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Pain abdomen since one day
Treatement
Vomitings since one day
He was apparently asymptomatic 2yrs ago.. Then he developed pain abdomen for which he visited local hospital and received medication.. At that time only, he was told to have diabetes and he is on regular medication (Met -500) since then he is having on and off symptoms every 2-3 months and received medication for 3days. .
On friday, (18/06/2021) he attended a function where he had spicy food and alcohol, then developed pain abdomen in the epigastric region progressive along with vomitings non projectile non bilious. For which he visited local hospital and was told to have ketone bodies in the urine. They referred to kims narketpally
Past history :
K/c/o DM ( on medication)
Not ak/c/o HTN, EPILEPSY, TB, ASTHMA CVD
Family history :
Not significant
Personal history :
Mixed diet
Appetite normal
Sleep adequate
He consumes alcohol every 2-3 days, 180ml, whisky since 10yrs
Smoking cigarettes. (5) during time of alcohol consumption since 10yrs.
No known allergies
General EXAMINATION :
PT is conscious, coherent, cooperative, well oriented to time place and person
no pallor
No icterus
No cyanosis
No clubbing
No pedal edema
No generalised lymphadenopathy
Vitals :
BP 130/90
PR 126bpm
temp: AFEBRILE
SpO2 98%
GRBS 484
Systemic Examination :
CVS:
S1 S2 HEARD
No murmurs.
RESP:
BAE +
NVBS +
No adventitious sounds
Per abdomen:
Distended abdomen
Tender
bowel sounds heard
CNS
intact
Provisional diagnosis :
Diaabetic ketoacidosis with acute on chronic pancreatitis
Investigations :
Treatement
19/06/2021:
NBM TILL FURTHER ORDERS
IVF- 1 NS BOLUS 3L WITHIN 1 HR OF ADMISSION
IVF NS @250 ML PER HOUR
INJ.HAI 8U IV STAT FOLLOWED BY INJ HAI 1 ML IN 39 ML NS @ 8 ML PER hr IV infusion
GRBS MONITORING HOURLY
STRICT I/O MONITORING
INJ.THIAMINE 200MG IN 100 NS /IV
INJ.OPTINEURON 1 AMP IN 100 ML NS /IV OVER 15 MIN
INJ.ZOFER 4MG IV/SOS
NJ PAN 40 MG IV /OD
20/06/21
IVF. 1 NS ,1 RL @150 ML PER HOUR
NBM TILL FURTHER ORDERS
INJ HAI 1 ML IN 39 ML NS @6ML PER HOUR/IV/INFUSION
INJ.THIAMINE 100 MG IN 100 ML NS /IV/BD
INJ. OPTINEURON 1 AMP IN 100 ML NS /IV/ OD
INJ.ZOFER 4MG IV/SOS
NJ PAN 40 MG IV /OD
INJ TRAMADOL 1 AMP IN 100 ML NS/IV/SOS
STRICT I/O MONITORING
GRBS MONITORING HOURLY
21/06/2021:(COMPLAINTS OF ABDOMINAL TIGHTNESS ,PASSED STOOOS SEMI SOLID ABOUT 5-6 TIMES)
BP: 120/90
PR 96 BPM
P/A SOFT
Rx:
IVF. 1 NS ,1 RL @150 ML PER HOUR
NBM TILL FURTHER ORDERS
INJ HAI 1 ML IN 39 ML NS @6ML PER HOUR/IV/INFUSION
