36M DKA ? Chronic Pancreatitis

 A 36 years old Male who is a Auto driver by occupation Resident of Cherlapally  presented to Casualty on 19/4/24 with Complaints of 

Pain Abdomen Since 5 Days 

Shortness of Breath Since 1 day 

Patient Was apparently Asymptomatic 4 years back and Started having Pain abdomen which is left Lumbar Region ; Which is aggrevated by Taking Food & Alcohol  for which he went to local doctor & Used to take tablets after which he got relieved partially. He had total of 3 similar episodes of Pain abdomen in the left lumbar region in the period of 4 years. On 13/4/24 he went to function in his in Laws house where he started drinking Alcohol Continuously for 2 days without taking adequate food then started having Pain Abdomen in Left Lumbar region (on 15/4/24) for which he took Some pain medication but did not relieved completely. Then on 18th Morning Patient induced Vomitings by keeping his fingers in Mouth by thinking he may get relieved from Pain Abdomen. Vomitings ( 4-5 Episodes ) Non Projectile, contained Food Particles; Non Bilious ; Non Blood/Bile Stained. Then From 18th Night Patient started having shortness of Breath which is sudden in onset for which he presented to our casualty on 19/04/24 Early Morning. 

Past History : 

N/K/C/O HTN ; DM ; TB ; Epilepsy; Asthma

Personal History: 

He stopped going to school after completion of 7th Standard. Then started driving auto near his village. He started drinking Toddy Along with his Friends. He used to drink Toddy 1-2 glasses/Day. He used to take carriage to his Father in Farm where he used to drink toddy. Later he started having toddy at his farm in More Quantity. He stopped Auto Driving after 4 years & Started swelling water cans. Then he married at the age of 22 years. After 2 years His sister who got married at his 21 years of age died ( Sister has 1 daughter). He stopped this water can job & started auto driving . He used to take alcohol daily in Large quantities. He has 2 children ( 1st child - 5th Standard & 2nd Child - 4th Standard ) 

Vitals at the time of admission: 

Patient is C/C/C

BP- 130/80mmHg

PR- 106/min 

RR - 31/min 

Spo2 - 98% on RA 

Temp : 99 F

GRBS : 390mg/dl

CVS : S1S2 + ; No Murmers

RS : BAE + ; NVBS +

P/A : Soft ; Non Tender 

CNS : NFND 

Clinical Images :



Investigations: 

CXR on 19/04/24 :



Diagnosis: 

DIABETIC KETOACIDOSIS

? Type 3C DIABETES 

? CHRONIC PANCREATITIS 

Treatment Given :

19/04/24 

1. NBM Till Further Orders

2.IVF 2L NS in 1st 2hrs F/b 125ml/hr 

3. Inj.HAI 6U IV f/b IV Infusion According to Algorithm 1

3. IVF FUSODEX @50ml/hr if GRBS < 250mg/dl 

4. GRBS Monitering Hourly 

20/04/24 

Insulin Infusion Continued.Patient Was allowed to take Oral diet as his appetite was good. Insulin Infusion Was Stopped at 4PM. Patient Had Idly after giving 10U HAI S/C. Patient Was shifted to 7 Point Profile GRBS Monitering.

Patient Was discharged on 22/04/24 in Hemodynamically Stable Condition.

Discharge summary:

Case History and Clinical Findings

C/O PAIN ABDOMEN SINCE 3 DAYS. PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED PAIN ABDOMEN SINCE 3 DAYS INSIDIOUS IN ONSET, LEFT LUMBAR REGION, SPASTIC TYPE OF PAIN,NON RADIATING.

A/W VOMITING 3 EPISODES PER DAY

A/W LOSS OF APPETITE SINCE 3 DAYS

H/O CONSTIPATION SINCE 3 DAYS,STEATORRHOEA

H/O BLOATING

NO H/O FEVER ,LOOSE STOOLS

NO H/O BURNING MICTURITION

NO H/O DECREASED URINE OUTPUT

PAST HISTORY:

H/O SIMILAR COMPLAINTS IN THE PAST

N/K/C/O HTN,DM,CVA,CAD,EPILEPSY,ASTHMA

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA.

VITALS:

BP:130/80

TEMP:97

RR:31

COURSE IN HOSPITAL:

THIS IS A CASE OF 36 YR OLD MALE CAME WITH C/O PAIN ABDOMEN SINCE 3 DAYS A/W VOMITINGS 3-4 EPISODES PER DAY.PATIENT WAS EVALUATED AND DIAGNIOSED WITH DIABETIC KETOACIDOSIS,ACUTE O CHRONIC PANCREATITIS

PATIENT WAS ADVISED FOR CECT ABDOMEN I/V/O PANCREATITIS BUT PATIENT AND ATTENDR DENIED FOR IT. ANTIBIOTICS ADEQATE,REHYDRATION WITH FLUIDS,SUGAR CONTROL WITH INSULIN DRIP F/B INSULIN S/C INJECTION .PATIENT CONDITION IMPROVED AND VITALS ARE STABLE AT THE TIME OF DISCHARGE


