Physician's Assistant

Refined clerking Fri 27 March 2026 18:43

Last Modified: 10 days ago

MRN:

Content:

Presenting Complaint:
Diabetic ketoacidosis

History of Presenting Complaint:
20-year-old lady with type 1 diabetes mellitus, diagnosed in 2018, admitted with diabetic ketoacidosis in the context of non-use of her insulin pump and running out of sensors after recent birth and difficulty managing a newborn.

She had a pump site infection in the left arm, which has now drained and is improving. She reported reduced oral intake since delivery, with early satiety and nausea after only a few bites of food. She also vomited on the way to hospital. There were no urinary or respiratory symptoms, and no symptoms of infection elsewhere. Her ketones and pH have been improving on the DKA protocol.

Past Medical History:
• Type 1 diabetes mellitus, diagnosed 2018
• Urinary tract infection, coded 2024
• Pregnancy, delivered by emergency caesarean section in February 2026
• Latest HbA1c: 47 mmol/mol (16/12/2025)
• Previous HbA1c: 59 mmol/mol (09/04/2025)

Drug History:
• Insulin pump
• Tresiba 30 units SC OD previously
• NovoRapid 4 to 5 units with meals previously

Allergy History:
NKDA

Social History:
Lives with newborn baby son, Leo.
Not breastfeeding.

On Examination:
Alert and well appearing.
Observations: Not recorded in the dictation.
 Cardiovascular: Normal
 Respiratory: Chest clear
 Abdomen: Normal
 Other: Left arm pump site infection, now drained and settling. No leg swelling or cellulitis.

Investigations:
 Renal function: Normal
 Urea: Normal
 AST: Normal
 ALT: 37
 CRP: 10
 Platelets: 444
 White cell count: Normal
 Coliform on low vaginal swab (02/07/2026): Heavy growth
 Urine MC&S (01/2026): Negative
 Urine MC&S (08/2025): Negative
 Antenatal serology for viral hepatitis and HIV (08/2025): Negative

Impression:
Diabetic ketoacidosis secondary to non-use of insulin pump, likely contributed to by recent pump site infection.
Possible underlying gastroparesis

Management Plan:
1. Continue DKA protocol until resolved.
2. Treat pump site infection with oral flucloxacillin.
3. Use long-acting or intermediate-acting insulin as per the diabetic team while off the pump.
4. Once DKA has resolved, restart insulin pump and aim for discharge home.
5. Consider gastroparesis if ongoing poor oral intake after metabolic stabilisation.

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Refined clerking Fri 27 March 2026 18:43

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