INJ.THIAMINE 100 MG IN 100 ML NS /IV/BD
INJ. OPTINEURON 1 AMP IN 100 ML NS /IV/ OD
INJ.ZOFER 4MG IV/SOS
NJ PAN 40 MG IV /OD
INJ TRAMADOL 1 AMP IN 100 ML NS/IV/SOS
STRICT I/O MONITORING
GRBS MONITORING HOURLY
IV FLUID 5%DEXTROSE @50 ML PER HOUR
22/06/2021:
No fresh complaints
BP 130/80 mmHg
PR 86 bpm
GRBS 154 mg/dl
P/A : soft, non tender
Rx :
Soft oral diet
IVF 1 NS, 1 RL @ 100ml per hour
INJ. HAI 1ML IN 39ML NS @2ML PER HOUR IV INFUSION
IVF. 5% DEXTROSE @50ML PER HOUR
INI. THIAMINE 1AMP IN 100ML ND /IV/BD
INJ. OPTINEURON 1AMP IN 100ML NS/IV/OD
INJ. ZOFER 4MG /IV/SOS
INJ. TRAMADOL 1AMP IN 100ML NS/IV/OVER 30MIN SOS
STRICT I/O MONITORING
STRICT GRBS CHARTING HOURLY
23/06/2021
Soft oral dietIVF 1 NS, 1 RL @
100ml per hour INJ. HAI 1ML IN 39ML NS @2ML PER HOUR IV INFUSIONIVF. 5% DEXTROSE
@50ML PER HOURINI. THIAMINE 1AMP IN 100ML ND /IV/BDINJ. OPTINEURON 1AMP IN 100ML
NS/IV/ODINJ. ZOFER 4MG /IV/SOSINJ. TRAMADOL 1AMP IN 100ML NS/IV/OVER 30MIN
SOSSTRICT I/O MONITORING STRICT GRBS CHARTING HOURLYON
24/06/2021
Soft oral
dietIVF 1 NS, 1 RL @ 100ml per hour INJ. HAI 1ML IN 39ML NS @2ML PER HOUR IV
INFUSION IVF. @50 ML PER hour
6ML PER HOURINI. THIAMINE 1AMP IN 100ML ND /IV/BDINJ. OPTINEURON 1AMP IN 100ML
NS/IV/ODINJ. ZOFER 4MG /IV/SOSINJ. TRAMADOL 1AMP IN 100ML NS/IV/OVER 30MIN
SOSSTRICT I/O MONITORING STRICT GRBS CHARTING HOURLY
DEPARTMENT OF GENERAL-MEDICINE
DISCHARGE SUMMARY
Age/Gender : 29 Years/Male
Admission Date: 19/06/2021 12:11 PM
Discharge Date
Date:25/06/2021
Ward:icu
Unit:6
Name of Treating Faculty
DR.ARJUN KUMAR(ASST PROF)
DR.AJITH KUMAR(PGY2)
DR.DURGA KRISHNA(PGY1)
DR. KEERTHI(INTERN)
DR.SREEJA(INTERN)
DR.SRIYA(INTERN)
DR.VAISHNAVI(INTERN)
DR.SHREYA(INTERN)
Diagnosis
DIABETIC KETOACIDOSIS WITH ACUTE ON CHRONIC PANCREATITIS
Case History and Clinical Findings
29 YR OLD MALE PRESENTED TO THE CASUALITY WITH THE CHEIF COMPLAINTS OF
PAIN ABDOMEN SINCE 1 DAY AND VOMITINGS SINCE 1 DAY
HE WAS APPARENTLY ASYMPTOMATIC 2 YRS AGO .THEN HE DEVELOPED PAIN ABDOMEN
FOR WHICH HE VISITED LOCAL HOSPITAL AND RECEIVEDMEDICATION ,AT THAT TIME ONLY
,HE WS TOLD TO HAVE DIABETICS AND HE IS ON REGULAR MEDICATION(MET-500) SINCE
THEN HE IS HAVING ON AND OFF SYMPTOMS EVERY 2-3 MONTHS AND RECEIVED
MEDICATION FOR 3 DAYS.ON FRIDAY(18/06/2021),HE ATTENDEDA FUNCTION WHERE HE
HAD SPICY FOOD AND ALCOHOL ,THEN DEVELOPED PAIN ABDOMEN IN THE EPIGASTRIC
REGION,WHICH IS PROGRESSIVE,ASSOCIATED WITH VOMITINGSWHICH ARE NON BILIOUS
AND NON PROJECTILE,FOR WHICH HE VISITED LOCAL HOSPITAL AND WAS TOLD TO HAVE
KETONE BODIES IN URINE AND GOT REFFERED HERE.
