So darren beresford 1192213 54 year old man past medical history diverticulosis type 2 diabetes mellitus with diabetic retinopathy medications list escitalopram 10 mg once a metrazole 20 mg once a day atorvastatin 40 mg once a day previously on tirzepatide once a week previously on semaglutide before that and also has previously been on metformin and glipizide in the past but not on any of those medicines at the moment investigations troponin t 18 eosin is normal with creatinine 92 sodium 135 and potassium 4.2 lft is normal glucose 16.4 crp 3 urea 7.7 ast 17 full blood count hemoglobin 144 white cells 12.8 h fills 9.7 I know caffeine too well venous blood gas ph 7.02 with sodium a 131 and base excess - 23.7 with glucose on the gas 17.7 I think I'm if I could catch up with triage so they are so back to reviewing medications list he's previously been on metformin and that by gliflozin but has but has recently been had them taken off his repeat prescriptions list due to not yet booking a diabetic yearly check so he was previously taking metformin 1 g twice per day and just maybe clear in that extra box on the screen but it hasn't actually it's just because I don't know like he's covered in the flu why are you seeing it I was like well I need to go to the clinic it's alright and what do you do do you have any pictures in the foot yeah so but note multiple acute prescriptions for dapagliflozin 10 mg tablets once per day so add that to the repeat medications list most recently issued 01/09/2026 and 12/18/2025 he is taking that so impression is euglycemic dka secondary to diabetes most less likely type 2 diabetes with concomitant secondary to eye infection so note that on the gp record that he's being treated by the general practitioner with chloramphetical eyedrops for conjunctivitis but then has been feeling nauseated losing balance short of breath lethargic and off food today and he had ketones on his urine dip and blood sugar's unreadable go and pull it out it's the last thing you need so that's because it's just so easy are we going to be coming back here yes well I don't think people should be here so I'll try and get you a bed somewhere but I think for now you've probably got a bed yeah just make sure the room's actually free or not I guess quite moody lighting in here yeah you're wherever yeah sorry it's nice to meet you and you and the medical registrars right okay I read about it from your gp a bit about what's been going on yeah that you had conjunctivitis yeah treating with some chloramphenicol eyedrops and then you felt nauseated and poorly this morning any other symptoms tell me all about it well if it's just the breath short of breath short of breath I can hear myself breathe I feel feverish yeah it's just kinda unsteady on your feet yeah I'm unsteady on my feet yeah and he's really really being shaken up are you going to sit on that have I taken this at all medical school if that's alright no it's been this morning has been nearly years had a few weeks mhmm I've really had really I really changed my diet mhmm on january 1 mhmm because I had formal adhd diagnosis in november and that made me understand my relationship with food and looking into it more and why I couldn't control my diabetes poor control I had and so I made this resolution I'm sorry to look at things differently and so since the january 1 I have changed dramatically I think school has brought up on me and I've overdone that yeah I doubt very much it's your ketotic diet causing things I doubt very much right okay I don't think you can be blamed for that we're but happy to they then did the ketosis strip and said that I had lots of ketones in your urine yeah and looking at your blood tests your blood is quite acidic which is making you breathe so hard and this is a condition called diabetic ketoacidosis is what you have it usually affects people with type 1 diabetes there's the possibility we've never imaged your pancreas and we've never looked as far as I can tell from looking at your results into whether you've got type 1 or type 2 diabetes incredibly strongly to be honest I think usually when people develop type 2 diabetes later in life we can label them as having type 2 diabetes but there's the possibility that you don't have type 2 diabetes and you've got type 1 diabetes which is why your control's been so bad okay it's a possibility the other possibility is that you're in diabetic ketoacidosis now because of the dapagliflozin that you're using and that can lead to a type of dka diabetic ketoacidosis which can affect people taking that medicine right okay I have had also problems with thrush and I think they call it valenitis valenitis yep but I've trekked that myself with canastan because I got that previously and I know that that was 1 of the side effects took me 3 or 4 weeks to get rid of that I actually thought to myself that was 1 of the reasons I might pass that on to my eye because I am routinely good with my hand hygiene and things like that but obviously constantly applying this cream constantly doing this like now and it's not your hand hygiene it's because your urine isn't full of sugar because of the dapagliflozin which means that bugs love growing in it right so it's not all your the froth and stuff from your urine it's frothy yeah and how much froth is there does it fill the bowl up really sometimes even now when my when my because I thought to myself it's an inhibitor but I'm not eating carbohydrates so why is it really frothy it's of course you've had no carbs at all whatsoever literally no carbs a slight amount but yeah yeah so it's crazy to me that was I was puzzled by that so I thought to myself if it's not under control and then we're eating carbs and this inhibitor supposedly stops carbs going into your it's not quite gluten free do that it just makes you wee out glucose right okay so the sugar that you absorb you just piss it out instead