NMS Q&A Family Medicine

Atopic, Food, and Contact Allergies 225diet. Foods are added back individually with 2 daysbetween each addition. When the urticaria or angioneuroticedema reappears, the most recently added fooditem is assumed to be at least one of the causes of thesymptoms. That food can then be avoided. Food allergiesin many cases appear for a certain epoch of apatient’s life, followed by remission. The period of themost intense symptoms, in some cases, may seem tocoincide with life stressors, such as crises in a marriageor child rearing.8. The answer is A. The condition is precipitated byexposure to mold spores, that is, Cladosporium and Alternariaorganisms, in a person sensitive specifically to theantigens. These are the second and third most intense andprevalent pollen allergens in the United States, generallyconfined to the eastern half of the country. Ragweed, themost prevalent and severe offending allergen, has a seasonthat begins on approximately August 15 at the 40th parallel,occurring earlier as one moves north (the allergy seasonis timed with the drying ripened flower). The peakage group for allergic rhinitis is between 15 and 25 years.There is no particular difference in the prevalence of allergicrhinitis between the sexes.9. The answer is C. Prednisone, given orally at 40 mgdaily, with the dosage reduced every 2 days to taper offover a 2-week period, is a regimen justified in cases suchas the one presented, which is typical for allergic rhinitisthat is due to a ragweed allergy in the eastern half of theUnited States. Skin testing and desensitization will not beable to address and relieve symptoms in the year in whichthe program is initiated. However, the need to employglucocorticoids in a given season for the relief of severe,otherwise nonresponsive symptoms should be the triggerto initiate skin testing, as systemic glucocorticoids shouldnot be prescribed lightly. The patient had no symptomsof sinusitis or of any other bacterial infection; thus,clarithromycin is not indicated and any other antibioticwould not be justified. Benadryl was already shown tocause drowsiness at a therapeutic dosage, and increasingthe dosage would only be expected to worsen the drowsiness.Avoidance may be effective in cases of animal danderallergy but is not practical for the management ofpollen allergy.10. The answer is E. Bananas and also melons cross-reactwith ragweed and therefore should be avoided during theseason of allergic symptoms (mid-August until the temperaturedrops below 40 F). Other cross-reacting foods includeapples and carrots with birch pollen. These foods mayincrease the symptoms of rhinitis. The other foods presentedas choices are prominent classic food allergens.Symptoms of classic food allergies are more likely to beangioneurotic edema or urticaria, rather than coryza.11. The answer is D. An increase in IgG and decrease inIgE antibodies specific to ragweed, in this case. The immediatelyreacting IgE is the offending antibody. Successfulimmunotherapy (desensitization) leads to a transientslight rise in IgE followed by a fall to much lower levelsthan beforehand and a rise in the blocking antibody IgG.(Remember: the “G” in IgG is “good,” applying to immunityto both allergens and infections in virtually all diseasestates to which it is relevant.)12. The answer is A. Five years of specific venom immunotherapy.This program is 98% effective in preventingsystemic reactions to specific stinging insects, such ashoney bees, wasps, hornets, yellow jackets, and immigrantfire ants. Epinephrine unit-dose syringe injections arenecessary for the acute reaction after the sting but shouldnot comprise the long-term management. Prednisone (orother oral glucocorticoids) is not suited to acute-phase(IgE) reactions and is not suited to long-term prevention.Both antihistamines chlorpheniramine and diphenhydramineare inadequate for acute treatment and have noplace in prevention. Cromolyn by inhalation is a preventative,specific for reactive airway disease, which must betaken thrice daily for effect but, unlike immunotherapy,does not have preventive effects for longer than the termof administration.13. The answer is C. Start inhaled glucocorticoids (orinhaled cromolyn). The patient has progressed from themild, intermittent stage (symptoms requiring use of abeta-2 agonist inhaler no more than twice weekly and nomore than twice in the night monthly), which could becalled stage 1. When he began having symptoms more thantwice weekly (but not as frequently as daily), he entered thestage called mild persistent, or stage 2. In the first two stagesdescribed, the FEV 1 and the PEF should be greater than80% of those predicted for age. The foregoing and thecomplete spectrum of the staging of asthma are based onguidelines published by the National Asthma Educationand Prevention Program (NAEPP).14. The answer is D. Start both inhaled glucocorticoidsand a long-acting beta-2 agonist (e.g., salmeterol or formoterol).The inhaled glucocorticoids, dosed mildly inthe second step of therapy, are prescribed as a mediumdosedproduct at step 3 and a high-dosed product at step4. The patient has entered the third stage of asthma, whichis moderate persistent asthma. It is defined as symptomsthat occur daily and more than once per week at night.Either the FEV 1 or the PEF is between 60% and 80% ofthe predicted values. Stage 4 is defined as continuoussymptoms and limited physical activity caused by asthma.Because long-acting beta-2 agonists and inhaled steroidsare not rapidly acting, they must still be supplementedwith rapid-acting medications such as albuterol. As stated