20yr Old female came to OPD with Pain Abdomen

CBBLE UDHC SIMILAR CASES.

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current based inputs.


20 year old female student by occupation came with the chief complaints of abdominal pain since yesterday morning 7:00 am.  22/3/2022.

History of 3 episodes of vomiting present( bilious in content non projectile).

Chief complaints of pain abdomen in epigastric region insidious in onset gradually progressive in nature associated with vomitings.

Patient was apparently asymtomatic 3 years back, met with an RTA and was admitted in hospital and diagnosed with Diabetes type 1 and was on Insulin mixtard subcutaneous ( 12u----x-----12u ).

Patient was alright till 8 months back then she had epigastric pain radiating to back insidious in onset and was diagnosed with acute pancreatitis and was on conservative management till then.

After 10 days, she developed hyperpigmented spots and patches on her lower back and lower limbs for which she consulted the doctor several times but they did not resolve. 

Non alcoholic , Non smoker.


GENERAL EXAMINATION

NO Pallor , Icterus , Cyanosis , Clubbing ,lymphadenopathy.

Vitals 
Temp - afebrile
BP      - 120/100 mm hg 
PR      -  120 bpm. 
RR      - 19 cpm 
spo2  100 @RA 
GRBS  - 259 mg/dl @ 3 Pm
CVS   - S1, S2 heard 
RS     : bae present 
P/A   : soft , tender , Guarding Present
CNS  : NA



** Dermatologist Referral has been taken i/v/o pigmentation over B/L legs 

O/E :- Multiple polysized, well-defined, scaly
annular plaque noted all over buttocks, groins, both legs, face.

∆ : Tinea Corporiset Cruris

Rx : Lulifin lotion all over the body / LA /BD x 2 weeks 



INVESTIGATION

On 24/03/2022
Serum Lipase      -  135
Serum Amylase   -  261


On 28/03/2022
Serum Lipase      - 36  
Serum Amylase   - 69


RBS             -  292 mg/dl

Urine Protein/Creatinine Ratio :

Spot urine protein : 45.7 mg/dl

Spot urine creatinine : 83mg/dl

Ratio : 0.55


Sickling Test on 27/03/22 - Negative

Rapid Dengue 27/02/22     - Negative


Serum Lipid Profile On 22/3/22

Total Cholesterol - 486mg/dl
TRIGLYCERIDES - 1128 mg/dl

Serum Lipid Profile on 24/03/2022

Total Cholesterol  -  261
Triglycerides         -   #932
HDL Cholesterol   -  #81
LDL Cholesterol    -  # 150


Serum Lipid Profile on 29/03/2022

Total Cholesterol   - 229
Triglycerides          - 563
HDL Cholesterol    - 60.9
LDL Cholesterol     - 137.5

HAEMOGRAM  23/03/2022
Haemoglobin  -  13 gm/dl
Total Count     -   13,200
RBC                  -  5.46
Platelet Count -  3.36 lakh

HAEMOGRAM 27/03/2022 
Haemoglobin  - 11.7 gm/dl
Total Count     - 8,300
RBC                  - 4.87
Platelet Count - 3.68 lakh

RFT
S Urea            - 29
S Creatinine  - 0.7
Uric acid       -  8.8
S Calcium     -  10.2
Na                  - 137
K                    - 4.5
Cl                   - 98

LFT
Total Bilirubin    - 1.52
Direct Bilirubin   - 0.62
Ast                      - 17
Alt                       - 9
Alk P                   - 181
Total Protein     - 6.8
Albumin             - 3.37
A/G                    - 0.98
 
CRP                   - 

HbA1c   -  6.9 %

Serology          - 


ECG


2D Echo


Chest Xray PA View

USG Abdomen


CECT ABDOMEN
https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:e1559607-8f0e-3174-8841-4d16f909684d

DIAGNOSIS 

Acute Pancreatitis with DKA with Type 1 Diabetes Mellitus ( since 3 year)