of absorbing it and helping your body with your fat or using it for your body if just you're eating sugar how is it doing the same thing yeah well that's the main topic and it's sort of driving your glucose down but your glucose in your blood is quite high so your body will produce glucose even if you don't eat anything your body will activate glucose and produce it there's the possibility that as I say that it is related to your ketotic diet that your your ketotic diet means that you're using fats for energy and when you use fats for energy you produce ketones as a form of energy however your ketone level is higher than we would expect from diet alone and I think as all things in medicine no doubt multifactorial combination of poorly controlled diabetes that may or may not be type 1 diabetes combination with the ketotic diet in combination with the infection and in combination with the dapagliflozin and all those things together have contributed to what's going on at the moment okay does that make sense sure your blood's quite acidic and so we need to get you to our higher observation area where you can have some more intensive treatments you need to be on a drip with insulin flowing into you all night to try and control this and get your blood looking a bit nicer all right in terms of the eye I think 1 of my colleagues outside who's just texting me just wants to tell me about something so you can stay here I'll just be 1 moment is that okay sorry alright take a digger down a little bit no we were were talking a bit about your symptoms work though when did it all start for you and when has it been going on with the difficulty in breathing and not feeling off your legs and stuff I'd say 2 days 2 days alright yeah can I also say that I think it probably is that I've super deviated because I've had periods of real good control have you okay where my I actually used to carry have to carry dextrose with me because my blood sugar went so low so low okay that's interesting mhmm what medicine were you on then was it the gliglizide that you grew up on I was on metformin and glucoside yeah and it's a family history because dad I have got family history actually same but when I was a driver I was very conscious of my you had to be sugar of course and so and I could sense when my blood sugar was going low and I checked it like really low yeah and I tested my dexterol glutizide drives the blood sugar down is how it works so and it works in a similar way to well not really but it has a similar effect to insulin in that it will it directly drives glucose down not by improving excretion but by improving reabsorption in the liver so in it will have a similar effect in whichever type of diabetes you have it will drive your blood sugar down but I agree I don't mean to put too much weight on the possibility of an alternative diagnosis I think it's academic really I think the most important thing is managing what's going at moment my? Is that we usually see this the diabetic ketoacidosis in patients with type 1 diabetes I have been extremely proud that I've just lived like a normal not even like a norm but like an overweight person I think because you've you've had there is an addiction with food yeah and I think now darren's had his adhd diagnosis started having yeah I I understand my compulsion to eat that if there's things there yeah and I've not changed with things like with high sugar based stuff horrendously I think darren's really obviously when you said type 1 diabetes oh sorry didn't mean to that no no no no I don't because he's obviously just worried that if it did come to that because I think well it's really diagnosis has changed my perspective around a lot of things in terms of how my mind deals with things and then I've come to terms with how I need to manage situations like my eating my ridiculous eating and so because you know if there is is food there as you as you know yeah I've had good stuff in past I I will eat it until it's gone mhmm and then go out and buy more have you ever been much bigger than you are now I've been 25 stone 25 stone okay and now I'm 17 and a half stone okay so and what did you do for a living you were driving I'm social worker you were social worker yeah but I used to while I was studying for social work I worked as a van driver for gunpowder school while I was training so I was very conscious of the fact that I was picking up young people taking them to school then taking them home so my conscience couldn't allow me so it was having those rules changed the way I behaved how long have you had your diagnosis of type 2 diabetes for 2013 2013 yeah about 2013 and you've been on metformin you've been on gliclozide and now you're on semaglutide for a while the ozempic stuff weren't you for some time yeah but the side effects for that were apparently not the 1 for you that is fine and mantougero as well for the yes but I have been on metformin for that entire. And you are on a good dose of metformin now maximum dose 1 g and you are on glipizide and now you not on glipizide anymore is that right yeah and the reason they took me off glipizide is for that. Of time it appeared to be managing it but you were having hypos yes and then now you're on dapagliflozin and the metformin yeah okay great I didn't mean to upset you with comment about what type of diabetes you have on no no no no no no I'm not upset about that it's that I have ambitions to move abroad for my retirement and things and like I think that my mind now is that I want to lose more and more weight because my uncle before he passed away after being a diabetic for many many years lost so much weight and then was able to control it by diet yeah understood even though he'd been diabetic for many many years yeah yeah I know that no need to do the same thing ties you in terms of weight loss how much weight have you lost recently over the last few months has it been dropping