Ashley hamilton 7 5 0 5 8 1 investigations amylase 121 venous blood gas ph 7.46 sodium a 124 chloride 83 glucose 20 ionized calcium 1.13 basic s 1.5 positive bicarb 25.9 full blood count hemoglobin 151 neutrophils 6.83 remained normal liver function test deranged alt 70 note has been chronically deranged over the last few months and over the last year in fact albumin of 53 bilirubin 27 what has previously been normal alp normal but has been slightly high in the recent past sodium 131 creatinine 49 test dropenin 8 crp 1 urea normal ast 87 note presented multiple times over the last few months most recently presented february 1 with alcohol dependent found in park by bystander hypothermic confused manage for hypothermia by the ed team and then went home the same day and then recently admitted under the medical team from the 30 first or from the thirtieth to the 30 first of jan december 2025 with dka secondary to viral illness 1 day history of vomiting nocturnal intake previous suspicions for dka alcohol dependent past medical history alcohol dependence alcohol withdrawal seizures in 2024 type 2 1 diabetes mellitus 2024 a k I requiring a. Of hemofiltration 2024 a couple of no previous episodes of diabetic ketoacidosis in march 2025 and september 2025 right so he's been admitted 3 times over 2025 with diabetic ketoacidosis and once in 2025 with acute pancreatitis medications list mirtazapine 30 mg once a day omeprazole 20 40 mg once a day creon 50000 units to be taken with each meal and 1 and 25000 units with snacks thiamine 200 mg twice a day novorapid insulin 2 jou 2 jou 2 0 jou insulin t o u j a o insulin he uses 60 units of 2 j in the morning and then he uses novorapid with meals which he titrates himself looks like he's been drinking from thursday to friday not eating food since wednesday produced vomiting from saturday watery then bilious some abdominal and burning chest pain which started after vomiting sleeping that's all the vitamins so a similar very similar thing happened to you this morning there's not snowfalls but basically I was thinking we had to do investigations let's chest x-ray has been some called quality film immediately no evidence of pneumothorax did they start what free hair under the diagram diaphragm no focal consolidation do you have any thoughts about the you have I don't know oh well I'll ask you about the 2 of course don't worry we'll sort it out okay thanks hi how are you just want to go and take his tablets or not I'm rob 1 of the medical experts postmedia is comfortable how are you yeah I'm fine yeah cool are you feeling better than you did when you came in you don't have to lie I'm not gonna lie on my own but on my own side good good thing and then the pain in your chest started after that is that right I didn't really have a lot of pain in my chest it's more in my chest a lot of chest and stuff and it's down it's just a test drug team test just a classic yeah you're saying you're you're turning here in your upper tummy and lower chest mhmm yeah and then my throat yeah okay give me a statement of my teeth how they feel I imagine I have a lot of acid yeah of course yeah yeah your stomach produces a lot of acid every day and if you vomit it just makes more tell me all about it I understand it all of starts on wednesday is that right so monday mhmm I think I had either a alcohol seizure yeah the draw seizure yeah because I've gone not drinking for like 3 months now okay and then last week wednesday thursday I think wednesday thursday bit of a blur yeah yeah so 2 days in a row I went for it what I tend to do is my pattern seems to be bad news or sad to upset me then I drink and then straight away I'm like that was fucking stupid what am I doing I need to stop but I also ran out of metazepam mhmm that week as well mhmm so got out of a shit week isn't it yeah jumped said earlier that I was selling myself alcohol really like if you you can withdraw from it yeah so I think that I have a bit of a combo I kind of think it was monday and then it's a week ago mhmm yeah I hit the deck and they're looking at hypothermia I've read about that mhmm that's a bit of a blur mhmm that's kinda fuzzled my brain a little bit mhmm and that was 8 days ago yeah so just about a week ago fine then similar this week another bit of bad news going through a divorce once again was like blue the next day in what way have fallen like sick I've had ketoacidosis before yeah so I recognised it straight away had it a couple of times this year by the look of it yes early years and that to me quite challenging mhmm mhmm especially like it's got hepatitis and it's a year I'm on a be young good dog yeah definitely yeah I'd say my general pattern is and I've been really good with that drinking but but you don't have to have time happen alright so you're gonna drink soda go on a binge yeah but it's been the longest time I think feels like 3 months that's really good so I am working with swan and that to brilliant get in do you take anything for glut so that's probably have you had ever been to smoke it's when I saw the fuse at home for quite some time it's like when I was younger I just wondered why my parents are chronic alcoholics mhmm very different to me the pain in the chest drink it all in the center like every night yeah mhmm what blood cells kick start and I just didn't want to do it I just was like oh I'm playing here again didn't drink for like 15 years so what quite young I was