Amitesh 148

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.