Transcription - 20260210T 10-57.mp3

So david greene 04/1988 49 year old man investigations lab serum glucose 41.2 millimoles per liter full blood count white cells 10.8 with neutral 7.15 but remained normal coagulation screen inr naught 0.9 euzenys sodium a 129 note previous hyponatremia down to a 124 at its lowest back in august 2024 creatinine 56 which is outpatient's baseline potassium 4 alp a 132 remainder of lfts normal crp 39 from previously 15 urea 5 ast normal venous blood gas ph 7.36 with ionized calcium normal lactate 2.9 base excess 1.7 okay so medications list amisulpride 500 mg twice per day 2 g o insulin according to requirements pregabalin 200 mg in the morning and 100 mg at night alongside pregabalin 75 mg at night for total dose of 200 mg in the morning 1 175 mg at night diazepam 3 mg in the morning 3 mg at lunchtime 2 mg in the evening and 2 mg at night for a total daily dose of 10 mg glopidogrel 75 mg once a day canagliflozin 100 mg once a day metformin 1 g twice per day lisinopril 5 mg once per day lanzoprazole 30 mg 1 in the morning and 30 mg at night floxedene 20 milli 60 mg in the morning so past medical history cannabis abuse coded october 2024 cocaine abuse coded october 2020 '4 and detained in hospital under section 1 3 6 of the mental health act in july 2023 previous overdoses in 2025 august intentional self harm in 2020 and overdoses of diazepam and zopiclone metabolic associated fatty liver disease also overdoses of paracetamol in the past paranoid schizophrenia coded 20 18 copd hypertension type 2 diabetes mellitus paranoid psychosis coded in 2017 christine lee she's ready to go is she she is yeah yeah just pack a good way to get her out yeah if you're if that's alright we're gonna go out of hospital bed ordered for her yeah that's check presents the emergency department in august 2025 following a mental health crisis and an overdose of medicines including fluoxetine pregabalin and diazepam background of multiple personality disorders and paranoid schizophrenia as well as a history of violence according to the notes check the start please jan see if they've got it I can't see any recent clinical letters from endocrinology but can see admission multiple admissions to forest ward most under the endocrinology team in the past has stopped insulin for days with the intention to stockpile and commit suicide is it mister green hi I'm rob I'm a medical registrar nice to meet you how are you you I'm good as a yeah how are not bad oh I'm sorry what's happened maybe my breathing is a little bit dizzy mhmm so at the time I just could not breathe mhmm it was coughing the blood rises I was panicking I had to breathe throughout my mouth and nose it just didn't touch my breath couldn't breathe this was just earlier today yes yeah well I'm the other day as well you're taking 5 days yeah good okay my diabetes blood sugars have just been really high for the last 4 days constant I've checked 4 or 5 times a day yeah unless there are it's been just been checked now and are you still using the jujio insulin no no what happened to that I just couldn't be bothered it's not the truth I'm terrible for being there yeah I understand I've seen it in back and forth on the floor you guys you've been on this kind of thing yeah exactly before I think that your struggles with your mental health have been a big part of it is that part of it today yeah I'm sorry feeling low was part of the reason you stopped taking the insulin as you I've been we think you've planning it caroline who I didn't is he she's a senior diabetic nurse here I don't know her she asked her once what would happen if I took because they come in a pack of 3 I asked her what would happen if I opted all 3 into me her words were day it would be the end loss was 3 so I started taking 10 then I told here that I could have 6 hours left to live when I did that next time I survived next time I did 30 cans without saying anyway those snowboarding nothing those arrived yeah I've been stuck by telling you that that it's not for you yeah they've got to I think you've got to stay with us for a bit yeah if that's alright yeah yeah so I I don't know I I only hate it I was so sick so I was gonna do sort of that tonight just to buy that a book that I had or stuffy cats or dogs I didn't know about that what's that about no I was saying that they've told me that I've got out of chest x-ray today yeah you should have chest x-ray and I'm hoping that the research is so real I've got worried about that at all and what makes you so unhappy what do you think to make you happier my life I'm of living I'm not scared of dying what scares you about living just everything the pressure people the toothpaste people the people that will scam you cheek and everyone's up to get something out of it and all I do is copy kind to everyone I meet they're all full of your witness and they're to take advantage everywhere and you've only just like well 2 years ago you reached out to mental health didn't you you weren't there I yet was the undermined since the age of 11 and there's meshed you around meshed you by name you've now taken meds for his antidepressants well psychotics or any changes in blood they're just only just laughing they're just letting down just 1 leg down after they're not sorry yeah they've recently changed your legs tell me about that when they get you but my week before 1 yeah maybe not yeah maybe a month what did they meet it to metazepine from fluoxetine okay well I've been on fluoxetine for 38 years saw you were still on foxtouch so now you've changed to metazepine how much metazepine do you take 15 but I usually go up next week to 30 okay and then up to 45 that would be good wouldn't it it might be yeah okay yeah so this time how many days has it been without the incident oh man I gonna say it must have spent the last time it was here I thought we were off right the last time it a great day 2 years apart from the only 1 thing yeah that time it was a good day