Reference no: EM133552848
Assignment
Textbook: Pagana: Mosby's Manual of Diagnostic and Laboratory Tests, 6th Edition.
Part I: Adolescent With Diabetes Mellitus (DM)
Case Study
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.
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Studies
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Results
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Serum glucose test (on admission), p. 227
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1100 mg/dL (normal: 60-120 mg/dL)
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Arterial blood gases (ABGs) test (on admission), p. 98
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pH
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7.23 (normal: 7.35-7.45)
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PCO2
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30 mm Hg (normal: 35-45 mm Hg)
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HCO2
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12 mEq/L (normal: 22-26 mEq/L)
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Serum osmolality test, p. 339
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440 mOsm/kg (normal: 275-300 mOsm/kg)
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Serum glucose test, p. 227
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250 mg/dL (normal: 70-115 mg/dL)
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2-hour postprandial glucose test (2-hour PPG), p. 230
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500 mg/dL (normal: <140 mg/dL)
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Glucose tolerance test (GTT), p. 234
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Fasting blood glucose
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150 mg/dL (normal: 70-115 mg/dL)
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30 minutes
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300 mg/dL (normal: <200 mg/dL)
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1 hour
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325 mg/dL (normal: <200 mg/dL)
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2 hours
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390 mg/dL (normal: <140 mg/dL)
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3 hours
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300 mg/dL (normal: 70-115 mg/dL)
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4 hours
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260 mg/dL (normal: 70-115 mg/dL)
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Glycosylated hemoglobin, p. 238
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9% (normal: <7%)
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Diabetes mellitus autoantibody panel, p. 186
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insulin autoantibody
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Positive titer >1/80
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islet cell antibody
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Positive titer >1/120
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glutamic acid decarboxylase antibody
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Positive titer >1/60
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Microalbumin, p. 872
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<20 mg/L
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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 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.
Task
A. Why was this patient in metabolic acidosis?
B. Do you think the patient will eventually be switched to an oral hypoglycemic agent?
C. How would you anticipate this life changing diagnosis is going to affect your patient according to his age and sex?
D. The parents of your patient seem to be confused and not knowing what to do with this diagnoses. What would you recommend to them?
Part II Esophageal Reflux
Case Study
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.
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Studies
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Results
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Routine laboratory studies
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Negative
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Barium swallow (BS), p. 941
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Hiatal hernia
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Esophageal function studies (EFS), p. 624
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Lower esophageal sphincter (LES) pressure
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4 mm Hg (normal: 10-20 mm Hg)
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Acid reflux
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Positive in all positions (normal: negative)
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Acid clearing
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Cleared to pH 5 after 20 swallows (normal: <10 swallows)
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Swallowing waves
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Normal amplitude and normal progression
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Bernstein test
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Positive for pain (normal: negative)
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Esophagogastroduodenoscopy (EGD), p. 547
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Reddened, hyperemic, esophageal mucosa
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Gastric scan, p. 743
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Reflux of gastric contents to the lungs
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Swallowing function, p. 1014
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No aspiration during swallowing
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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.
Task
A. Why would the patient be instructed to avoid tobacco and caffeine?
B. Why did the physician recommend 6 weeks of medical management?
C. How do antacid medication work in patients with gastroesophageal reflux?
D. What would you approach the situation, if your patient decided not to take the medication and asked you for an alternative medicine approach?