Case
Discussion Part One (graded)
John is a 19-year-old college football player who presents with sneezing, itchy eyes, and nasal
congestion that worsens at night. He states that he has a history of asthma, eczema and
allergies to pollen. There is also one other person on the football team that has similar
symptoms. His vitals are BP 110/70, P 84, R 18, T 100 F.
Write a differential of at least five (5) possible items from the most likely to less likely. For
each disease include information about the epidemiology, pathophysiology and briefly
argue why this disease fits the presentation and why it might not fit the presentation.
Topic responses
Discussion
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Mijanou Marretta-Lewis
8/28/2016 5:49:22 AM
Discussion Part One
Dr. Brown and Classmates,
Chronic and recurring nasal congestion is common in the United States with approximately 20 %
of the population suffering from one of several common conditions (Goroll & Mulley, 2014).
Atopy is a term used to describe the response of production of the antibody referred to
immunoglobulin E (IgE), which attaches itself to mast mucosal cells. This response creates an
antigen-antibody trigger which in turn releases antihistamines, prostaglandins, cytokines and
esterases in large amounts in response to the antigens in the area. Atopy triggers are common in
such allergic conditions as hay fever, eczema, and asthma and most commonly seen in children.
Differential Diagnosis:
1. Allergic Rhinitis- is a response to antigens such as pollens in the environment that
cause common nasal congestion, sneezing watery nasal discharge, itchy eyes, nose,
, throat accompanied with fatigue. This commonly called hay fever and can have a
genetic component. Most commonly affecting 10to 30 percent of children in the U.S.
who also have eczema, asthma and general allergies (Greiner, Helling, Rotiroti,
Scadding, 2011). Allergic rhinitis is a symptomatic response from allergens
specifically IgE that peaks during teenage years and is frequently under diagnosed.
This condition is commonly seen in the am then it fades until later in the evening.
This condition is usually seen during the warmer times of the month when pollen and
ragweed are highest and can be a lifelong condition (Greiner et al., 2011). This
response to antigens may impede sleep due to nasal congestion. The high level of IgE
may continue long after pollen count is down and could be due to reactions to animal
dander. In this case the avoidance of pollens and antigens that trigger these responses
may not be feasible for this young football player. The use of first generation
antihistamines may also not be best practice as they cause drowsiness and can limit
psycho-motor skills and academic performance (Greiner et al., 2011). The symptoms
currently displayed appear to fit this diagnosis as the young man states an increase in
discomfort in the evening hours.
2. Acute Sinusitis- is an inflammation of the paranasal sinuses commonly referred to
sinusitis (Shapiro, Gonzales, Cabana, Hersh, 2011). In children and young adults
streptococcus pneumoniae is common in in acute sinusitis and otitis media, and
accounts for more than three million ambulatory visits in the primary care setting per
year (Sharpiro et al., 2011). This infection process which is usually viral in nature,
displays signs of headaches, nasal congestion with mouth breathing, post nasal drip,
facial pain, with the inability to taste or smell. When discharge becomes purulent in
nature the use of antibiotics may be of some benefit as this condition may become
bacterial in nature (Fairlie, Shapiro, Hersh, Hicks, 2012). This is a possibility for this
young man if he is complaining of facial pressure and headaches; however, it does not
say this is the case.
3. Rhinovirus- is also known as the common cold. This viral based condition also
displays symptoms such as sore throat, ear infections, with possible sinus infections
(Papi, Contoliu, Adcock, Bellettato,Padovani et al.,2013). This condition can also be
accompanied by muscle stiffness, fatigue, headaches coughing, sneezing, and loss of
appetite. Asthma is seen in this patient’s history and is a chronic inflammatory disease
that is treated most frequently with inhaled steroid treatment. Rhinoviruses are seen
most frequently in patients with exacerbation of asthma (Papi et al., 2013). If this
patient is on steroid inhalers for his asthma the use of these steroids may make the
, mechanisms of viral infection from rhinovirus interfere with corticosteroid use by
inhibiting steroid effectiveness causing steroid insensitivity. Since this young man is
currently not complaining of asthma exacerbation this diagnosis may not be the case.
Currently there is no effective treatment currently available for rhinovirus.
Understanding the history of this patient’s medications and what asthma related
drugs as currently used requires further research and exploration to decide if this is a
possibly.
