Presentation
A 52-year-old woman presented to the emergency department with altered mental status and abdominal pain. She had a medical history of controlled hypertension, ischemic heart disease, hyperlipidemia, asthma, and newly diagnosed type 2 diabetes mellitus. She described the pain as periumbilical, radiating to the flanks, worsening after meals and during sleep. Her symptoms had been progressing over the previous two months and included unintentional weight loss of 23 kg, polyuria, polydipsia, malaise, anorexia, and recent onset of fever and chills .Flank and abdominal pain were temporarily relieved by NSAIDs, specifically diclofenac sodium. She denied any history of jaundice. The patient also reported a recent hospitalization one month prior for angina and abdominal discomfort, but was discharged with treatment for presumed asthma, which proved ineffective. Her family history included hypertension in her mother and sister, gastric cancer in an uncle, and thyroid disease in her mother.

Examination
On arrival, she was in a state of reduced consciousness with signs of metabolic decompensation. Physical examination was notable for periumbilical tenderness radiating to the flanks. There was no evidence of jaundice, scleral icterus, or peripheral edema. Her vital signs and systemic examinations were otherwise unremarkable.

Diagnosis
Laboratory tests showed a fasting plasma glucose of 439 mg/dL and an HbA1c of 12.3%.Urinalysis showed 3+ glucose and 3+ ketones, and venous blood gas analysis confirmed metabolic acidosis. These were consistent with diabetic ketoacidosis (DKA).Inflammatory markers were elevated. Vitamin D deficiency was severe. Liver function tests and complete blood count profile were within normal limits, aside from mild leukopenia. Pancreatic enzyme levels were low, and tumor markers were markedly elevated, suspecting for an underlying malignancy. Abdominopelvic sonography revealed hypoechoic liver lesions. An infection workup, including urine culture and Wright agglutination test, returned negative. These findings prompted advanced imaging. Abdominal CT scan of the abdomen revealed a 45 × 40 mm mass in the body of the pancreas with occlusion of the splenic vein and encasement of the splenic artery. Multiple liver metastases were also identified, confirming the likely diagnosis of pancreatic malignancy.

Management
Initial management focused on stabilization of DKA through intravenous fluids, insulin infusion, and correction of electrolyte imbalances. Once stabilized, the patient was transitioned to subcutaneous insulin therapy, including 22 units of glargine at night and pre-meal doses of Aspart (7 units before breakfast, 11 before lunch, and 6 before dinner).She was subsequently transferred to the endocrinology unit for further evaluation and then referred to gastroenterology for malignancy workup. A fine-needle aspiration biopsy under endoscopic ultrasound guidance confirmed the diagnosis of moderately differentiated pancreatic adenocarcinoma with hepatic metastases.

Follow-Up
The patient remained hospitalized for nine days, after which she was referred for oncological care. Discussions regarding treatment options, prognosis, and palliative care were initiated. She continued to be followed by endocrinology and gastroenterology for coordination of diabetes management and cancer care.