K/C/CO DM AND IS ON MEDICATION
HE CONSUMES ALCOHOL EVERY 2-3 DAYS ,180 ML WHISKY SINCE 10 YRS
HE SMOKES CIGARETTES DURING THE TIME OF ALCOHOL CONSUMPTIONSINCE 10 YRS
Investigation
USG:
ALTERD ECHOTEXTURE OF HEAD OF PANCREAS CORELATE WITH S.LIPASE &S.AMYLASE
MINIMAL COLLECTION NOTED IN PERISPLENIC AND RT PERI NEPHRIC SPACE
GRADE 2 FATTY LIVER
COMPLETE URINE EXAMINATION (CUE) 19-06-2021 12:16:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
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
BLOOD UREA 19-
06-2021 12:16:PM
40 mg/dl 42-12 mg/dl
SERUM
CREATININE 19-06-
2021 12:16:PM
1.3 mg/dl 1.3-0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) 19-06-2021 12:16:PM
SODIUM 126 mEq/L 145-136 mEq/L
POTASSIUM 4.1 mEq/L 5.1-3.5 mEq/L
CHLORIDE 94 mEq/L 98-107 mEq/L
ABG 19-06-2021 12:18:PM
PH 7.42
PCO2 23.8
PO2 88.7
HCO3 15.2
St.HCO3 19.2
BEB -6.5
BEecf -8.4
TCO2 27.6
O2 Sat 96.5
O2 Count 25.9
HBsAg-RAPID 19-
06-2021 01:00:PM
Negative Kit Name:
Abon
Anti HCV Antibodies
- RAPID 19-06-2021
01:00:PM
Non Reactive Kit
Name:Life Band
SERUM ELECTROLYTES (Na, K, C l) 19-06-2021 08:17:PM
SODIUM 133 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 98 mEq/L 98-107 mEq/L
ABG 19-06-2021 08:17:PM
PH 7.42
PCO2 26.6
PO2 34.9
HCO3 17.0
St.HCO3 19.6
BEB -5.2
BEecf -6.6
TCO2 32.6
O2 Sat 70.7
O2 Count 16.3
COMPLETE URINE EXAMINATION (CUE) 20-06-2021 11:15:AM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +++
SUGAR ++
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 4-5
EPITHELIAL CELLS 2-4
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
ABG 20-06-2021 05:13:PM
PH 7.45
PCO2 20.5
PO2 81.8
HCO3 14.1
St.HCO3 18.4
BEB -7.4
BEecf -9.1
TCO2 27.5
O2 Sat 93.8
O2 Count 18.8
SERUM ELECTROLYTES (Na, K, C l) 21-06-2021 08:17:AM
SODIUM 126 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 104 mEq/L 98-107 mEq/L
ABG 21-06-2021 08:17:AM
PH 7.37
PCO2 38.2
PO2 18.1
HCO3 21.9
St.HCO3 20.3
BEB -2.3
BEecf -2.4
TCO2 40.3
O2 Sat 29.2
O2 Count 9.0
SERUM ELECTROLYTES (Na, K, C l) 21-06-2021 06:05:PM
SODIUM 131 mEq/L 145-136 mEq/L
POTASSIUM 3.4 mEq/L 5.1-3.5 mEq/L
CHLORIDE 95 mEq/L 98-107 mEq/L
SERUM ELECTROLYTES (Na, K, C l) 21-06-2021 10:31:PM
SODIUM 124 mEq/L 145-136 mEq/L
POTASSIUM 3.2 mEq/L 5.1-3.5 mEq/L
CHLORIDE 92 mEq/L 98-107 mEq/L
BLOOD UREA 22-
06-2021 08:44:AM
29 mg/dl 42-12 mg/dl
SERUM
CREATININE 22-06-
2021 08:44:AM
0.7 mg/dl 1.3-0.9 mg/dl ABG 23-06-2021 04:32:PM
PH 7.52
PCO2 31.0
PO2 57.6
HCO3 25.4
St.HCO3 28.0
BEB 4.4
BEecf 2.6
TCO2 42.5
O2 Sat 91.0
O2 Count 29.1
Treatment Given(Enter only Generic Name)
ON 19/06/2021
NBM TILL FURTHER ORDERSIVF- 1 NS BOLUS 3L WITHIN 1 HR OF
ADMISSIONIVF NS @250 ML PER HOURINJ.HAI 8U IV STAT FOLLOWED BY INJ HAI 1 ML IN 39
ML NS @ 8 ML PER hr IV infusionGRBS MONITORING HOURLYSTRICT I/O MONITORING
INJ.THIAMINE 200MG IN 100 NS /IVINJ.OPTINEURON 1 AMP IN 100 ML NS /IV OVER 15 MIN
INJ.ZOFER 4MG IV/SOSNJ PAN 40 MG IV /OD
20/06/21
IVF. 1 NS ,1 RL @150 ML PER HOURNBM
TILL FURTHER ORDERSINJ HAI 1 ML IN 39 ML NS @6ML PER
HOUR/IV/INFUSIONINJ.THIAMINE 100 MG IN 100 ML NS /IV/BDINJ. OPTINEURON 1 AMP IN 100
ML NS /IV/ ODINJ.ZOFER 4MG IV/SOSNJ PAN 40 MG IV /ODINJ TRAMADOL 1 AMP IN 100 ML
NS/IV/SOSSTRICT I/O MONITORING GRBS MONITORING HOURLY
21/06/2021
(COMPLAINTS OF
ABDOMINAL TIGHTNESS ,PASSED STOOOS SEMI SOLID ABOUT 5-6 TIMES)BP: 120/90PR 96
BPMP/A SOFT Rx:IVF. 1 NS ,1 RL @150 ML PER HOURNBM TILL FURTHER ORDERSINJ HAI 1
ML IN 39 ML NS @6ML PER HOUR/IV/INFUSIONINJ.THIAMINE 100 MG IN 100 ML NS /IV/BDINJ.