PROVISIONAL DIAGNOSIS:-

DIABETIC KETOACIDOSIS [RESOLVED] WITH DENOVO DIABETES MELLITUS

SECONDARY TO ACUTE ON CHRONIC PANCREATIT


Investigation:-

ABG 19-04-2024 06:08:AM:-

PH7.12

PCO27.2

PO2129

HCO32.3

St.HCO37.1

BEB-28.4

BEecf- 26.4T

CO24.7

O2 Sat96.1

O2 Count23.0

COMPLETE URINE EXAMINATION (CUE) 19-04-2024 07:04:AM:-

 COLOURPaleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN+

SUGAR+++

BILE SALTS - Nil

BILE PIGMENTS - Nil

PUS CELLS - 3-4

EPITHELIAL CELLS - 2-3

RED BLOOD CELLS - Nil

CRYSTALS - Nil 

CASTS - Nil

AMORPHOUS DEPOSITS - Absent

OTHERS - Nil

HBsAg-RAPID19- 04-2024 07:04:AM - Negative 

Anti HCV Antibodies - RAPID19-04-2024 07:04:AM :-Non Reactive

 BLOOD UREA19-04-2024 07:04:AM - 38 mg/dl42-12 mg/dl

SERUM CREATININE19-04-2024 07:04:AM0.7 mg/dl1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 19-04-2024 07:04:AM SODIUM133 mmol/L145-136 mmol/L

POTASSIUM5.0 mmol/L5.1-3.5 mmol/L

CHLORIDE101 mmol/L98-107 mmol/L

LIVER FUNCTION TEST (LFT) 19-04-2024 07:04:AM :-

Total Bilurubin1.20 mg/dl1-0 mg/dl

Direct Bilurubin0.18 mg/dl0.2-0.0 mg/dl

SGOT(AST)12 IU/L35-0 IU/L

SGPT(ALT)13 IU/L45-0 IU/L

ALKALINE PHOSPHATASE205 IU/L128-53 IU/L

TOTAL PROTEINS6.2 gm/dl8.3-6.4 gm/dl

ALBUMIN3.4 gm/dl5.2-3.5 gm/dlA/G RATIO1.21

SERUM AMYLASE19-04-2024 07:04:AM - 88 IU/L140-25 IU/L

HAEMOGRAM - 19-4-24

HAEMOGLOBIN - 13.9 gm/dl

TOTAL COUNT - 17,400 cells/cumm

NEUTROPHILS - 89 %

LYMPHOCYTES - 03 %

EOSINOPHILS - 01 %

MONOCYTES - 7 %

BASOPHILS 00 %

PCV - 38.3 VOL%

MCV - 92.5 fl

MCH -33.6 pg

MCHC - 36.3 %

RDWCV 12.3 %

RDWSD 42.4 fl

RBC COUNT - 4.14 millions/cumm

PLATELET COUNT - 3.94 lakhs/cumm

SMEAR:-

RBC - NORMOCYTIC NORMOCHROMIC

WBC - COUNTS INCREASED ON SMEAR WITH NEUTROPHILS

PLATELETS - ADEQUATE IN NUMBER AND DISTRIBUTION

HAEMOPARASITES - NO HAEMOPARASITES SEEN

IMPRESSION - NORMOCYTIC NORMOCHROMIC BLOOD PICTURE WITH NEUTROPHILIC LEUKOCYTOSIS

BLOOD - SUGAR FASTING

FBS - 399 mg/dl

HIV 1/2 RAPID TEST

NON REACTIVE

GLYCATED HAEMOGLOBIN

HBA1C - 7.2 %

LIPID PROFILE

TOTAL CHOLESTROL- 150 mg/dl

TRIGLYCERIDES - 171 mg/dl

HDL CHOLESTROL - 35 mg/dl

LDL CHOLESTROL - 76 mg/dl

VDL - 34.2 mg/dl

HEMOGRAM - 20/4/24

HB-13.8

TC -13200

PLT-3.23

HEMOGRAM 22/4/2024

HB -12.6

TC-9900

PLT-3.29LAKH

ABG 20/4

PH -7.34

PCO2 -22.8

PO2 -40.9

HC03-12.0

SERUM LIPASE - 53


Treatment Given:-

IVF 2PINT NS BOLUS

IVF NS 100ML/HOUR

INJ PAN 40MG IV/OD

INJ THIAMINE 200MG IN 100ML NS IV/BD

INJ HAI (1ML) IN 39ML NS 6ML/HR INCREASE/DECREASE ACCORDING TO GRBS

INJ HAI 40U 6U-6U-6U S/C TID

INJ NPH 6U-X-6U S/C BD

INJ MONOCEF 1GM IV /BD FOR 5 DAYS

SYP CREMAFFIN 10 ML PO HS



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