Physician's Assistant

Patient Details

Refined clerking (298 days ago 14:25)

Refined clerking Thu 12 June 2025 14:25

Last Modified: 298 days ago

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Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Hypoglycaemia

History of Presenting Complaint:
Sudden onset of epigastric pain with nausea yesterday evening. Patient checked capillary blood glucose which was 2.3mmol/L and administered hypo treatment but was unable to raise levels. Became drowsy and ambulance crew administered 10% glucose 100ml IV, raising capillary glucose to 7mmol/L. Symptoms resolved by arrival at emergency department.

Patient reports vomiting episode one week prior with associated mild hypoglycaemia, treated with NovoRapid insulin for subsequent hyperglycaemia. Yesterday's episode differed as blood sugars were low before vomiting occurred. Patient omitted long-acting insulin dose yesterday due to hypoglycaemia concerns.

No recent fevers, rigors or infective symptoms reported.

Past Medical History:
• Type 1 diabetes mellitus since 1986 with diabetic nephropathy (CKD stage 4)
• High risk diabetic feet bilaterally
• Background diabetic retinopathy
• Chronic venous insufficiency
• Diabetic neuropathy
• COPD (diagnosed February 2007)
• Hypertension
• Diabetic ketoacidosis (2017)
• Cystectomy and formation of ileal conduit (2009) for neuropathic bladder secondary to diabetes
• Osteoarthritis (February 2002)

Drug History:
• Lansoprazole 30mg PO OM
• Hydroxocobalamin 1mg IM (frequency not specified)
• Salmeterol 25mcg 2 puffs BD
• Loperamide 2mg PO TDS PRN for diarrhoea
• Colecalciferol 1000 units PO OD
• Furosemide 20-40mg PO OD (suspended)
• Lantus insulin 15 units SC nocte
• NovoRapid insulin 8-10 units SC TDS with meals
• Salbutamol 100mcg 2 puffs QDS PRN

Allergy History:
Penicillin

Social History:
Lives alone with pet cat. Independent with activities of daily living.
Smoking: Current smoker, 2 cigarettes per day currently. 10 per day for approximately 50 years prior.
Alcohol: Denies alcohol consumption

On Examination:
General Appearance: Alert, cooperative, appeared well
Observations: HR 81, BP 133/46, Temp 36.5°C (afebrile since presentation), RR 18, O2 sats 96% on air
• Cardiovascular: Regular rhythm, rate 86bpm on monitor
• Respiratory: Clear
• Abdomen: Soft, non-tender on palpation
• Other: Bilateral lower limb oedema noted, tongue appears dry, JVP not elevated

Investigations:
• CRP: 12
• WCC: 13.3 with neutrophils 12.4
• Potassium: 5.5, repeat 5.2
• Creatinine: 202, previous May 2025: 215, January 2025: 148
• Urea: 28.5
• ALP: 280
• Ferritin (May 2025): Low with associated anaemia
• Initial ABG: pH 7.15, glucose 5.4, low CO2 (metabolic acidosis with respiratory compensation)
• Subsequent ABG: pH 7.19, glucose 14.8
• Previous ABG: pH 7.17, glucose 26
• Current ABG: pH 7.3, CO2 3.16, glucose improving, ketones 2.6
• Chest X-ray: Clear lung fields

Impression:
Euglycaemic diabetic ketoacidosis secondary to insulin omission on presentation to ED
Now hyperglycaemic DKA
+/- Diabetic gastroparesis contributing to vomiting episodes
Neutrophilia more likely to be secondary to vomiting than infection
Iron deficiency anaemia

Management Plan:
1. Continue IV fluid resuscitation and insulin infusion for DKA treatment as per protocol
2. Monitor serial ABGs and glucose levels as per protocol
3. Hold furosemide whilst dehydrated, restart before discharge [x]
4. Urine sample for microscopy and culture to exclude UTI [_]
5. Endocrinology team referral [x]
6. Resume Lantus insulin 15 units nocte alongside insulin infusion [x]
7. Escalation plan discussed: Patient agreeable to full resuscitation including CPR and ITU care if required
8. Stop antibiotics [x]
9. Antiemesis [x]
10. Outpatient investigation of gastroparesis and IDA

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Refined clerking Thu 12 June 2025 14:25

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