4. Sinus Obstruction-paranasal sinuses are hollow, small chambers inside the nose and
head that allow the weight of the facial bones to be reduced. These cavities allow the
passage of mucous drainage, increase the resonance of the voice and aid in
safeguarding against facial trauma. Healthy sinuses are filled with air but during an
allergic reaction such as the common cold or an infectious process the sinuses narrow
and become obstructed, making it difficult to breathe through the nose. When the
sinuses are blocked the inflammation process begins and the pressure inside drop and
they become engorged with fluid, which could lead to a secondary complication such
as sinus infection. Since this young man is a football player, one must rule out
possible mechanical obstruction such as an old nasal fracture causing a deviated
septum from sports. Although not all deviated septums are caused by a sports injury
this condition needs to be addressed to rule out. The development of polyps is not
uncommon and can be caused by allergies, vasomotor rhinitis and chronic sinusitis
(Kahveci, Miman, Yucel, Yucedag, Okur et al., 2012). Patients that have asthma have
a propensity to polyps. One method to evaluate the need for septoplasty is the Nasal
Obstructive Symptom Evaluation (NOSE) scale. The Nose scale begins with a
questionnaire to help gain significant history to the difficulty in breathing through the
nose. The removal of nasal obstructions including deviated septums in one study by
Gandomi, Bayat, Kazemel (2010), shows the median age of patients undergoing
surgery to be about 22.4 years old. Obstructions such as polyps do not shrink
automatically on their own and can continue to grow causing a complete obstruction
and mouth breathing. Our patient at this time appears to not be complaining about
mouth breathing but a need to check his nares for swollen membranes versus
obstructions is necessary.
5. Drugs- Illegal drugs would not fit the profile of this young athlete and therefore this
would be the most unlikely of the five potential diagnoses for this young football
player. Close monitoring by the school and the need to have had a physical for
clearance to play football would be necessary for this young man to play such a
, physical sport. However, the use of over the counter medication can also not be ruled
out. Drugs such as antihistamines for nasal drip can give temporary relief but over
use of topical nasal decongestants can worsen the symptoms which include nasal drip,
itchy, watery eyes, sore throat from post nasal drip, facial pain from blocked sinuses,
and headaches. The cessation of over the counter medications will worsen the
symptoms for several weeks as the body has become dependent on the antihistamine
effect. The constant use of over the counter medication (OTC) can be seen in more
than 65% of patients complaining of post and anterior nasal drip despite the fact that
most of these patients are well versed in the overuse of antihistamines (Mehuys,
Gevaert, Brusselle, Van Hees, Adrians et al.,2014). The encouragement of normal
saline or neti pots to unblock and flush sinuses has become more popular in the older
generation but not so in the younger population who are looking for a quick fix
(Mehuys et al.,2014). With the use of OTC drugs to eliminate itchy watery eyes or
colored mucous increased the risk of a more severe blocked nose for longer periods of
time (Mehuys et al., 2014). This diagnosis could be a potential issue if further
investigation of OTC medication has been used by this young adult.
Mijanou
References
Fairlie, T., Shapiro, D. J., Hersh, A. L., & Hicks, L. A. (2012). National trends in visit rates and
antibiotic prescribing for adults with acute sinusitis. Archives of internal medicine, 172(19),
1513-1514. doi:10.1001/archinternmed.2012.4089
Gandomi, B., Bayat, A., & Kazemei, T. (2010). Outcomes of septoplasty in young adults: the
Nasal Obstruction Septoplasty Effectiveness study. American Journal of Otolaryngology, 31(3),
189-192.doi:10.1-16/j.amjoto.2009.02.023
Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and
management of the adult patient (7th ed.). China: Wolters Kluwer.
Greiner, A. N., Hellings, P. W., Rotiroti, G., & Scadding, G. K. (2012). Allergic rhinitis. The
Lancet, 378(9809), 2112-2122. doi:10.1016/S0140-6736(11)60130-x
Kahveci, O. K., Miman, M. C., Yucel, A., Yucedag, F., Okur, E., & Altuntas, A. (2012). The
efficiency of nose obstruction symptom evaluation (NOSE) scale on patients with nasal septal
deviation. Auris Nasus Larynx, 39(3), 275-279. doi:10.1016/j.ani.2011.08.006
Discussion Part One (graded)
John is a 19-year-old college football player who presents with sneezing, itchy eyes, and nasal
congestion that worsens at night. He states that he has a history of asthma, eczema and
allergies to pollen. There is also one other person on the football team that has similar
symptoms. His vitals are BP 110/70, P 84, R 18, T 100 F.
