergency treatment. In addition, the penicillin V should be stopped and a substitute nonpenicillin antibiotic chosen. Careful monitoring at home, with instructions to return to your office or the nearest emergency department if he becomes short of breath or loses consciousness.
Most anaphylactic reactions are due to drugs, latex, foods, and Hymenoptera venom. Oral drugs carry a higher risk of anaphylaxis than that associated with injected drugs Explanation: Reactions to medications can be reduced and minimized by using oral medications in preference to injected forms. Anaphylactic reactions to foods usually begin within minutes to 2 hr of exposure. Administration of which of the following drugs is the treatment of choice for anaphylaxis?
Aqueous epinephrine , by intramuscular injection Explanation: The principal treatment of choice for anaphylaxis is aqueous epinephrine, ,, 0. Intravenous epinephrine may be added as a continuous drip for persistent shock. Intramuscular or intravenous H1 and H2 antagonist antihistamines, oxygen, intravenous fluids, inhaled -agonists, and corticosteroids may also be required.
A yr-old with history of anaphylaxis to Hymenoptera suffers a sting on an extremity. The first-aid kit that is available includes aqueous epinephrine , and other necessary medical supplies. All of the following measures for management of this sting are appropriate except:. Infiltration of one half of the epinephrine dose subcutaneously around the site of the sting.
Incision of and suction of venom from the site of the sting Explanation: With anaphylaxis due to injection of allergen extract or to a Hymenoptera sting on an extremity, one half of the dose of epinephrine may be diluted in 2 mL of normal saline and infiltrated subcutaneously at the site of the sting to slow absorption.
Doses can be repeated at min intervals if necessary. A tourniquet above the site can also slow systemic distribution. The tourniquet can be loosened after improvement or briefly at intervals of 3 min. Food allergy Explanation: Food allergy is the most common cause of anaphylaxis occurring outside of the hospital, accounting for about one half of the anaphylactic reactions reported in pediatric surveys.
A yr-old child with a history of allergy to yellow jackets is stung and immediately begins experiencing tightness in the chest and wheezing. The drug of first choice for management of this child is:. Intramuscular epinephrine Explanation: The principal treatment of choice of anaphylaxis is aqueous epinephrine, ,, 0.
Which of the following would be the optimal long-term management of the child described in Question 51? A 2-yr-old child who has completed 8 days of a day course of cefaclor presents with low-grade fever, malaise, irritability, lymphadenopathy, and a generalized erythematous rash that is mildly pruritic.
Type III hypersensitivity reaction Explanation: Serum sickness is a classic example of a type III hypersensitivity reaction, or immune complex disease. The symptoms develop as antibodies appear against the antigen at a time when the antigen is still present.
Immune complexes may stimulate complement and deposit in joints, the skin, and the renal glomeruli. A yr-old child received equine-derived antivenom for a snake bite 5 yr ago and now requires it again. Results of skin testing to the product are negative.
Negative skin tests indicate that it is highly unlikely that he will develop serum sickness. Serum sickness may begin within a few days of administration of the antivenom Explanation: Because he received the preparation previously, he may experience an accelerated form of serum sickness starting before the usual time course of 7- 12 days following injection.
Premedication with corticosteroids does not prevent serum sickness. Skin testing helps to identify the potential for immediate-type hypersensitivity IgE antibody-mediated to the serum components but does not predict serum sickness a type III, immune complex-mediated hypersensitivity reaction. If there is no alternative treatment, then there is no contraindication to receive the product more than once.
Frequent, intermittent dosing frequency compared with prolonged, continuous dosing Explanation: Risk factors for adverse drug reactions include previous exposure, previous reaction, age yr , route of administration parenteral , dose high , and dosing schedule intermittent , as well as genetic predisposition e. Frequent, intermittent administration is more likely to elicit sensitization than prolonged, continual administration.
Which of the following statements concerning adverse drug reactions is true? Both parental and topical exposures to a drug increase the risk for an adverse reaction Explanation: Parenteral administration poses greater risk than topical administration, but both contribute to risk for an adverse reaction. A 7-yr-old boy presents with fever and otalgia. On examination, he has a bulging right tympanic membrane. As you hand his mother a prescription for amoxicillin, she informs you that when the child was 4 yr old, he broke out in an itchy rash during treatment with amoxicillin.
The most appropriate approach to management of this patient would be:. Reassure the mother that since more than 2 yr have passed, it is highly unlikely that the child is still allergic and he can now take the amoxicillin safely.
Explain to the mother that most adverse drug reactions to amoxicillin are not IgE mediated and that amoxicillin can be safely given. Prescribe a cephalosporin and explain to the mother that there is no cross-reaction between penicillins and cephalosporins.
Prescribe a macrolide antibiotic and explain to the mother that there is no cross-reaction between penicillins and macrolides Explanation: Risk factors for adverse drug reactions include previous exposure and previous reaction. A macrolide is recommended for otitis media in penicillin- allergic patients.
The parents of a 6-yr-old girl relate a history of urticarial reaction and vomiting following administration of amoxicillin in the past. Skin testing to major and minor determinants of penicillin is positive. Which of the following statements regarding administration of a cephalosporin constitutes appropriate advice for the parents?
