Physician's Assistant

Refined clerking Tue 10 February 2026 11:29

Last Modified: 55 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Shortness of breath and hyperglycaemia

History of Presenting Complaint:
Patient presented to ED with acute shortness of breath and feeling dizzy. Describes being unable to breathe, coughing up blood, and having to breathe through both mouth and nose. Symptoms started earlier today but similar episode occurred 5 days ago. Blood glucose levels have been persistently elevated for 4 days, checking 4-5 times daily with consistently high readings.

Patient has intentionally stopped taking Tresiba insulin. When questioned, admits this was deliberate and related to low mood and suicidal ideation. Has history of stockpiling insulin with intention to overdose. Previously asked diabetic nurse what would happen if he injected all 3 insulin pens, receiving response that it "would be the end". Subsequently attempted overdoses with 10 units, then 30 units.

Background of recurrent hospital admissions to Forest Ward, mostly under endocrinology team. Multiple previous suicide attempts including overdoses of fluoxetine, pregabalin, diazepam, paracetamol, and zopiclone. Most recent overdose August 2025 during mental health crisis.

Mental health history includes paranoid schizophrenia diagnosed 2018, multiple personality disorders, and history of violence. Detained under Section 136 Mental Health Act July 2023. Recently changed from fluoxetine (38 years duration) to mirtazapine 15mg with plan to increase to 30mg next week then 45mg. Patient expresses feeling unable to cope with life pressures and describes pervasive feelings of being taken advantage of by others.

Significant social stressors include relationship with boyfriend of 5 years who has agoraphobia, received 2-year suspended sentence for domestic violence, and requires significant support. Boyfriend has support worker called Tally but patient describes feeling overwhelmed by caring responsibilities.

Recent substance misuse includes crack cocaine (stopped 2 weeks ago) and ongoing cocaine use. Long-term cannabis abuse. Current smoker 40-60 cigarettes daily.

Clinically appears dehydrated. No chest pain. No urinary symptoms. No abdominal pain. Cough productive of blood.

Past Medical History:
• Paranoid schizophrenia (2018)
• Type 2 diabetes mellitus
• Metabolic-associated fatty liver disease
• COPD
• Hypertension
• Paranoid psychosis (2017)
• Cannabis abuse (October 2024)
• Cocaine abuse (October 2024)
• Previous hyponatraemia - lowest 124 mmol/L (August 2024)
• Detained under Section 136 Mental Health Act (July 2023)
• Multiple previous overdoses (2025, 2020) including intentional self-harm, diazepam, zopiclone, paracetamol

Drug History:
• Amisulpride 500mg PO BD
• Tresiba insulin according to requirements (not currently taking)
• Pregabalin 200mg PO mane and 175mg PO nocte
• Diazepam 3mg PO mane, 3mg lunchtime, 2mg evening, 2mg nocte (total 10mg daily)
• Clopidogrel 75mg PO OD
• Canagliflozin 100mg PO OD
• Metformin 1g PO BD
• Lisinopril 5mg PO OD
• Lansoprazole 30mg PO BD
• Fluoxetine 60mg PO mane
• Mirtazapine 15mg (recently commenced, plan to increase to 30mg)

Recently Stopped Medications:
• Fluoxetine - changed to mirtazapine approximately 1 month ago

Allergy History:
Not documented

Social History:
Lives with girlfriend of 5 years and 2 dogs. Also has 2 cats, 4 scorpions, and 2 grandchildren. Boyfriend has significant mental health issues including agoraphobia and is supported by mental health worker. Patient provides substantial care and support. Current smoker 40-60 cigarettes daily. Recent crack cocaine use (stopped 2 weeks ago). Ongoing cocaine use. History of cannabis abuse. Not currently working.

On Examination:
General Appearance: Alert, appears unwell and dehydrated
Observations: Not documented
• Respiratory: Clinical signs consistent with left basal pneumonia
• Other systems: Not documented in detail

Investigations:
• Serum glucose: 41.2 mmol/L
• White cell count: 10.8 (neutrophils 7.15)
• INR: 0.9
• Sodium: 129 (previous hyponatraemia 124 in August 2024)
• Creatinine: 56 (patient's baseline)
• Potassium: 4
• ALP: 132
• CRP: 39 (previously 15)
• Urea: 5
• AST: Normal
• Venous blood gas: pH 7.36, ionized calcium normal, lactate 2.9, base excess 1.7
• Chest X-ray: Pending

Impression:
Left basal pneumonia leading to infective exacerbation of COPD leading to decompensation and severe hyperglycaemia with hyperosmolar state (not meeting full criteria for HHS)

Secondary issues: Chronic non-compliance with insulin due to severe mental health issues and suicidal ideation. Acute on chronic dehydration. Active substance misuse.

Management Plan:
1. Manage as HHS with HHS protocol - aggressive IV fluid resuscitation and insulin sliding scale
2. Stop canagliflozin and metformin during admission
3. Antibiotics and steroids for infective exacerbation of COPD and pneumonia
4. Await chest X-ray to confirm pneumonia
5. Obtain urine sample to exclude urinary tract infection
6. Urgent mental health team review given ongoing suicidal ideation and non-compliance with life-saving medication
7. Respiratory bed
8. Resuscitation status discussed - patient initially reluctant but agreed to full resuscitation following discussion. For CPR and escalation to ITU if required.

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Summary:

Investigations:

Tasks

Feedback

• Resuscitation status discussion was appropriate but occurred relatively late in consultation - this should be addressed earlier when significant acute illness identified, particularly given patient's active suicidal ideation
• Mental capacity assessment not explicitly documented despite clear concerns about patient's ability to make decisions about life-saving treatment - formal capacity assessment should be clearly documented when patient refusing/non-compliant with essential medication
• Limited exploration of protective factors or reasons for living despite extensive discussion of suicidal ideation - important to identify and strengthen any positive factors
• Safety plan for discharge not discussed - patient needs clear crisis plan and follow-up arrangements before leaving hospital, particularly given ongoing substance misuse and relationship stressors
• Collateral history from girlfriend present but not fully utilized - could have obtained more detail about recent deterioration, medication compliance patterns, and home support available
• No discussion of smoking cessation despite acute respiratory illness and 40-60 cigarettes daily - missed opportunity for health promotion during admission
• Examination findings not fully documented (no vital signs recorded) - essential to document full set of observations and systematic examination findings for acutely unwell patient
• No documentation of whether patient has capacity to refuse treatment if becomes more unwell despite resuscitation discussion - important given mental health background
• Could have explored substance misuse in more detail - timeline of crack cocaine use, triggers for recent relapse, interest in substance misuse services