Write a differential of at least five (5) possible items from the most likely to less likely. For
each disease include information about the epidemiology, pathophysiology and briefly
argue why this disease fits the presentation and why it might not fit the presentation.
Topic responses
Discussion
Expand All
More
Sort By:
Mijanou Marretta-Lewis
8/28/2016 5:49:22 AM
Discussion Part One
Dr. Brown and Classmates,
Chronic and recurring nasal congestion is common in the United States with approximately 20 %
of the population suffering from one of several common conditions (Goroll & Mulley, 2014).
Atopy is a term used to describe the response of production of the antibody referred to
immunoglobulin E (IgE), which attaches itself to mast mucosal cells. This response creates an
antigen-antibody trigger which in turn releases antihistamines, prostaglandins, cytokines and
esterases in large amounts in response to the antigens in the area. Atopy triggers are common in
such allergic conditions as hay fever, eczema, and asthma and most commonly seen in children.
Differential Diagnosis:
1. Allergic Rhinitis- is a response to antigens such as pollens in the environment that
cause common nasal congestion, sneezing watery nasal discharge, itchy eyes, nose,
, throat accompanied with fatigue. This commonly called hay fever and can have a
genetic component. Most commonly affecting 10to 30 percent of children in the U.S.
who also have eczema, asthma and general allergies (Greiner, Helling, Rotiroti,
Scadding, 2011). Allergic rhinitis is a symptomatic response from allergens
specifically IgE that peaks during teenage years and is frequently under diagnosed.
This condition is commonly seen in the am then it fades until later in the evening.
This condition is usually seen during the warmer times of the month when pollen and
ragweed are highest and can be a lifelong condition (Greiner et al., 2011). This
response to antigens may impede sleep due to nasal congestion. The high level of IgE
may continue long after pollen count is down and could be due to reactions to animal
dander. In this case the avoidance of pollens and antigens that trigger these responses
may not be feasible for this young football player. The use of first generation
antihistamines may also not be best practice as they cause drowsiness and can limit
psycho-motor skills and academic performance (Greiner et al., 2011). The symptoms
currently displayed appear to fit this diagnosis as the young man states an increase in
discomfort in the evening hours.
2. Acute Sinusitis- is an inflammation of the paranasal sinuses commonly referred to
sinusitis (Shapiro, Gonzales, Cabana, Hersh, 2011). In children and young adults
streptococcus pneumoniae is common in in acute sinusitis and otitis media, and
accounts for more than three million ambulatory visits in the primary care setting per
year (Sharpiro et al., 2011). This infection process which is usually viral in nature,
displays signs of headaches, nasal congestion with mouth breathing, post nasal drip,
facial pain, with the inability to taste or smell. When discharge becomes purulent in
nature the use of antibiotics may be of some benefit as this condition may become
bacterial in nature (Fairlie, Shapiro, Hersh, Hicks, 2012). This is a possibility for this
young man if he is complaining of facial pressure and headaches; however, it does not
say this is the case.
3. Rhinovirus- is also known as the common cold. This viral based condition also
displays symptoms such as sore throat, ear infections, with possible sinus infections
(Papi, Contoliu, Adcock, Bellettato,Padovani et al.,2013). This condition can also be
accompanied by muscle stiffness, fatigue, headaches coughing, sneezing, and loss of
appetite. Asthma is seen in this patient’s history and is a chronic inflammatory disease
that is treated most frequently with inhaled steroid treatment. Rhinoviruses are seen
most frequently in patients with exacerbation of asthma (Papi et al., 2013). If this
patient is on steroid inhalers for his asthma the use of these steroids may make the
, mechanisms of viral infection from rhinovirus interfere with corticosteroid use by
inhibiting steroid effectiveness causing steroid insensitivity. Since this young man is
currently not complaining of asthma exacerbation this diagnosis may not be the case.
Currently there is no effective treatment currently available for rhinovirus.
Understanding the history of this patient’s medications and what asthma related
drugs as currently used requires further research and exploration to decide if this is a
possibly.
