[CASE BASED OSCE] 20 y/o girl with pain abdomen since 1 day

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment. 

DOA -  20/11/23 

Case - 

A 20 yr old girl came to the GM OPD with complaints of •pain abdomen since 1 day

•vomitings about 8-10 episodes since yesterday night 

History of presenting illness - 

Patient was apparently alright 4 yrs back then she sustained some injury on her left leg for which she was operated and a rod was inserted. During this time it was discovered that she suffers from high blood sugar levels and was started on insulin since then. 

About 1 yr back she visited our hospital with similar complaints of pain abdomen which is increased in intensity on lying down and changing her position. She was then diagnosed to have acute pancreatitis by running some investigations and scanning and was adviced treatment accordingly. 

Since 1 yr she is on some anti-diabetic medication as prescribed in Miryalaguda. (Unknown as the patient didn’t bring it along) 

Yesterday night she complained of pain in the abdomen in epigastric region which is continuous, more on lying straight and decreased in assuming lateral position. It is non-radiating and dull aching type. The pain is associated with 8-10 episodes of continuous vomitings which is projectile in nature, watery in consistency and non-bilious with no food particles as she did not feel like eating anything that night. She also didn’t take her night dose of medication as she skipped food.She was taken to local RMP and treatment was given after which vomitings subsided. 

No h/o loose stools, fever, cough, cold, breathlessness, burning micturition 

No h/o chest pain, palpitations, paroxysmal nocturnal dyspnea , pedal edema 

No h/o any bleeding manifestations 

Past history - 

K/c/o DM since 4 yrs took insulin, now on unknown medication since 1 yr 

K/c/o pancreatitis since 1 yr 

N/k/c/o HTN, TB, asthma, epilepsy, CVA, CAD, thyroid disorders 

Personal history - 

She is an undergraduate student in some health facility in Miryalaguda. 

Wakes up, has breakfast - idly , goes to college.

Has lunch - poori / rice 

Comes back at evening and relaxes/ studies. 

Has dinner - jonna roti 

And goes back to sleep. 

Appetite - decreased 

Diet - mixed 

Bowel - regular 

Micturition - normal 

Sleep - adequate 

No known allergies 

No addictions 

Family history - 

No significant family history 

Her grandmother has diabetes 

Menstrual history - 

Age of menarche - 12 yrs 

LMP - 20/11/23 

Cycles are regular 28/5 , no pain & no clots 

General physical examination - 

Pt is conscious, coherent and cooperative and well oriented to time, place and person. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema 

Vitals on admission - 

Temp - 98F 

BP - 100/70 mm hg 

PR - 84bpm 

RR-  20cpm 

Grbs - 377mg/dl 

SpO2 - 96% @ RA 

Systemic examination - 

CVS -  S1, S2 heard, no murmurs 

RESP SYS - trachea - central , bilateral air entry +, NVBS heard, no added sounds 

PER ABDOMEN - soft, tenderness present in the epigastric region, no organomegaly, bowel sounds heard 

CNS - NFND 

GRBS trends  and units of insulin administered- 

Latest - 23/11/23 

Pre dinner grbs - 188mg/dl —-> 10 HAI ,  8 NPH 

2hrs post dinner - 255mg/dl 

12am - 175mg/dl 

2am - 197mg/dl 

4am - 208

6am - 227 

Provisional diagnosis- 

Diabetic ketosis secondary to non-compliance to medication 

K/c/o TYPE 1 DM since 4 yrs 

K/c/o pancreatitis since 1.5 yrs secondary to hypertriglyceridemia 

Investigations - 

ECG 

Usg abdomen and pelvis 

2d echo 

Chest X ray PA view 

Final diagnosis - 

Diabetic ketosis secondary to non-compliance to medication 

K/c/o TYPE 1 DM since 4 yrs 

K/c/o pancreatitis since 1.5 yrs secondary to hypertriglyceridemia 

Plan of treatment - 

Diabetic diet 

IV fluids NS and RL @100ml/hr 

INJ TRAMADOL 1 amp in 100ml NS IV SOS 

INJ PAN 40 mg IV OD 

INJ HAI IV INFUSION 40U+39ml NS @ 5 units/hr - increased or decreased according to grbs 

Changed to ———-> 

INJ HAI s/c TID pre-meals (14units-14units-10units) 

INJ NPH s/c BD (8units - x - 8 units) 

Changed to ————> 

INJ HAI s/c BD (15units - x - 10units) 

INJ NPH s/c BD (10units - x - 12units) 

Tab FENOFIBRATE 160 mg PO OD  

Monitor GRBS 7 point profile 

Strict I/o charting 

OSCE 

How is a case of acute pancreatitis diagnosed? 

Increased levels of serum amylase and lipase about three times the upper limit of normal value. 

Normal S.amylase - 23-85 U/L 

             S. lipase - 0-160 U/L 

Ultrasound or CT evidence of pancreatic swelling 

Which is more specific serum amylase or lipase? 

Serum lipase has greater diagnostic accuracy as it remains elevated for a longer period of time i.e about 8 to 14 days. 

What is the cause of pancreatitis in this case? 

The most probable cause of pancreatitis in this case is hypertriglyceridemia. 

How does hypertriglyceridemia cause pancreatitis? 

The mechanism by which elevated triglyceride levels lead to pancreatitis is not fully understood. A leading hypothesis is that the interaction of high levels of triglyceride rich lipoproteins with pancreatic lipase in the pancreatic capillaries leads to the breakdown of triglycerides to free fatty acids and phospholipids to lysophosphatidylcholine. Both free fatty acids and lysophosphatidylcholine could induce pancreatic damage resulting in pancreatitis. Additionally, the elevated chylomicron levels increase plasma viscosity in the pancreatic capillaries resulting in stasis and hypoxia that can injure the pancreas.

Chylomicronemia may be due to a monogenic disorder (familial chylomicronemia syndrome; FCS) or due to multiple genes (polygenic) in association with other factors (multifactorial chylomicronemia syndrome; MFCS). Greater than 95% of patients with chylomicronemia have MFCS rather than FCS.

https://www.ncbi.nlm.nih.gov/books/NBK279082/

What is the cause of diabetic ketosis in this case? 

Non-compliance to anti-diabetic medication 

Types of diabetes mellitus. 

Type 1 DM - juvenile onset - absolute deficiency of insulin due to beta cell destruction 

Type 2 DM - adult onset - relative insulin deficiency or insulin resistance - genetic and environmental factors are responsible 

Type 3 DM - 

A) Genetic defects of beta cell function (MODY) 

B) Genetic defects in insulin action 

C) Disease of exocrine pancreas 

D) Endocrinopathies (acromegaly, Cushing syndrome) 

E)Drugs or chemical induced ( eg - nicotinic acid, thiazides) 

F) Infections (congenital rubella , cytomegalovirus infection) 

G)Uncommon forms of immune mediated diabetes 

H) Other genetic syndromes (Down’s syndrome, Klinefelter’s syndrome) 

What are the types of insulin? 

What diet would you suggest for a diabetes patient? 

Diabetic diet - 

According to the American Diabetes Association (ADA), a beneficial diet for people with diabetes includes the following:

• fruits and vegetables
• lean protein
• foods with less added sugar
• fewer processed foods

Consumption of whole grains rich in fibres such as brown rice, whole grain bread rather than refined white grains as they have low Glycemic index. 

Eat small meals at frequent intervals rather than heavy meals at longer intervals of time.