[NP-Clinical] Help with Hives update

[David or Diane Dito]

Kathleen,

 

If she is truly allergic to something, it may be on-going allergic reaction
that is causing nasal congestion and cough from histamine release and not a
"sinus infection." Just a thought. Of course, she could have another
etiology for a sinus infection, such as fungal. This far out, I don't think
I'd be thinking this is still viral.but anything is possible as patients can
always prove ya wrong. And they could be idiopathic. Who knows at this
point?

 

Is there anything, ANYTHING, that changed or was added just before the hives
started.besides the obvious abx? Is she taking ibuprofen regularly, which I
believe can cause hives via a different pathway and is less responsive to
the usual treatments? Did she start using a new cosmetic, soap, body wash,
laundry detergent, food, drink, candy, lotion, new pet, friend with new pet,
etc.? I know, we've been through this before, but I will tell you that
sometimes it isn't until WAY down the line that something thinks of
something, even when the daughter of a health care provider!

 

All that said, unless she has frankly purulent nasal d/c and fever or is
acting outright unwell, I'd personally be reluctant to start yet another abx
without further w/u. At this point, I'd absolutely consider a sinus CT and
CBC, or baring that, a referral to an ENT who specializes in
allergy/immunology for further w/u.

 

If she's been using decongestants all along, try switching products as
completely as you can. Maybe she's allergic to a dye or additive in one of
the meds if there's one that's been consistently used throughout her
illness. If she's already used a nasal decongestant spray for at least 3
days, I probably wouldn't go there further, unless it's been at least a
couple weeks since her last dose, then you could repeat for 3 days. Or you
could have her try some Astelin nasal spray. If she's been using
phenylephrine decongestants, try pseudoephedrine instead (have to ask at the
pharmacy counter in most states now).or vice versa if she's been using
pseudoephedrine. Continue either the Zyrtec or Benadryl as needed.

 

I'll tell you, these hives cases can be vexing. But hers have gone on long
enough to warrant specialty evaluation, in my opinion.

 

Take care. Please keep us posted.

 

Diane Dito, NP 

 

  _____  

From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of Kathleen
Sent: Friday, January 19, 2007 9:48 PM
To: np-clinical at nurse.net
Subject: [NP-Clinical] Help with Hives update

 

My 15 yo daughter completed a Z pack last Monday, the 15th, still has
urticaria welts that are itchy but fade rather quickly with Benadryl on
board. Still has cough, some nasal congestion. Lungs clear. Doc prescribed
Zyrtec 10 mg qd for hives and Ceftin 500 mg bid for continuing sinus
infection today (to start tomorrow for ten days, after five days on the Z
pack, and 10 days on Amoxicillin). She has had no blood work (even though I
suggested it) or films or cultures done. No hives tonight with only one dose
of Benadryl today.  Doc did not palpate sinuses, just looked in nose (and
asked about allergies to pets, asthma...brother) and mouth and said she had
a lot of drainage. Is not concerned about mono, no lymph nodes are swollen.
I asked about diarrhea and doc suggested eating yogurt. Wants to see her on
Monday if she develops a "rash or hives that won't go away". According to my
drug information, Ceftin should be used with caution in a PCN allergy and
that a culture should be done before prescribing. Thoughts????

Kathleen, Psych. NP

  

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