But even I'm it's just on my temperature it my sugar mhmm is alright it's alright now yeah you're on the treatment the aed which probably just started yeah what do think triggered this dk off I I don't know I I had some long lasting insulin mhmm and I went to get some on monday I'd already did it a week before and it wasn't regular mhmm so I've had that over the weekend and I've been trying to just give myself normal insulin instead of the so you haven't had your long acting weekend no that'll be why then yeah yeah I know and what happened how did it run out well I had a week and I've said to her I've I've ordered over a week ago so I developed them they said yeah you did but you did nothing and what insulin do you take I take is it lantus it's in in I don't if it's in no it humulini or it's fizz and that's a quick acting 1 fizz fizz yeah and the other 1 how many units jio how many units are do you you doing take I think it's lantus I think takes 60 units of lantus at night then then how much does 2 13 with food and and those guys a day 3 times a day yeah and how do you work out how much insulin to take how much is the I drink for a while then I'll talk a bit more bit more to get it right and then you got the fennel I got the fennel how long have you had type 1 diabetes since 2012 and what cause have you come on do you know I don't know I don't really do to be fair yeah and tell me about your life more generally you live at home with you knee wife and daughter lovely how old is that well it was 23 alright cool yeah so that's it that age what age that's how I was that age yeah yeah yeah yeah that's alright fair enough alright fair and do you drink or smoke no no you're clean living kind of gas I've kind I I did drink years ago right I don't take I don't do it I'm all because I can't get pancreatic or people right so you have recurrent pancreatitis stuff yeah well you've got type 1 diabetes yeah and then I've got the you know so so this isn't really type 1 diabetes it's type 3 yeah diabetes absolutely so they call type 3 a yeah I think it's that so that's fine alright great can I have a little look at these allergic to anything I've got can't it yeah can not having that yeah okay quickly yeah heavy on and I'll keep you updated in terms of big breaths will every week yeah now that's lovely and again good to go okay so nice to do a chest nice normal heart sounds what operations have you had on your tummy oh keyhole operation take the gallbladder out yes now I had I don't remember what about for the study doctor charles so you have a typical yeah with the pines I've had it since I've had that enzyme thing I never I've had different different oh like it yeah yeah and you've got a libre sensor here in your tummy yeah that's not for me great yeah great alright and is your tummy sore at all no it's soft and long tapered no it's it's soft you sure that's not good and can I have a look at the legs any rashes there at all any pain passing water I've had some problems with my left feet so can I have a look at it yeah yeah it's I think it's healed up a big toe what did you do to it I hit it first and then it was like 4 blisters on there looks sore is it painful no no can I feel me touching the chest I've had that toe on for 13 days now because I was going back and it didn't tell well didn't go back so your right big toe looks a bit inflamed doesn't it yeah a little bit unhappy with an air it doesn't feel hot to touch so that's good yeah but there's an area of skin breakdown just on the medial aspect yeah can you feel me touching your feet not really not feet quite numb yeah alright thank you it's okay you got your socks back on yay your socks back on that's because I've anchored out great alright so I'll get the diabetic foot team to have a look at this first guide see if there's anything they can sort of last week say again I did say the foot peep glass great or say don't know what she's gonna be doing when she looked at it but I said that I wouldn't take it off what the coat the or the bandage the bandage because I said would just be worse then again of course yeah so alright well I guess I would have a look at the hip dressing on it okay yeah carry on the dka treatment with breakfast but with dinner you might be able to come off if your numbers look good okay the stop this drip so you don't have to have it overnight that's fantastic I'll restart you on your long acting insulin yeah do you feel dehydrated is your tongue okay yeah it should be a little we'll be you got a bit dry your tongue does look a bit dry we'll get you a bit more iv fluid alongside you to rehydrate you that's great and then thank you and then we'll take a left that sound alright yeah that sounds alright good it was nice to meet you lovely to meet you good job thank you so a bit of an update it's john rieden +1 425708 so this is john rieden which is r r r I o r d a n +1 425708 61 year old man past medical history lanzoprazole 30 mg at night pregabalin 75 mg in the morning and sorry 50 mg in the morning and 75 mg in the evening pancrex 5 oral powder half to 1 2 and a half milliliter spoonful with each main meal tresiba long acting insulin and fiasp short acting insulin accrete d 3 1 to be taken twice a day promazine 5 25 mg to be taken at night lisinopril 2.5 mg once per day clopidogrel 75 mg once per day atorvastatin 40 mg once per day leuphorpec hundred / 6 microgram inhaler 2 puffs to be inhaled twice a day salbutamol inhaler is required nortriptyline 10 mg 2 at night venlafaxine 225 mg modified release capsules 1 to be taken a day carbocetin 375 mg capsules 1 3 times a day mirtazapine 15 mg tablets once at night gaviscon is required allergic so drug allergies to penicillin past medical history knee osteoarthritis type 1 diabetes diagnosed in 2013 but more likely to be type 3 diabetes as chronic pancreatitis in the background nonalcoholic steatohepatitis 2018 bronchiectasis 2021 diabetic neuropathy and nephropathy with microalbuminuria osteopenia migraine hiatus hernia investigations initial venous blood gas ph 7.13 improving to ph 7.33 with treatment corrected calcium 2.81 alp a 134 sodium a 131 when previously a 142 creatinine a 121 from baseline 85 which is aki 1 rest of that is normal crp 22 has been chronically raised through september and august urea 17.1 magnesium normal full blood count normal apart from platelets 675 neutrophils 13.04 so presenting complaint dka history of presenting complaint ran out of long acting insulin which is tresiba over the weekend so missed at least 3 days of doses and has and felt more unwell today which led to him coming into hospital on examination chest clear anteriorly heart sounds normal abdomen soft and nontender observations respiratory rate 17 sats 99% pulse a 103 blood pressure a 166 over a 105 with temperature 36.5 impression dka secondary to missed long acting insulin number 2 aki with clinical dehydration number 3 increasing platelets and high inflammatory markers markers raise the possibility of infection no clear focus identified currently the number next left great toe diabetic ulcer for further review plan number 1 empirical antibiotics to cover chest and urine number 2 iv antibiotics number 3 continue dka protocol until next meal number 4 tissue viability or diabetic nurse review of toe number next endocrinology review number next input output monitoring number next iv fluid number next daily uni while in aki number next restart long acting insulin number next suspend lisinopril in aki number next chest x-ray number next blood cultures number next msu and septic screening number next tet full escalation number next endocrinology ward xhance