hero
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71 A 23-year-old woman is evaluated in the emergency department because of generalized pruritic rash and difficulty breathing, both of which developed minutes after she ate at a nearby restaurant. The patient developed a rash some years ago after eating in a restaurant, but she is unsure whether she has food allergy.
On physical examination, the patient is very anxious and in significant respiratory distress. Her temperature is 36.7 C (98 F), pulse rate is 120/min and regular, respiration rate is 30/min, and blood pressure is 85/50 mm Hg. Periorbital edema is present. Diffuse wheezing and prolonged expiratory phase are noted on auscultation. There is diffuse erythema over the trunk and extremities.
The patient is promptly treated with subcutaneous epinephrine, intravenous fluids, inhaled β-agonist
s, corticosteroids, and antihistamines. After 2 hours she feels better, her vital signs have returned to normal, and there is no wheezing on minimal prolongation of expiratory phase.
Which of the following is the most appropriate next step in this patient’s management?
A. Observe her in the emergency room for another hour, and discharge her if she remains stable.
B. Discharge her and prescribe a tapering dose of corticosteroids for 1 week.
C. Hospitalize her for further observation.
D. Discharge her with an epinephrine and instructions to consult an allergist.
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| viket
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I would go with D. There is no need to observe her any more since she is feeling better. I am sure that she needs to see an allergist, and epipen could be life-saving if this simptoms occure again.
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| neurom
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D. Have a patient to visit an allergist, who would identify an allergen and provide a medical indentification bracelet.
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| tamerbashir
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B?
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| sprint123
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Is this scombroid poisoning? Given that, the patient could be managed conservatively at home with anti-histaminics
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| bax
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a
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| jasmin
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d
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| kpmle2
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D. Discharge her with an epinephrine and instructions to consult an allergist.
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| hero
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you'll be surprised 
The correct answer is C
This patient most likely has a food allergy. The classic anaphylactic response is an allergic reaction involving antigen- and IgE-specific effector cells. When stimulated by the antigen-IgE compound, these effector cells release a host of mediators producing the clinical manifestations of anaphylaxis. Common food antigens include peanuts, soybeans, eggs, milk, shellfish, and nuts. Anaphylaxis can progress to shock, multiple-organ dysfunction, and death. Appropriate diagnosis and treatment in a timely fashion are essential in reducing morbidity and mortality.
Improvement with treatment may be followed by late phase-reactions, typically 6 to 12 hours after the initial reaction, as a result of migration of effector cells into areas of antigen introduction. Patients presenting to the emergency department with severe anaphylaxis (hypotension or airway compromise or both) should be admitted for further observation in a monitored setting.
Observing the patient in the emergency room for another hour would not provide sufficient time to rule out a late-response reaction. Follow-up with an allergist, instruction on use of epinephrine, and a corticosteroid taper are important considerations for patients with anaphylaxis. Discharging a patient from the emergency department after presentation with severe anaphylaxis would not be prudent.
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| kpmle2
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Very good Q hero Thx for posting.
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| viket
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Ok, but are u sure this is the right answer? This is anaphylactic response, and for late response reaction we have to thanks to mediators like TNF and Il-4 with some others from mast cells. By adminstering corticosteroids we have prevented production of these mediators so late response reaction can not occur. Am I wrong?
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