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2923793/#!po=44.6429



TREATMENT

1. Nbm till further orders.
2. IVF- NS & RL @ 150ml/hr.
3. Inj HAI ( 39ml Normal Saline + 40 IU HAI ) @ 4 ml / hr according to Algorithm
4. Inj. Pantop 40mg/IV/OD.
5. Inj. Zofer 4mg/IV/OD.
6. Inj. Tramadol 1amp in 100 ml/NS/IV/BD.
7. Inj. THIAMINE 2amp in 1 NS/IV/TID.
8. Monitor vitals.
9. Measure abdominal girth.


SOAP NOTES

ICU Day 2 Bed 4

http://medicineelogcasesturpusharathchandra.blogspot.com/2022/03/20yr-old-female-came-to-opd-with-pain.html

S : 
No Fresh Complaints 
 

O - Patient is conscious,coherent,cooperative

vitals :

Temp - afebrile
BP - 110/80 mm hg 
PR - 99 bpm. 
RR - 18 cpm 
spo2 - 100 @RA 
GRBS - 222 mg/dl @ 8 am
CVS - S1, S2 heard 
RS - bae present 
P/A - Soft , Non tender
bowel Sounds - Present
Stools - Not Passed
CNS - NAD

I/O - 2000/1800 ml



A - Acute Pancreatitis with DKA Type 1 Diabetes 

P -
NBM 
IVF- NS & RL @ 100 ml/hr.
Inj Pantop 40mg/IV/OD.
Inj. Zofer 4mg/IV/SOS.
Inj. Tramadol 1amp in 100 ml/NS/IV/ SOS
Inj. THIAMINE 2amp in 1 NS/IV/TID.
Monitor vitals.


AMC Day 3 Bed 1

http://medicineelogcasesturpusharathchandra.blogspot.com/2022/03/20yr-old-female-came-to-opd-with-pain.html

S : 
No Fresh Complaints 
 

O - Patient is conscious,coherent,cooperative

vitals :

Temp - afebrile
BP - 110/80 mm hg 
PR - 75 bpm. 
RR - 18 cpm 
spo2 - 100 @RA 
GRBS - 215 mg/dl @ 8 am
CVS - S1, S2 heard 
RS - bae present 
P/A - Soft , Non tender
bowel Sounds - Present
Stools - Not Passed
CNS - NAD

I/O - 1500/1300 ml



A - Acute Pancreatitis with DKA with Type 1 Diabetes 

P -
Oral Sips Of water Given
IVF- NS & RL @ 100 ml/hr.
Inj Pantop 40mg/IV/OD.
Inj. Zofer 4mg/IV/SOS.
Inj. Tramadol 1amp in 100 ml/NS/IV / SOS
Inj. Optineuron 1amp in 100ml NS/IV/OD
Monitor vitals.


Ward Day 4

S : 
No Fresh Complaints 
 

O -  Patient is conscious,coherent,cooperative

vitals :

Temp   -  afebrile
BP        - 110/80  mm hg 
PR       -   72 bpm. 
RR       - 18 cpm 
spo2    - 100 @RA 
GRBS   - 243  mg/dl @  7 am
CVS     - S1, S2 heard 
RS       - bae present 
P/A     -  Soft , Non tender
bowel Sounds - Present
Stools - Passed
CNS    -  NAD

I/O - 1500/1300 ml



A -  Acute Pancreatitis secondary to Hypertriglyceridemia with DKA , with type 1 DM 

P -
Oral feeds allowed
IVF- NS & RL @ 100 ml/hr.
Inj Pantop 40mg/IV/OD.
Inj. Zofer 4mg/IV/SOS.
Inj HAI acc to GRBS TID / SC
Inj. Tramadol 1amp in 100 ml/NS/IV / SOS
Inj. Optineuron 1amp in 100ml NS/IV/OD
Monitor vitals.








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