A 45-year-old woman complained of heartburn and frequent regurgitation of sour material into her mouth. Often while sleeping, she would be awakened by a severe cough.

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Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition

Esophageal Reflux

Case Studies

A 45-year-old woman complained of heartburn and frequent regurgitation of “sour” material into

her mouth. Often while sleeping, she would be awakened by a severe cough. The results of her

physical examination were negative.

Studies Results

Routine laboratory studies Negative

Barium swallow (BS), p. 941 Hiatal hernia

Esophageal function studies (EFS), p. 624

Lower esophageal sphincter (LES)

pressure

4 mm Hg (normal: 10–20 mm Hg)

Acid reflux Positive in all positions (normal: negative)

Acid clearing Cleared to pH 5 after 20 swallows (normal:

<10 swallows)

Swallowing waves Normal amplitude and normal progression

Bernstein test Positive for pain (normal: negative)

Esophagogastroduodenoscopy (EGD), p. 547 Reddened, hyperemic, esophageal mucosa

Gastric scan, p. 743 Reflux of gastric contents to the lungs

Swallowing function, p. 1014 No aspiration during swallowing

Diagnostic Analysis

The barium swallow indicated a hiatal hernia. Although many patients with a hiatal hernia have

no reflux, this patient’s symptoms of reflux necessitated esophageal function studies. She was

found to have a hypotensive LES pressure along with severe acid reflux into her esophagus. The

abnormal acid clearing and the positive Bernstein test result indicated esophagitis caused by

severe reflux. The esophagitis was directly visualized during esophagoscopy. Her coughing and

shortness of breath at night were caused by aspiration of gastric contents while sleeping. This

was demonstrated by the gastric nuclear scan. When awake, she did not aspirate, as evident

during the swallowing function study. The patient was prescribed esomeprazole (Nexium). She

was told to avoid the use of tobacco and caffeine. Her diet was limited to small, frequent, bland

feedings. She was instructed to sleep with the head of her bed elevated at night. Because she had

only minimal relief of her symptoms after 6 weeks of medical management, she underwent a

laparoscopic surgical antireflux procedure. She had no further symptoms.

Critical Thinking Questions

1. Why would the patient be instructed to avoid tobacco and caffeine?

2. Why did the physician recommend 6 weeks of medical management?

Case Studies

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2

3. How do antacid medication work in patients with gastroesophageal reflux?

4. What would you approach the situation, if your patient decided not to take the medication

and asked you for an alternative medicine approach?

Copyright © 2018 by Elsevier Inc. All rights reserved.

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition

Adolescent With Diabetes Mellitus (DM)

Case Studies

The patient, a 16-year-old high-school football player, was brought to the emergency room in a

coma. His mother said that during the past month he had lost 12 pounds and experienced

excessive thirst associated with voluminous urination that often required voiding several times

during the night. There was a strong family history of diabetes mellitus (DM). The results of

physical examination were essentially negative except for sinus tachycardia and Kussmaul

respirations.

Studies Results

Serum glucose test (on admission), p. 227 1100 mg/dL (normal: 60–120 mg/dL)

Arterial blood gases (ABGs) test (on admission),

p. 98

pH 7.23 (normal: 7.35–7.45)

PCO2 30 mm Hg (normal: 35–45 mm Hg)

HCO2 12 mEq/L (normal: 22–26 mEq/L)

Serum osmolality test, p. 339 440 mOsm/kg (normal: 275–300

mOsm/kg)

Serum glucose test, p. 227 250 mg/dL (normal: 70–115 mg/dL)

2-hour postprandial glucose test (2-hour PPG), p.

230

500 mg/dL (normal: <140 mg/dL)

Glucose tolerance test (GTT), p. 234

Fasting blood glucose 150 mg/dL (normal: 70–115 mg/dL)

30 minutes 300 mg/dL (normal: <200 mg/dL)

1 hour 325 mg/dL (normal: <200 mg/dL)

2 hours 390 mg/dL (normal: <140 mg/dL)

3 hours 300 mg/dL (normal: 70–115 mg/dL)

4 hours 260 mg/dL (normal: 70–115 mg/dL)

Glycosylated hemoglobin, p. 238 9% (normal: <7%)

Diabetes mellitus autoantibody panel, p. 186

insulin autoantibody Positive titer >1/80

islet cell antibody Positive titer >1/120

glutamic acid decarboxylase antibody Positive titer >1/60

Microalbumin, p. 872 <20 mg/L

Diagnostic Analysis

The patient’s symptoms and diagnostic studies were classic for hyperglycemic ketoacidosis

associated with DM. The glycosylated hemoglobin showed that he had been hyperglycemic over

the last several months. The results of his arterial blood gases (ABGs) test on admission

indicated metabolic acidosis with some respiratory compensation. He was treated in the

Case Studies

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2

emergency room with IV regular insulin and IV fluids; however, before he received any insulin

levels, insulin antibodies were obtained and were positive, indicating a degree of insulin

resistance. His microalbumin was normal, indicating no evidence of diabetic renal disease, often

a late complication of diabetes.

During the first 72 hours of hospitalization, the patient was monitored with frequent serum

glucose determinations. Insulin was administered according to the results of these studies. His

condition was eventually stabilized on 40 units of Humulin N insulin daily. He was converted to

an insulin pump and did very well with that. Comprehensive patient instruction regarding self-

blood glucose monitoring, insulin administration, diet, exercise, foot care, and recognition of the

signs and symptoms of hyperglycemia and hypoglycemia was given.

Critical Thinking Questions

1. Why was this patient in metabolic acidosis?

2. Do you think the patient will eventually be switched to an oral hypoglycemic agent?

3. How would you anticipate this life changing diagnosis is going to affect your patient

according to his age and sex?

4. The parents of your patient seem to be confused and not knowing what to do with this

diagnoses. What would you recommend to them?