when I was 18 I'm like I can't so I just always assumed that I could turn that switch off again yeah I've seen so much going on and when you develop that as a coping mechanism psychologically it's growing up it's incredibly fun so I think my wife was always my coping mechanism so going through a breakup that's now I feel you can be some yeah of course are you yeah just think that sore everywhere so a week ago you yeah were drinking stopped drinking collapsed possibly had a seizure came and woke up in hospital we discharged you and then a couple of days after that you started to feel nauseated had you been drinking between coming out of hospital you had a seizure and so when's the last time you had something to drink so again it's a bit of a blur mhmm I think that involves a bit longer than monday is it sunday morning mhmm because I was a bit worried about having a seizure but we drink yeah so I think it was sunday today yesterday yeah so it would have been saturday I drank epic mhmm and then sunday I had and then so yeah you feel very dizzy yeah very nice I a lot of seizures mhmm I see and and that just that's when I started high blood pressure or anything in that just a pinch of the pincer mhmm so it was pretty much all day and your tummy pain started after before it was after after yeah I could feel my headaches just you know when when that what what's the normal use of this before yeah not a bit still feel a bit naughty now about the same thing yeah alright so you have 2.5 this is not is that gonna work so it's a bit of bugger so we're start a new job as well and what's your new job it's bulgaria sinus hotel yeah and chef yeah yeah obviously now I can't pay what she's quite like yeah what's the well know you can tell them you're bony and your diabetes know things like that yeah no don't know is he been drinking okay but my yeah I tend to it sometimes isn't it so your heart rate is especially for me I feel alright 7 and 1 yeah have you eaten anything today no I haven't been eating any do you feel like eating anything I don't think I could I can't eat down any fluids really fine so when you drink anything can just vomit as yeah sorry let's get you some good anti sickness to try and make things better because having something to eat is gonna be really gonna make you feel good you know after you've been vomiting you feel terrible something just in your stomach makes you feel a lot better yeah yeah exactly and you need 3 to heal you're right I think last time I had a check-in 3 days to be able to in hospital to be able to thankfully you haven't got diabetic ketoacidosis this time okay it seems like you managed to keep taking your insulin properly yes so I noticed that's because something so I was having more with the paramedics so novorapid mhmm yeah and how much memory rapid do you use depends yeah so you carb count or you look at the sugars yeah and decide what's the kind of range that you you take it really just depends so hundred and 1 in the morning and 73 long form 1 so oh yeah yeah nothing of 2 g o yeah and then if I I found nothing that works maybe that I do it for medical care basically for me why that you're aware of should be around to like 15 to 6 do you look at the half half the amount of units compared with the claims I'll take about 7 units yeah that seems to have worked really well okay good I was taking it on regular I've all kept on high dose mhmm so do you smoke a drink no just have it as a regular yeah oh okay you smoke like 3 things and do you smoke yeah I'm taking no any recreational drugs no nothing nothing not perfect like another than the flu you're not drinking you know but no it's like sort sadness of happened in the last couple days was it anything like fatigue or anything no it's the same no was having a lot of anxiety yeah could easily just be little bit out of self care yeah yeah and tell me about your life more generally did you did you did it by yourself at home yes and you got your new job at the hotel who was I I said well I have something to do with my alright alright so I'm gonna put my wife back in the back I'm telling her well can I go on to try the little other than about yes mhmm and your diabetes is unhappy things don't heal fantastically have you caught them or scratch them or anything like that no that's why I asked if he smoked just because I wondered if I them right in your bag and put a cigarette in there I think that is a burn from work okay the ones on your back oh really fine 2 little scratches on your back they are scabbing over and healing but they're not so much fun to do with your legs got loads of tattoos where did you get them all done the patient's very used to that just do need to try any bricks in okay thank you thanks and then my no wipes yeah I guess fine I only get rid of the as well so we've finished a lot of it fine cool can I see your tummy if you like or after the extra day's time and that's your? That's very sore any pee sorry no I think again I've been sweating a would be a bit swollen it's a bit you're feeling it so so that's good so let's get you some treatment for the like the the ketones and the ketones and all that stuff so you're having that at the moment which is a drink of some insulin and some sugar yeah to keep your sugar levels nicely and let your body burn away those ketones by using them to keep everything nicely in range this gives you good anti sickness to make you feel better try and get you to