4. Sinus Obstruction-paranasal sinuses are hollow, small chambers inside the nose and
head that allow the weight of the facial bones to be reduced. These cavities allow the
passage of mucous drainage, increase the resonance of the voice and aid in
safeguarding against facial trauma. Healthy sinuses are filled with air but during an
allergic reaction such as the common cold or an infectious process the sinuses narrow
and become obstructed, making it difficult to breathe through the nose. When the
sinuses are blocked the inflammation process begins and the pressure inside drop and
they become engorged with fluid, which could lead to a secondary complication such
as sinus infection. Since this young man is a football player, one must rule out
possible mechanical obstruction such as an old nasal fracture causing a deviated
septum from sports. Although not all deviated septums are caused by a sports injury
this condition needs to be addressed to rule out. The development of polyps is not
uncommon and can be caused by allergies, vasomotor rhinitis and chronic sinusitis
(Kahveci, Miman, Yucel, Yucedag, Okur et al., 2012). Patients that have asthma have
a propensity to polyps. One method to evaluate the need for septoplasty is the Nasal
Obstructive Symptom Evaluation (NOSE) scale. The Nose scale begins with a
questionnaire to help gain significant history to the difficulty in breathing through the
nose. The removal of nasal obstructions including deviated septums in one study by
Gandomi, Bayat, Kazemel (2010), shows the median age of patients undergoing
surgery to be about 22.4 years old. Obstructions such as polyps do not shrink
automatically on their own and can continue to grow causing a complete obstruction
and mouth breathing. Our patient at this time appears to not be complaining about
mouth breathing but a need to check his nares for swollen membranes versus
obstructions is necessary.
5. Drugs- Illegal drugs would not fit the profile of this young athlete and therefore this
would be the most unlikely of the five potential diagnoses for this young football
player. Close monitoring by the school and the need to have had a physical for
clearance to play football would be necessary for this young man to play such a
, physical sport. However, the use of over the counter medication can also not be ruled
out. Drugs such as antihistamines for nasal drip can give temporary relief but over
use of topical nasal decongestants can worsen the symptoms which include nasal drip,
itchy, watery eyes, sore throat from post nasal drip, facial pain from blocked sinuses,
and headaches. The cessation of over the counter medications will worsen the
symptoms for several weeks as the body has become dependent on the antihistamine
effect. The constant use of over the counter medication (OTC) can be seen in more
than 65% of patients complaining of post and anterior nasal drip despite the fact that
most of these patients are well versed in the overuse of antihistamines (Mehuys,
Gevaert, Brusselle, Van Hees, Adrians et al.,2014). The encouragement of normal
saline or neti pots to unblock and flush sinuses has become more popular in the older
generation but not so in the younger population who are looking for a quick fix
(Mehuys et al.,2014). With the use of OTC drugs to eliminate itchy watery eyes or
colored mucous increased the risk of a more severe blocked nose for longer periods of
time (Mehuys et al., 2014). This diagnosis could be a potential issue if further
investigation of OTC medication has been used by this young adult.
Mijanou
References
Fairlie, T., Shapiro, D. J., Hersh, A. L., & Hicks, L. A. (2012). National trends in visit rates and
antibiotic prescribing for adults with acute sinusitis. Archives of internal medicine, 172(19),
1513-1514. doi:10.1001/archinternmed.2012.4089
Gandomi, B., Bayat, A., & Kazemei, T. (2010). Outcomes of septoplasty in young adults: the
Nasal Obstruction Septoplasty Effectiveness study. American Journal of Otolaryngology, 31(3),
189-192.doi:10.1-16/j.amjoto.2009.02.023
Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and
management of the adult patient (7th ed.). China: Wolters Kluwer.
Greiner, A. N., Hellings, P. W., Rotiroti, G., & Scadding, G. K. (2012). Allergic rhinitis. The
Lancet, 378(9809), 2112-2122. doi:10.1016/S0140-6736(11)60130-x
Kahveci, O. K., Miman, M. C., Yucel, A., Yucedag, F., Okur, E., & Altuntas, A. (2012). The
efficiency of nose obstruction symptom evaluation (NOSE) scale on patients with nasal septal
deviation. Auris Nasus Larynx, 39(3), 275-279. doi:10.1016/j.ani.2011.08.006
