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Patient Details

Refined clerking (152 days ago 18:47)

Refined clerking Wed 05 November 2025 18:47

Last Modified: 152 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
DKA

History of Presenting Complaint:
Ran out of long-acting insulin (Tresiba) on Saturday.

He attempted to manage with short-acting insulin only but felt increasingly unwell today, prompting hospital attendance.

No symptoms of intercurrent infection

Past Medical History:
• Type 1 diabetes diagnosed 2013 (likely Type 3c secondary to chronic pancreatitis)
• Chronic pancreatitis with pancreatic enzyme replacement therapy
• Non-alcoholic steatohepatitis (2018)
• Bronchiectasis (2021)
• Diabetic neuropathy and nephropathy with microalbuminuria
• Knee osteoarthritis
• Osteopaenia
• Migraine
• Hiatus hernia
• Previous cholecystectomy (laparoscopic)

Drug History:
• Lanzoprazole 30mg PO ON
• Pregabalin 50mg PO mane, 75mg PO nocte
• Pancrex V oral powder 0.5-2.5ml with each main meal
• Tresiba long-acting insulin 60 units at night
• Fiasp short-acting insulin 13 units TDS
• Accrete D3 BD
• Promazine 25mg PO ON
• Lisinopril 2.5mg PO OD (suspended due to AKI)
• Clopidogrel 75mg PO OD
• Atorvastatin 40mg PO ON
• Fostair 100/6 microgram inhaler 2 puffs BD
• Salbutamol inhaler PRN
• Nortriptyline 10mg 2 tablets ON
• Venlafaxine 225mg MR OD
• Carbocisteine 375mg TDS
• Mirtazapine 15mg ON
• Gaviscon PRN

Allergy History:
• Penicillin

Social History:
Lives with wife and daughter
Non-smoker, teetotal (stopped drinking due to pancreatitis)

On Examination:
Alert, clinically dehydrated with dry tongue
Observations: HR 103, BP 166/105, Temp 36.5°C, RR 17, O2 sats 99%
• Cardiovascular: Normal heart sounds
• Respiratory: Chest clear anteriorly
• Abdomen: Soft, non-tender
• Feet: Diabetic neuropathy with reduced sensation. Right great toe inflamed with skin breakdown on medial aspect and area of ulceration. Patient has had dressing in situ for 13 days
• Has Libre glucose sensor in situ

Investigations:
• Initial VBG: pH 7.13, improving to pH 7.33 with treatment
• Corrected calcium: 2.81
• ALP: 134
• Sodium: 131 (previously 142)
• Creatinine: 121 (baseline 85) - AKI stage 1
• CRP: 22 (chronically raised through September and August)
• Urea: 17.1
• FBC: Normal except platelets 675, neutrophils 13.04
• Magnesium: Normal
• CXR: Bilateral consolidation L>R

Impression:
DKA secondary to missed long-acting insulin
AKI with clinical dehydration
Likely left CAP
Diabetic foot ulcer

Management Plan:
1. Continue DKA protocol until next meal, then may discontinue IV insulin if acidosis resolved
2. IV fluids
3. Treat CAP with Abx
4. Restart long-acting insulin
5. Suspend lisinopril during AKI
6. Daily U&Es while in AKI with input/output monitoring
7. Diabetic foot team review of right great toe ulcer
8. Blood cultures, MSU
9. Endocrinology review
10. Endocrinology ward 
11. Full escalation plan discussed

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Refined clerking Wed 05 November 2025 18:47

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