three differential diagnoses based on Janet’s subjective and objective data

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

Based on the subjective and objective data from Janet, the primary diagnosis would be allergic rhinitis. The signs and symptoms such as runny nose, itchy eyes, and postnasal drainage are all indicative of allergic rhinitis (Mayo Clinic, 2018). The next diagnosis for Janet would be seasonal allergic rhinitis. The indication for this diagnosis is that Janet experiences these type symptoms during the spring and fall (Mayo Clinic, 2018). The last diagnosis for Janet would be atopic dermatitis. Widespread lesions generally characterize atopic dermatitis, and these occur during an immediate hypersensitivity reaction (McCance &Huether, 2014). 

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

Additional history questions to evaluate Janet would be: Does she have a family history of seasonal allergic rhinitis? Does she have any pets in her home, if so cats, dogs, etc? What is her work environment? Does she keep the windows of her home open? Is she frequently outside? These questions help assess the exposure to the seasonal allergens that are affecting Janet. 

3. Discuss the pathophysiological process of your primary diagnosis.

When an individual is exposed to an allergen, an allergic- specific immunoglobulin E is produced (IgE). The IgE antibodies then bind to IgE receptors that are on mast cells and in the respiratory mucosa, and they bind to basophils in the peripheral blood. Once the allergy is inhaled, the IgE antibodies are then bridged on the cell surface by allergen, which activates the cell. The mast cells that are in the nasal tissues then release granule associated chemical mediators, and thus the symptoms of allergic rhinitis occur (deShazo& Kemp, 2017). 

4. Differentiate the types of hypersensitivity mechanisms.

There are four type of hypersensitivity mechanisms: I, II, III, IV 

Hypersensitivity I: IgE- Mediated hypersensitivity reactions- Type I reactions are mediated by the antigen specific IgE as well as the products of tissue mast cells (McCance &Huether, 2014). Most common allergies (seasonal allergies) are type I reactions, thus many healthcare providers use the term allergy when referencing an IgE- mediated reactions. Type I reaction is an immediate reaction and thus anaphylactic reaction is also included in type I. 

Hypersensitivity II: Tissue specific reaction- This reaction is also immediate and it involved IgG and IgM antibodies, as well as the macrophages in tissues. Common disorders of hypersensitivity type II are autoimmune thrombocytompenic purpura, graves disease, and hemolytic anemia (McCance &Huether, 2014).

Hypersensitivity III- Immune complex mediated- this reaction is also immediate and involves the IgG and IgM antibodies, as well as neutrophils. Common disorders include systemic lupus erythematosus (McCance &Huether, 2014). 

Hypersensitivity IV- Cell- mediated reaction- This response is a delayed response that involves no specific antibodies but does involve lymphocytes and macrophages. Common reactions include contact sensitivity to poison ivy as well as metals, such as jewelry ( McCance &Huether, 2014). 

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

Janet is experiencing a type I hypersensitivity reaction because she has been exposed to an allergen (pollen, pet dander, etc) and is now experiencing the allergic rhinitis symptoms.

Discussion #2

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

          Based off the patient’s presentation and symptoms, the most likely diagnosis is allergic rhinitis accompanied with atopic dermatitis.  Common symptoms associated with allergic rhinitis include sneezing, congestion, post-nasal drainage, enlarged nasal mucosa, and nasal polyps (Ehrlich, Fedorowicz, & Li, 2018).  Atopic dermatitis, also known as atopic eczema, commonly accompanies allergic rhinitis, asthma, and food allergies (McCance &Huether, 2014).  Janet’s symptoms also occur seasonally suggesting that her condition is related to an environmental allergen exposure.  It is possible that Janet could be experiencing a non-allergic rhinitis such as a drug- induced hypersensitivity reaction or sinusitis, although these diagnoses are less likely based on her symptoms.

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

          Additional questions that could be useful in the evaluation and diagnosis of Janet’s condition include:

  • Does anyone else in your family experience these or similar symptoms?
  • Have you started any new medications?
  • Have you had any issues taking medications in the past?
  • Do your symptoms change with location? Such as indoors vs outdoors, homes with pets or smoking?
  • Do you smoke?
  • Do the skin symptoms start at the same time as the nasal symptoms? Do you ever have the skin issues without the nasal issues?

3. Discuss the pathophysiological process of your primary diagnosis.

          Allergic rhinitis is a type I IgE hypersensitivity reaction that is a mast cell mediated response to allergens (McCance &Huether, 2014).  Response to the allergen is immediate, occurring within minutes of exposure, and results in the release of histamines which causes bronchial constriction, increased vascular permeability, edema, and vasodilation (McCance &Huether, 2014).  The histamine release induces symptoms of itching, sneezing, increased secretions, and nasal obstructions (McCance &Huether, 2014).    

4. Differentiate the types of hypersensitivity mechanisms.

          There are four types of hypersensitivity disorders: I, II, III, and IV.

Type I: IgE-mediated reaction that has an immediate onset of development after exposure and involves mast cells.  Type I reactions are commonly seen in seasonal allergic rhinitis (McCance &Huether, 2014).   

Type II: Tissue-specific reaction that has an immediate onset of development.  This type of hypersensitivity reaction involves both IgG and IgM antibodies and macrophages in the tissue.  Type II reactions are commonly seen in autoimmune conditions such as thrombocytopenia purpura, Graves disease, and hemolytic anemia (McCance &Huether, 2014). 

Type III: Immune-complex mediated reaction that has an immediate onset of development.  This type of reaction involves both IgG and IgM antibodies and the neutrophils.  Type III reactions are commonly associated with systemic lupus erythematous (McCance &Huether, 2014). 

Type IV: Cell-mediated reaction that has a delayed onset of development.  This type of reaction involves no antibodies and but does include lymphocyte and macrophage responses.  Type IV reactions are commonly seen in relation to contact sensitivity to poison ivy and metals (McCance &Huether, 2014). 

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

          In the provided case study, Janet’s symptoms indicate that she is experiencing the type I hypersensitivity reaction, IgE-mediated reaction, commonly associated with allergic rhinitis. 

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