OPTINEURON 1 AMP IN 100 ML NS /IV/ ODINJ.ZOFER 4MG IV/SOSNJ PAN 40 MG IV /ODINJ
TRAMADOL 1 AMP IN 100 ML NS/IV/SOSSTRICT I/O MONITORING GRBS MONITORING
HOURLYIV FLUID 5%DEXTROSE @50 ML PER HOUR
22/06/2021
No fresh complaints BP 130/80
mmHgPR 86 bpmGRBS 154 mg/dlP/A : soft, non tenderRx :Soft oral dietIVF 1 NS, 1 RL @ 100ml per
hour INJ. HAI 1ML IN 39ML NS @2ML PER HOUR IV INFUSIONIVF. 5% DEXTROSE @50ML PER
HOURINI. THIAMINE 1AMP IN 100ML ND /IV/BDINJ. OPTINEURON 1AMP IN 100ML NS/IV/ODINJ.
ZOFER 4MG /IV/SOSINJ. TRAMADOL 1AMP IN 100ML NS/IV/OVER 30MIN SOSSTRICT I/O
MONITORING STRICT GRBS CHARTING HOURLYON
23/06/2021
Soft oral dietIVF 1 NS, 1 RL @
100ml per hour INJ. HAI 1ML IN 39ML NS @2ML PER HOUR IV INFUSIONIVF. 5% DEXTROSE
@50ML PER HOURINI. THIAMINE 1AMP IN 100ML ND /IV/BDINJ. OPTINEURON 1AMP IN 100ML
NS/IV/ODINJ. ZOFER 4MG /IV/SOSINJ. TRAMADOL 1AMP IN 100ML NS/IV/OVER 30MIN
SOSSTRICT I/O MONITORING STRICT GRBS CHARTING HOURLYON
24/06/2021
Soft oral
dietIVF 1 NS, 1 RL @ 100ml per hour INJ. HAI 1ML IN 39ML NS @2ML PER HOUR IV
INFUSION IVF. @50 ML PER hour
6ML PER HOURINI. THIAMINE 1AMP IN 100ML ND /IV/BDINJ. OPTINEURON 1AMP IN 100ML
NS/IV/ODINJ. ZOFER 4MG /IV/SOSINJ. TRAMADOL 1AMP IN 100ML NS/IV/OVER 30MIN
SOSSTRICT I/O MONITORING STRICT GRBS CHARTING HOURLY
Course in the hospital :
This is
case of 29year old male with Acute on Chronic pancreatitis with Diabetic ketoacidosis with K/c/o
Diabetes mellitus since 2 years ...The patient was admitted on 19/06/21 and his urine for ketones
showed positive and ABG showed metabolic acidosis ..The patient was kept on NBM for bowel rest
and Ryles tube for decompression and to remove the aspirate from stomach. Inj IV Insulin was given
for controlling blood sugars initially in the form of bolus and later on continues infusion till the ABG
showing normal..IV fluids were given to rehydrate and 3rd space fluid loss and Nutrition.Inj Zofer was
given for vomting and Inj Tramadol for pain and Inj Pan to decrease gastric acid production and reflux
and Tab Sporolac and T.Metrogyl was given for loose stools.. Patient was started on oral feeds and
Inj NPH and Inj HAI ( Basal bolus regimen)...the patient was tolerating feeds and his sugars were
under control..So, the patient was advised discharge on 25/06/21.
Advice at Discharge
1) Inj NPH S/C 16u - x- 14u2) Inj HAI S/C 10- 10- 10.3) Tab Metrogyl 400mg TID for 3 days .4) Tab
Pan 40mg PO/OD for 15days5) Tab Benfomate plus PO/OD for 15 days .6) Strict Alcohol
abstinence7) Strict Diabetic diet.
Follow Up
AFTER 15 DAYS
When to Obtain Urgent Care
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