A Patient with Dysuria, Nausea and Abdominal Pain You are asked to see a 32-year-old female with Type I diabetes who presents to the Emergency Department complaining of abdominal pain and dysuria. The patient had been feeling well until two days prior to admission when she began to notice dysuria and urinary frequency. On the morning of admission she began to have nausea and abdominal pain, and because she was unable to eat she stopped taking her insulin. The abdominal pain became worse so she came to the hospital. The pain is in the epigastric region without radiation. She denies bloody diarrhea, fever, chills, sweats. She had not vomited yet but felt severe nausea. She states that she was too busy to check her finger sticks but that she had been strict with her diet. She is married, has one child; denies alcohol or tobacco use. She has no allergies. Meds: Glargine 28 u qhs, Aspart 4-10u TID AC. Physical exam - uncomfortable but in NAD. RR 26 labored. Supine: BP = 108/62, HR 116; upright BP 86/50, HR 138; Temp 99.8. SKIN: normal. HEENT - conjunctivae pink, anicteric, oropharynx/sinuses/TMs are clear; fundi benign. HEART - regular rhythm without murmurs or rub CHEST - clear Bs, (-) rales ABD - normoactive bowel sounds, mild midepigastric tenderness and flank tenderness, no organomegaly or masses. Rectal - no masses, nontender, hemoccult negative. Extremities: no edema. LABS Na 136, K 5.4, Cl 111, HCO3 8, glu 640, Cr 1.3 Hb 14.0, Hct 42.1, WBC 12.1, plts 420 K LFTs = wnl, Phosphate = 6.0, Ca++ = 8.9, Amylase = 300, Alb = 3.9 UA - specific gravity 1.022/+ ketones/ 20 WBC/2 RBC per HPF CXR - clear lung fields EKG - NSR; normal intervals, negative ST/T wave changes ABG (room air): 7.08/pCO2 20/pO2 107 Questions 1. What is most likely diagnosis? What urgent treatment is required?

Question 1

The most likely diagnosis is acute pancreatitis.

Question 2

The patient requires urgent treatment for diabetic ketoacidosis. This includes insulin, fluids, and electrolytes.

Step-by-step explanation

Question 1

• Acute pancreatitis is a relatively common disease that can occur in patients with and without diabetes. Patients with diabetes are at an increased risk for developing acute pancreatitis due to the presence of chronic pancreatitis and the potential for decreased pancreatic function. Patients with acute pancreatitis typically present with abdominal pain, nausea, vomiting, and dysuria. 
•  The most common laboratory abnormalities observed in patients with acute pancreatitis include elevated levels of serum amylase and lipase. The patient in this case has several of the classic symptoms and signs of acute pancreatitis, including abdominal pain,   vomiting, dysuria and  nausea. 
• Additionally, the patient's laboratory values are consistent with acute pancreatitis. The patient's increased blood sugar and ketones are likely due to the fact that she has stopped taking her insulin. The patient's high white blood cell count may be due to pancreatic inflammation.
•  The patient's elevated calcium level may be due to the fact that she is not taking her insulin, which can lead to a decrease in serum calcium levels. The patient's elevated phosphate level may be due to the fact that she is not taking her insulin, which can lead to a decrease in serum phosphate levels. 
• The patient's normal liver function tests and negative rectal exam are also consistent with acute pancreatitis. Overall, the patient's clinical presentation and laboratory values are highly suggestive of acute pancreatitis.

Question 2

• The patient requires urgent treatment for pancreatitis, which may include aggressive hydration, antibiotics, and pain control.
• Treatment for pancreatitis depends on the cause and the severity of the illness. In most cases, the patient will require aggressive hydration and pain control. antibiotics may also be necessary.
• Aggressive hydration (with crystalloid fluids, sometimes with colloids) should be started early in the course of pancreatitis. The ability to tolerate oral fluid intake is often a good sign that aggressive fluid replacement is not needed; however, close monitoring and frequent reassessment are essential to the prevention of complications related to acute pancreatitis.
• Broad-spectrum antibiotics are also indicated until blood cultures and surgical infection guidelines results return to rule out infection.
•  Pain control begins with narcotics administration in the form of fentanyl, oxycontin, or morphine under the direction of a physician. Patients with chronic pancreatitis are at increased risk of recurrence and should be educated on smoking cessation to decrease the chance of repeated attacks.