off quicker than you expect I can lose weight if I put my mind to it and but you haven't been having uncontrolled unintentional weight loss no no good no what I'd say I would probably die of an initial episode of food in younger but he said that and now I'm a 17 year and you're asking a lot of cinnamon but it's at 1. What would be happening now a little bit different but and I suppose that's 1 of the issues I have with the ozempic and that other drug is that I feel that I need to lose weight by my own means and that is the most likeness of me keeping off I need to have that interest pulses are going to fast I'm going get this support yeah and they said that yeah can I see all your heart's a little bit of support I'm gonna it that's great that's good out that's lovely and again and now and this 1 and it's always been commented that my blood pressure is pretty good oh I've got a good good good good pressure results but they tell that the doctors are wrong but my heartbeat was beating higher because of their levels yeah it was completely unusual and I think sometimes they're damaging when a nap you can see a change mhmm so I think that's when he start to check a little bit right and this is over the last few days yeah mhmm and any fevers over the last few days well my head has found felt strangely hot in the back of my neck and so that's made for a difficult situation in going to bed I always sleep with the window open I like cool fresh air yes and so I've been cold so wanting to put stuff on but having to have it not come any higher than my chest I see because it's my head so it's so hot so hot yeah fine and then obviously you've got this conjunctivitis as well yeah can I see your tongue if you mind that's fine let's look at the bone in your neck do want me to look over the actual looking at the I'm just looking to rest back slightly that's lovely and look over again and try and rest your head back on the thing if you can that's lovely thank you let's I haven't got any rashes on this head or back or anything that causes a lot of this that's fine you can stop fine so there's lots of things we should do for you now you're in hospital we'll move you to our major's or resuscitation area we'll pop another drip in so you've got lots of access we do lots of fluid I'm gonna give a fixed rate insulin infusion to control this diabetic ketoacidosis okay and we'll manage that overnight it may be that we put another line into 1 of your arteries in your arm just so we can take lots of blood tests because we need hourly blood tests overnight when you're on this infusion okay I'll send your urine off to look for infection but I'll also send your urine off to look for the protein level in your urine and we can assess whether there's any urine infection driving your symptoms which can make you more at risk of getting these diabetic ketoacidosis and I'll also look for whether there's any protein in your urine as a cause for the frothy urine I'll ask for a chest x-ray for you to look for whether there's an infection in the chest causing things and we'll carry on your chloro eye drops for your eyes okay the symptoms that you're getting from the dapagliflozin doesn't sound like we should continue it to me given you've had an episode of dka now which can be life threatening associated with the dapagliflozin as well as the problem that you're having down stairs with it but I think we should probably think again and try something different okay and I'll speak to my endocrinology colleagues who are specialists in managing diabetes and ask them to come and see you when you're either in the resuscitation area tomorrow morning or on our acute medical unit so that they can take everything I suggest they'll probably want to do some more blood tests and maybe also a scan of your pancreas to look at the pancreas in bit more detail to decide what kind of diabetes we can take care and what the best management that that would be but I think there's more tests that we need to do okay for that is that alright sound like a bit of a plan yeah no no it's great any questions or anything like that no I think it's just to process it all yeah it's all I mean obviously am I alright yeah yeah I'm just getting a little bit shaky sorry it's a lot of information on the website today I think that's just how dan's been that's just how I've been yeah it's just I don't know what's causing it think I mean am I okay to leave dan tonight we're we're welcome to we we look after him and I must say that every time we manage your numbers look bad on the screen in terms of your blood being very acidic but every time we as long as we give the right protocol of treatment which we're about to do it gets better every single time so it will get better okay but it will take some time to get better and you'll be in hospital all night having some intensive treatment you won't have much rest tonight you're obviously welcome to stay but you're also much concerned you're not just giving up to you yeah I'm really to go on this okay and there's always the potential for people to go to intensive care with this not because you need tubes put in horrible places and you go to sleep but because sometimes you need that 1 to 1 nursing care for all of the blood tests that you can allow in all your nursing things but depending on what's up to your test over the first few hours I'm gonna ask the intensive care team to come and see but we'll we'll we can cross that bridge later okay sound alright yeah yeah fine I should always talk to everyone I talk to everyone that comes to hospital about resuscitation I think we should do everything for you to keep you alive including jumping up and down in your chest if it came to it I'm not expecting that to happen but I just have to talk to you about it because I have to do a form on the computer to say you should have everything is that alright yes you're welcome great can I just