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1. Provide three differential diagnoses based on Janet’s subjective and objective data and discuss your reasoning for each.

Hay fever, food allergies and viral infection that presents as a cold with allergic symptoms would be the top three indications based off of the signs and symptoms being presented by Janet (Mayo Clinic, 2019b). Hay fever causes seasonal allergies along with a clear runny nose, post-nasal drip and irritated nares. Food allergies can cause eczema and allergic symptoms affecting the ear note and throat (Mayo Clinic, 2017). A viral infection such as the common cold can also exacerbate a runny nose, sneezing, post-nasal drainage and inflamed lymph nodes (Mayo Clinic, 2019a).

2. What additional history questions would be useful in your evaluation of Janet?

You can ask valid questions such like when did the symptoms begin? Have you been around anyone else who is sick? What makes the symptoms worse? Have you had a recent in change in environment or food? What makes the symptoms seem worse or better? Have you tried taking any medication and if so, what has worked/not worked? Does anyone in your family suffer from any allergies? Have you had seasonal/food allergies ever checked? 

3. Discuss the pathophysiological process of your primary diagnosis.

Janet is suffering from Hay fever during the changes in seasons during Spring and Fall which is when pollen counts are elevated. According to Mayo Clinic (2019) Hay fever, also called allergic rhinitis, causes cold-like signs and symptoms, such as a runny nose, itchy eyes, congestion, sneezing and sinus pressure. But unlike a cold, hay fever isn’t caused by a virus. Hay fever is caused by an allergic response to outdoor or indoor allergens, such as pollen, dust mites, or tiny flecks of skin and saliva shed by cats, dogs, and other animals with fur or feathers (pet dander).

4. Differentiate the types of hypersensitivity mechanisms.

Type I hypersensitivity is also known as immediate or anaphylactic hypersensitivity. The reaction may involve skin (urticaria and eczema), eyes (conjunctivitis), nasopharynx (rhinorrhoea, rhinitis), bronchopulmonary tissues (asthma) and gastrointestinal tract (gastroenteritis). The reaction may cause a range of symptoms from minor inconvenience to death. The reaction usually takes 15 – 30 minutes from the time of exposure to the antigen, although sometimes it may have a delayed onset of 10-12 hours (Ghaffar, 2016).

Type II hypersensitivities are also known as cytotoxic hypersensitivities and may affect a variety of organs and tissues. The antigens are normally endogenous, although exogenous chemicals (haptens) which can attach to cell membranes and lead to type II hypersensitivity. Drug-induced hemolyticanemia, granulocytopenia and thrombocytopenia are examples. The reaction time is minutes to hours. Type II hypersensitivity are primarily mediated by antibodies of the IgM or IgG classes and complement. Phagocytes and K cells may also play a role (Ghaffar, 2016).

Type III hypersensitivity is also known as immune complex hypersensitivity. The reaction may be general such as serum sickness or may involve individual organs including skin like systemic lupus erythematosus, an Arthur reaction, kidneys, lupus-nephritis, lungs-aspergillosis, blood vessels-polyarteritis, joints-rheumatoid arthritis, or other organs. This reaction may be the pathogenic mechanism of diseases caused by many microorganisms.

Type IV hypersensitivity is involved in the pathogenesis of many autoimmune and infectious diseases (tuberculosis, leprosy, blastomycosis, histoplasmosis, toxoplasmosis, leishmaniasis, etc.) and granulomas due to infections and foreign antigens. Another form of delayed hypersensitivity is contact dermatitis such as with poison ivy, and heavy metals (Ghaffar, 2016).

5. As per your analysis, what type of hypersensitivity reaction is Janet experiencing?

Allergic disorders (type I hypersensitivity) associated with asthma, hay fever, and drug reactions, as well as parasitic infections (particularly with metazoan parasites) are often cited as causes. Allergic reactions can present as the patient having and increased number in eosinophilia is an absolute increase (more than 450/μL) in the total numbers of circulating eosinophils (McCance&Huether, 2014).

References

Ghaffar, A. (2016, April 2). Hypersensitivity reactions. Retrieved from http://www.microbiologybook.org/ghaffar/hyper00.htm

Mayo Clinic. (2019, April 20). Common cold Symptoms and causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/common-cold/symptoms-causes/syc-20351605

Mayo Clinic. (2017, May 2). Food allergy Symptoms and causes.Retrieved from https://www.mayoclinic.org/diseases-conditions/food-allergy/symptoms-causes/syc-20355095

Mayo Clinic. (2019, March 19). Hay fever symptoms and causes.Retrieved from https://www.mayoclinic.org/diseases-conditions/hay-fever/symptoms-causes/syc-20373039

McCance, K., Huether, S. (2014). Pathophysiology: The Biologic Basis for Disease in Adults and Children, (7th Ed). Mosby, St. Louis, Missouri. [Vital Book File]. HASDOIHFOCINDLKCNBION

 

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A 56-year-old male was brought to the emergency room with a chief complaint was right flank pain.

History of present Illness:

One day prior to admission, the patient developed a change in the color of his urine from pale yellow to red in color. There was no associated fever, painful urination, or penile discharge. He decided to consult with his primary physician the following day.

One hour prior to admission, the patient developed severe right flank pain associated with nausea. Upon admission, the patient was noted by the ER physician to be in severe pain, with a pain scale of 9 from a visual analog pain scale from 1  to 10. On physical exam, patient had the following findings:

• Vital Signs BP: 140/90 mm Hg 
• Heart rate: 110 bpm  
• Respiration rate: 15 breaths per minute patient 
• Temperature: 98.6 deg C 
• All exam findings for the head, neck, heart, lungs, and abdomen were normal.  
• On examination of the back, patient had tenderness on the right flank upon palpation. 
• On examination of the genitalia, there was no penile discharge. 
• Note of a 1 x 1 cm tophus on right big toe. 

The following diagnostic exams were ordered

• CBC with WBC differential count  
• Urinalysis  
• Serum uric acid 
• KUB x-ray 
• MRI Scan abdominopelvic area 

Past Medical History:

• Diagnosed with gout one year prior to admission 
• On medication with allopurinol 
• No heart and lung disease 
• No diabetes or hypertension 

Click here to review the results of the diagnostic exam.

Questions and topics for discussion:

1. After considering his signs, symptoms, findings, and diagnostic exams, what would be the clinical diagnosis in this patient? (1 pt)
2. What is causing the hematuria to occur?  (1 pt)
3. Why are his vitals (BP, HR, breathing) elevated? (1 pt)
4. What is causing the severe right flank pain? (1 pt)
5. How are the elevated levels of serum uric acid and positive uric acid crystals in the urinalysis related to your diagnosis? (1 pts)
6. What pain medication would you provide to this patient? Why would you choose this medication? (2 pts)
7. What treatment would you recommend for removing the cause of his pain?  Explain your answer.  (3 pts)

 

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