The child can receive a cephalosporin with no greater risk of anaphylaxis than in the general population. If a patient has a history of penicillin allergy and requires a cephalosporin, skin testing to major and minor determinants of penicillin should preferably be done to determine if the patient has penicillin-specific IgE antibodies. If results of skin tests are negative, the patient can receive a cephalosporin with no greater risk than in the general population. A yr-old girl, who has a long-standing seizure disorder for which she takes phenytoin, develops fever and a urinary tract infection and is prescribed trimethoprim-sulfamethoxazole.
After 9 days of antibiotic treatment she has recurrence of fever and develops confluent purpuric macules on her face and trunk with erosive mucosal lesions of her mouth and conjunctivae. Which of the following best describes this disorder? Stevens-Johnson syndrome Explanation: Stevens-Johnson syndrome is a blistering mucocutaneous disorder induced by drugs, classically sulfonamides. All of the following may be manifestations of insect allergy except:. Uveitis Explanation: Clinical findings in allergy caused by insects are similar to those occurring with usual inhalant allergens e.
Biting insects may cause local reactions that do not involve IgE. Venom from stinging insects causes IgE-mediated sensitivity that may lead to urticaria and anaphylaxis. All of the following statements concerning allergic reactions to stinging insects are true except:. Negative results on skin testing and RAST reliably exclude the likelihood of anaphylaxis Explanation: There are patients with convincing histories of sting anaphylaxis with negative skin test results and RAST results. Immunotherapy provides symptomatic improvement in all of the following except:.
Local reaction to bee sting Explanation: Local reactions to Hymenoptera venom in children are not managed by immunotherapy. An 8-yr-old boy experienced immediate urticaria surrounding a large local reaction to a honeybee sting 2 mo ago.
He had no other symptoms. Skin testing with honeybee venom has been strongly positive at a weak concentration. Appropriate recommendations include all of the following except:. Hymenoptera venom immunotherapy Explanation: Immunotherapy is indicated only for systemic reactions. Individuals with local reactions are not at increased risk for severe systemic reactions on a subsequent sting and are not candidates for Hymenoptera venom immunotherapy. An epinephrine auto-injector EpiPen for administration after a subsequent sting.
A yr-old girl was stung on her left cheek by a yellow jacket. She is experiencing pain. By 4 hr following the sting the left side of her face is so swollen that her left eye is virtually closed.
There are no other complaints. The best course of action would be:. Apply cold compresses, and consider antihistamines and pain medication Explanation: The child has experienced a large local reaction to the sting. Supportive care directed at the reaction is appropriate. Individuals who have experienced only large local reactions, or children younger than 17 yr who have experienced systemic reactions confined to the skin generalized urticaria , are not at significantly increased risk for a severe systemic reaction upon subsequent stings, so testing for allergy and providing emergency medications are not warranted.
A 7-yr-old boy was stung by an unidentified insect and within minutes developed generalized urticaria, a repetitive cough, difficulty breathing, and extreme dizziness. He was treated in the emergency department with antihistamines, epinephrine, and corticosteroids. Which of the following statements is accurate? If skin tests to Hymenoptera venom are performed 1 wk later and results are negative, he is not a candidate for venom immunotherapy.
Testing and venom immunotherapy cannot be undertaken until the insect is identified. While venom immunotherapy carries some risks for local and systemic adverse effects, the benefits outweigh the risks for those at high risk for anaphylaxis from a subsequent sting.
Test results may be negative during a refractory period in the weeks following the reaction, so they should be repeated, along with RAST, after wk if they are negative initially. It is not necessary to know exactly which insect caused the sting before proceeding with testing and treatment. Although venom immunotherapy may not be indicated for patients without identifiable IgE to the venom, in cases of anaphylaxis proximate to a sting, patients should be equipped with self-administered epinephrine because the risk for a subsequent anaphylactic reaction is increased.
A yr-old with a history of seasonal hay fever now also has itchy eyes, profuse tearing, and reddened and edematous conjunctivae. A treatment option effective for the ocular symptoms would be:. Children often complain of stinging or burning with use of topical ophthalmic preparations and usually prefer oral antihistamines for allergic conjunctivitis.
The patient described in Question 66 continues to have symptoms. Combination therapy such as with an antihistamine and a vasoconstrictive agent. Local administration of topical corticosteroids may be associated with increased intraocular pressure, viral infections, and cataract formation. Allergen immunotherapy can be very effective in seasonal and perennial allergic conjunctivitis, especially when associated with rhinitis.
It can decrease the need for oral or topical medications to control allergy symptoms. All of the following statements concerning allergic reactions to foods are true except:. Skin tests are of little diagnostic value for cell-mediated gastrointestinal hypersensitivity.
Cow's milk sensitivity is the most common cause of protein- induced enteropathy. Gastrointestinal anaphylaxis is mediated by IgA Explanation: Gastrointestinal anaphylaxis generally presents as acute abdominal pain and vomiting that accompanies other IgE-mediated allergic symptoms.
The majority of children with positive results on prick skin tests to a food will not react when the food is ingested.
Elimination diets are the only means to establish the diagnosis of food allergies. Which of the following is an uncommon clinical manifestation of food allergies?
Chronic fatigue Explanation: Chronic fatigue is not recognized to be caused by food allergies. Acute urticaria and angioedema but not chronic urticaria and angioedema , acute rhinoconjunctivitis, bronchospasm wheezing , vomiting, and protracted diarrhea are all manifestations of food allergies. Content uploaded by.
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