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Pancreatic adenocarcinoma presenting as first-onset diabetic ketoacidosis

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Clinical record

A 47-year-old African American man was brought by his partner to the emergency department of a peripheral hospital with increasing confusion and a 1-week history of asthenia, anorexia and significant weight loss. Significant thirst, polyuria and nausea were not indicated by the corroborative history. He had no previous medical history and did not regularly take any medications. He had never smoked and his alcohol consumption was moderate. He had not travelled overseas recently. The patient’s mother and maternal grandfather had both died of pancreatic cancer while still young, but this was not known at the time of his initial presentation.

The patient weighed 89 kg, with a body mass index of 26.0 kg/m2. His vital statistics were: heart rate, 130 beats/min; blood pressure, 99/60 mmHg; respiratory rate, 20 breaths/min; pulse oximetry, 98% on room air; and tympanic temperature, 36.7ºC. He had ketotic breath and signs of severe hypovolaemia. Incoherent responses and disorientation with respect to both time and place were exhibited during neurological examination, but no focal neurological deficits. Cardiovascular, respiratory and abdominal examinations showed nothing unusual.

The results of his initial laboratory tests are listed in the Box. They were consistent with the diagnosis of first-onset diabetic ketoacidosis…