Physician's Assistant

Patient Details

Refined clerking (89 days ago 21:50)

Refined clerking Wed 07 January 2026 21:50

Last Modified: 89 days ago

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Medical ST5 Miller Clerking
07/01/2026 23:20

Presenting Complaint:
SOB, lethargy

History of Presenting Complaint:
This 54-year-old gentleman presented with a 2-day history of nausea, shortness of breath, lethargy, and unsteadiness on his feet. He had been feeling feverish and noted frothy urine. Recent conjunctivitis with chloramphenicol eyedrops prescribed by his GP. Urine dipstick showed ketones and blood glucose was unreadable on finger-prick testing with GP.

The patient recently commenced a ketogenic diet on 1st January following an ADHD diagnosis in November 2025, which helped him understand his relationship with food and poor diabetic control. He had dramatically changed his eating habits, consuming virtually no carbohydrates. He reported previous episodes of excellent diabetic control requiring him to carry dextrose due to hypoglycaemic episodes, particularly when on metformin and gliclazide.

He has ongoing issues with recurrent thrush and balanitis since starting dapagliflozin.

Previous weight: 25 stone, current weight: 17.5 stone - no recent unintentional weight loss

Past Medical History:
• Type 2 diabetes mellitus (diagnosed 2013) - HbA1c 131 March 24
• Diverticulosis
• Diabetic retinopathy
• ADHD (diagnosed November 2025)

Drug History:
• Escitalopram 10mg PO OD
• Atorvastatin 40mg PO OD
• Dapagliflozin 10mg PO OD (on acutes)
• Metformin 1g PO BD (removed from repeat prescription due to pending diabetic annual review)

Previous Medications:
• Gliclazide - stopped due to hypoglycaemic episodes
• Tirzepatide - previously discontinued
• Semaglutide - previously discontinued due to side effects

Allergy History:
NKDA

Social History:
Social worker by profession, previously worked as van driver but not professionally driving now
No smoking or excessive alcohol
Independent with wife.

On Examination:
Kussmal breathing, SOB, ketotic smell
• Cardiovascular: Tachycardic heart sounds, no murmurs
• Respiratory: Tachypnoeic but clear chest
• Other: Conjunctivitis present, no rashes on head or back
• Dry MMs
• No oedema

Investigations:
• Troponin T: 18
• U&E: Creatinine 92, Sodium 135, Potassium 4.2, Urea 7.7
• LFTs: Normal, AST 17
• Glucose: 16.4
• CRP: 3
• FBC: Hb 144, WCC 12.8, Platelets 9.7
• VBG: pH 7.02, Sodium 131, Base excess -23.7, Glucose 17.7

Impression:
Multifactorial euglycaemic diabetic ketoacidosis secondary to 
- dapagliflozin
- conjunctivitis
- Ketogenic diet
- +/- possibility of type 1 diabetes given poor control on metformin and dapagliflozin
Conjunctivitis on treatment

Management Plan:
1. Transfer to resuscitation area from fit to sit
2. Fixed rate insulin infusion protocol for DKA management
3. IV fluid resuscitation
4. Discontinue dapagliflozin given DKA, balanitis
5. Send urine for microscopy, culture and PCR
6. Chest X-ray 
7. Continue chloramphenicol eyedrops for conjunctivitis
8. Endocrinology referral for diabetes type clarification and optimal management
9. T1DM diagnosis bloods including diabetes autoantibodies
10. TEP: Full escalation
11. ITU review if not improving despite FRII

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Refined clerking Wed 07 January 2026 21:50

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