eat something and drink something to try and see if we can get you feeling a bit better I'll have check a of a few more blood tests I'll add on a blood test to look at your insulin or your diabetic control over the last few months I'll carry on with the alcohol withdrawal treatment your blood tests from your liver are slightly elevated definitely good sign so you're likely sometimes the liver can be inflamed for lung problems that's all not really compared to like the stomach it's mostly painful and back as well so there's 1 of the blood tests for slight inflammation in the pancreas is slightly raised and there's a possibility you've got some pancreatitis which can cause vomiting so I wonder whether that's what's going on and we should probably have a scan at the front can I have a look at you I've got this option sheet here have a look okay start so with the so I'm take tongue 1 I'm gonna say a look at is there a tender cut up of the oh yeah saw that there's no evidence of any break in the oesophagus which is 1 of the reasons why we're doing it because when you vomit a lot sometimes you can have small tear in the esophagus this should cause pain there's no evidence of that and your the rest of your chest looks fine no chest infection yeah that looks lovely okay curious what's the what do you think I'm not aware of that want to dive into ketoacidosis because you do have ketones so it's a bit academic really with enough time you would have developed ketoacidosis purely from your blood test your blood wasn't acidic so by definition you didn't have diabetic ketoacidosis but if you left it for 6 hours you would have but we got in that stage before pre ka we call it so yeah what you did with your insulin was the right and trying to get fluid and things like that the right thing to do coming in soon is the right thing to do because when you're poorly from dka things get harder so we've stopped you going into dka with the treatment you've had you've had a very similar treatment to what you would get for dka instead of getting a fixed rate of insulin infused you've had a variable rate which is the top side either way it'll stop you from going into dka I think you feel poorly because of the combination of the ketones in your blood because you're not able to move any glucose around because you're vomiting with all the things can see as well as your allergies alright so on examination tremulous and sweaty but denies fevers no asterixis or evidence of chronic liver disease on examination heart sounds normal chest clear to auscultation abdomen mildly tender in the epigastrium with radiation of the pain to the back however no clear right upper quadrant tenderness and murphy's sign negative remainder abdomen soft and tender no peripheral edema no rashes core scores reviewed 12 at peak in 04:00 in the morning now down to 5 with chlordiazepoxide ecg sinus tachycardia at 101 with slightly high voltages and the precordial leads report r wave progression and no evidence of ischemia burned there should be some in the thing I'll I'll have to place the little bit on here oh don't they send them here I wouldn't be surprised if I see this 1 yeah it's a gold lab oh well they might not be if you want something I'll just find it so you can find it so you find I no stones in your gallbladder that's good sometimes corn will change people with this kind of thing and there's certain movements sand can sometimes cause that abnormal blood tests generally I'm quite hyperbohydrate guy I'm a specialified drunkard try to get the water after yeah and those things are going what you're seeing in the bit here it's a bit shiny in keeping with it being a bit replaced by fat which could happen because of alcohol certainly your blood tests have been your liver blood tests have been elevated for some time really since our records began about a year ago and this current acute system may have been elevated for long time ducts in your liver are normal sized barely see the blood vessels across here that's yeah essentially I've gone into improved ketoacidosis so but apparently got here in good stead been okay there's obviously any big ducts around your liver or any cystos but I'm also keen on fantastic it's probably getting someone who only does those scans to have a good look at that from the available screens but I'm not happy with either alright I'll send you the a look at the prescription so gonna look at okay so if that's gonna have a you're have the fax anyway you know I'm trying figure out I'm not a problem of course that she has that's fine it's like 1 of the facts that goes towards the hospital cool that's cool what do you think blake's how bad could that feel I don't think she understands the nervous system very much mhmm so she's been feeling anxious mhmm and that was a problem and she doesn't feel like she's having panic her side she's she drank too much and it fell on her mhmm she just keeps saying I want to go home to see with my husband and isn't really aware of it either hey we're going to call this out you can't have a life stroke you can die mhmm and all of that is but I just find calling my husband and asking what he's going to tell me yeah because was well I'll come back if I'm here yeah it's gonna go and I try saying well I can't just yeah be peter get her before but she thought he could come to the eu instead but she in that hallway that either like I'm hungry stay where it is mhmm I don't think she has a