DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Diabetic ketoacidosis.
2. Acute pancreatitis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with a past medical history significant for diabetes mellitus for 20 years, who came to the ER with vomiting and diarrhea as well as weakness for one day. The patient denied fevers or chills, headache, chest pain, shortness of breath or abdominal pain.
PAST MEDICAL HISTORY: Significant for diabetes mellitus. The patient took oral medications for the first 10 years and has been on insulin as well as pills for the last 10 years.
PAST SURGICAL HISTORY: Significant for hernia repair.
MEDICATIONS: The patient was on regular insulin, Glucophage, as well as Lipitor 10 mg daily and Prinivil 10 mg daily.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient smokes two times daily. The patient also admits to drinking hard liquor, up to two glasses per day.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient was afebrile. Pulse was 98, respiratory rate was 26, and blood pressure was 118/56. O2 saturation was 97%. GENERAL: The patient was awake and appeared to be in moderate distress and appeared lethargic. HEENT: The tongue was parched, and the mucous membranes were dry. HEART: Examination showed a regular rate and rhythm. S1 and S2 present. There were no murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, and nondistended. EXTREMITIES: Revealed no clubbing, cyanosis or edema.
LABORATORY DATA: White blood cells were 25,600, hematocrit 47.4, hemoglobin 15.8, and platelets 288,000. Sodium 125, potassium 6.8, chloride 100, BUN 54 with a blood sugar greater than 700. ABG revealed a pH of 6.98, bicarbonate was 14.3, and pO2 was 142. Lipase was 1604 and amylase 534. Anion gap was measured to be 23. The lactate level was 2.5.
IMPRESSION:
1. Diabetic ketoacidosis.
2. Pancreatitis.
PLAN: The patient was admitted to the ICU and treated aggressively with IV fluids of D5W with four amps of bicarbonate at 250 mL per hour. He was also placed on an insulin drip with Accu-Chek every hour and BMPs every four hours. He was also given IV Unasyn.
HOSPITAL COURSE: The patient was seen by Dr. John Doe from Endocrinology and Dr. Jane Doe from Gastroenterology. An ultrasound of the abdomen was performed, which revealed no gallstones. His electrolyte imbalances were corrected during the admission. Infectious etiologies were entertained; however, pancultures were negative. His amylase and lipase slowly improved, and the pancreatitis was thought to be biochemical in nature in the setting of diabetic ketoacidosis and alcohol abuse. His diet was advanced. At discharge, the patient felt well, and his blood sugars were running in the range of 150 to the low 200s. He will follow up with Dr. John Doe for further control of his diabetes mellitus. The patient is also planning to seek outpatient treatment for his alcohol abuse.
