Tag: Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by Brian Leakey

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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 selfblood 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?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by Brian Leakey

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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 selfblood 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?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by Brian Leakey

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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 selfblood 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?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by Brian Leakey

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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 selfblood 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?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by Brian Leakey

Case Studies
A 55-year-old male developed painless hematuria. He was otherwise completely asymptomatic.
The results of his physical examination were within normal limits (WNL).
Studies Results
Routine laboratory studies WNL
Urinalysis, p. 896
Blood Positive (normal: no blood)
Red blood cells (RBCs) Too numerous to count (TNTC) (normal: up to 2)
Intravenous pyelogram (IVP), p.
1001

  1. Distortion of renal outline, compatible with a right renal
    mass
  2. Questionable bladder tumor
  3. Mild right ureteral dilation
    Computed tomography (CT)
    scanning of the mass, p. 962
    Normal kidneys, probable renal cyst present
    Renal ultrasound, p. 810 Mass in the right kidney is a fluid-filled cyst
    Cystography, p. 978 Bladder tumor
    Cystoscopy, p. 538 Bladder tumor seen lying near the right ureteral orifice
    Renal biopsy, p. 706 Transitional cell carcinoma
    Retrograde pyelography, p. 1001 Bladder tumor involving right distal ureter
    Bladder tumor markers, p. 856 BTA: 23 units/mL
    NMP22: 32 units/mL
    Survivin: 700 pg/mL
    Diagnostic Analysis
    The urinalysis results documented this patient’s hematuria. Three distinct abnormalities on IVP
    could have been responsible for the hematuria. The renal mass could have been a solid tumor or
    a benign cyst. CT scanning and ultrasonography indicated that the mass was the result of a
    benign renal cyst and was not the cause of the hematuria. No treatment was required for the cyst.
    The questionable bladder tumor seen on IVP was more clearly demonstrated by cystography, and
    a specimen for biopsy was taken during cystoscopy. The diagnosis was transitional cell
    carcinoma of the bladder. The bladder tumor markers were consistent with that diagnosis. Right
    ureteral dilation (seen on IVP) implied possible ureteral involvement by the bladder tumor. A
    retrograde pyelography study indicated that this was indeed the situation.
    After 2 months of preoperative radiation, the patient had a total cystectomy and ileal urinary
    diversion. Tumor markers returned to normal 6 months after surgery. Two years later the tumor
    markers began to rise, and the patient was found to have bladder metastasis to the lung.
    Case Studies
    Copyright © 2018 by Elsevier Inc. All rights reserved.
    2
    Studies Results
    Blood urea nitrogen
    (BUN), p. 453
    58 mg/dL (normal: 7–20 mg/dL)
    Creatinine, p. 171 3.2 mg/dL (normal: 0.7–1.5 mg/dL)
    Renal ultrasound, p. 830 Dilated ureters bilaterally
    Antegrade pyelography,
    p. 1001
    Obstruction of both ureters where the ureters join into the ileal
    conduit (new bladder made at the time of the previous surgery)
    caused by recurrent tumor
    Bilateral nephrostomies (tubes placed in the ureter to relieve obstruction) were placed at the time
    of antegrade pyelography. The patient died of his recurrent bladder cancer 8 months later.
    Critical Thinking Questions
  4. Why did this patient require a retrograde pyelography and an antegrade pyelography?
  5. If, after cystoscopy, this patient had complained of lower abdominal pain and had
    developed a temperature, what would you suspect?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by Brian Leakey

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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 selfblood 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?

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

Posted on | by Brian Leakey | Leave a Comment on : Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition

 

 

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?
.
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?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by admin3

 

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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 selfblood 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?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by admin3

 

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
Copyright © 2018 by Elsevier Inc. All rights reserved.
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?

Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests

Posted on | by

 

 

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 selfblood 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?