Occult 2

A 43-year-old man presents with severe epigastric pain, nausea, and vomiting for two hours. There is no history of fever, dyspnea, or chest pain.

He was diagnosed with type 2 diabetes mellitus four years ago, for which he is currently on insulin therapy, due to inadequate control with oral hypoglycemics. His last HbA1C was 7.2%.

He also experienced an episode of acute pancreatitis a year ago, during which an abdominal ultrasound scan revealed multiple gallstones in the common bile duct and gallbladder. He was managed conservatively and refused further endoscopic or surgical treatment.

Serial ECGs are unremarkable, with no dynamic changes. Ultrasonography of the abdomen reveals no new abnormalities.

A complete blood count is significant for a WBC of 16,000/mm3 (normal: 4,600-11,000), while his random plasma glucose is 480 mg/dL (27mmol/L).

Select Relevant Investigations
Renal and Liver profiles + Pancreatic enzymes

Performed

Na+: 135 mEq/L (135-145)
K+: 3.6 mEq/L (3.5-5.1)
Cl-: 101 mEq/L (97-105)
Blood urea: 35 mg/dL (13-50)
S. creatinine: 1.2 mg/dL (0.7-1.3)
AST: 33 U/L (8-33)
ALT: 39 U/L (10-40)
Bilirubin: 1.0 mg/dL (0.3-1.2)
Albumin: 5.3 g/L (3.5-5.5)
S. Amylase: 25 U/L (23-85)
S. Lipase: 45 U/L (0-160)
Arterial blood gases

Performed

pH: 7.18 (7.35-7.45)
pO2: 93 mmHg (83-108)
pCO2: 22 mmHg (35-45)
HCO3: 8.2 mmol/L (21-28)
Base excess: -18.3 (+/- 2)
Lactate: 3.4 mmol/L (<1.3)
Contrast CT Abdomen

Performed

No abnormalities are seen on the CT scan.
Serum ketone bodies

Performed

Serum ketone bodies: 4.2 mmol/L (normal: < 0.6)

Select Relevant Management
Insulin stat
IV fluids stat
IV Antibiotics
IV Sodium Bicarbonate