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.For chronic or recurrent urticaria important considerations include previous causative factors and the effectiveness of various treatments as follows Precipitants such as heat cold pressure exercise sunlight emotional stress or chronic medical conditions Other medical conditions that can cause pruritus usually without rash such as diabetes mellitus chronic renal insufficiency primary biliary cirrhosis or other nonurticarial dermatologic disorders Family and personal medical history of angioedema Characteristics of angioedema include vasodilation and exudation of plasma into deeper tissues than with simple urticaria swelling that is generally nonpitting and nonpruritic and usually occurs on the mucosal surfaces of the respiratory and GI tracts and hoarseness For acute urticaria the main consideration involves possible precipitants such as the following Recent illness Medication use IV radiocontrast media Travel Foods New perfumes hair dyes detergents lotions creams or clothes Exposure to new pets dander dust mold chemicals or plants Pregnancy usually occurs in last trimester and typically resolves spontaneously soon after delivery Contact with nickel rubber latex industrial chemicals and nail polish Sun or cold exposure Exercise Physically urticaria is characterized by the following Blanching raised palpable wheals which can be linear annular circular or arcuate serpiginous can occur on any skin area are usually transient and migratory and may coalesce rapidly to form large areas of erythematous raised lesions that blanch with pressure Dermographism urticarial lesions resulting from light scratching The physical examination should focus on conditions that might precipitate urticaria or could be potentially lifethreatening including the following Angioedema of the lips tongue or larynx Individual urticarial lesions that are painful longlasting or ecchymotic or that leave residual hyperpigmentation or ecchymosis upon resolution Systemic signs or symptoms Scleral icterus hepatic enlargement or tenderness Thyromegaly Pneumonia or bronchospasm asthma Cutaneous evidence of bacterial or fungal infection See Clinical Presentation for more detail.two drugs cause an effect greater than the sum of each alone synANESTHESIA methoxyflurane and enflur ane s isoflurane s desflurane and sevoflurane s. 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