A 45-year-old woman experienced heartburn, regurgitation, and coughing at night. Tests found low LES pressure, acid reflux, and esophagitis. She was prescribed medication and lifestyle changes but had minimal relief, so underwent surgery with no further symptoms. A 16-year-old football player was brought to the ER unconscious from diabetic ketoacidosis. Tests confirmed type 1 diabetes. He was treated with insulin and recovered in the hospital, then managed long-term with an insulin pump and education. His parents were confused by the diagnosis.

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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

2. 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

3. 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?

4. 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

5. 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)

6. 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

7. 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

8. 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

9. diagnoses. What would you recommend to them?