how many pence have you got to own then 50 pounds the 2 chair area yeah double the staff and then I've taken my fingers on 3 drops of tablets for diabetes I probably have been 3 paniclyphilosis yeah yeah there you go okay no problem okay any cough or cold pain passing water any infective symptoms at all lately no pain in the tummy no no and I understand that drugs have hit a peak in the past as well overdose is not drugs that's is that something you're saying not not intentional overdosing okay so so only those in the past but unintentional ones yeah yeah yeah and tell me about your life or generally you guys have kept it yeah yeah so there's been plenty around my life isn't she yeah he's yeah the paramedic came out for making terms about it and they said all which is her her preparation or something no so but she's good but yeah we've gone from well in the last couple of weeks he'll for like 5 years mhmm we'll come out 5 years yeah and basically he should become a recruit to his house like he doesn't feel like at all like many times that he has been out he he's had a massive court case which is being with my parents and looked to you know my sister and my parents said that 5 days he's he's got a 2 year suspension sentence and he's got the patient's 2 years okay so he knows that that happens to me he contact me if I can get to film or stuff like that oh he just kept me stressed out how many times do I left my front jaw to take 5 times a month when I was working enough for you no I was was he didn't he didn't like to go outside he's not on camera there because he's he's on camera at at home excellent I will say that he was just generally there he just can tell his his ear and things just that I hate smoking just making cannabis no no that's an idea you see that's yeah yeah and how many cigarettes do you take 46 weeks every day yeah yeah okay so recently I've been smoking crack crack mhmm recently I've only been didn't feel like don't feel like it's gonna happen been smoking that anymore when did you last yourself with me okay but I've I've sniffed cocaine drinks mhmm that was what I used to do mhmm but I would do a little bit after everyone so you don't know if right because it's so good you'll want more mhmm but unfortunately I did and and they kept using it yeah well I've been doing shovelling for I wonder shovelling so he has got like he has got mental health gal called tally mhmm and he's and he's got shovelling he's he's he's he's he's support him he and he is working really hard when he's reached he's out to shri did tend to reach out to the doctor he might get him out of the door if he wants to be able to go out he wants to be able to do it it's just you know like you know with mental health just everything takes time everything is just all the appointments and the flat out it's just when it's time meds and all that just everything takes time and it just doesn't help in the in this kind of situation you just kinda you can fix that load do you feel dehydrated and fasting yeah I'm not but you say well you should be I mean he's been drinking a lot but obviously that's gonna be unfortunately your sugars get very high like this when you're not using words know sucks all the water out of your body yeah and then you wee it out yeah and then over time over how long it's been months you've become incredibly dehydrated on a chronic basis and now you've got an infection which has pushed you just over the edge so this is a acute on chronic dehydration we call it hhs by definition you don't have it yet but with a bit more time for it if we had to coordinate it we get it we're managing you as if you've got hhs which is essentially boatloads of fibula so it's a little of to the brain with lots of fluid and a little bit of insulin which is a little bit trickling over and bringing glucose levels down okay yeah yeah good I'll stop a few of your medicines the ones you're not taking anyway the canagliflozin while you're in hospital and the metformin because there's a slight raised marker on 1 of the blood tests we'll start using some antibiotics to cover for infection somewhere I'll just examine you and have them find out where it is if not then if they will a sample of your urine take a chest x-ray and then see if it's fine okay yeah I could say yeah that on friday when I'm thinking about putting it do have any symptoms that are going that way I could get a scar part it's forced completion sounds like you've got to get into it you got to be alright matt yep where is this 1 is that I was more I was telling you we we need more paid I'm gonna get 1 no any birds or animals at home yes got we've got 2 dogs 2 kids 4 4 scorpions 2 grandkids girlfriend and oh wow I've always yep he's probably got mad cow disease more than anything everyone that comes into hospital I should speak to about resuscitation that's what you want to become more unwell would I think you should be resuscitated yeah we're unwell yeah I understand I think that your mental health issues probably play into that a lot yes yes yes my perspective I my medical recommendation would be that you are you would be resuscitated in which you are k yeah that would be wonderful okay I think that's better alright know you I know you don't feel up to it okay so he always says like he wouldn't let not suffer like this he just says that he's up to all the times when people say to him like oh it's selfish that you've no got no no no and he he says that so but he will get better with the meds and with the blood thinners okay he'll he'll get you feeling better we'll get there any questions or anything like that no no it's nice to meet you so did you think it was possibly pneumonia that he sounds like I'll treat you for that okay and we'll get a chest x-ray to make sure and it's not gonna be urine to be sure okay but I suggest that you 2 bottles there before you take them no that's just for your body I need a bed done by room alright alright we're going to the er now our acute I'm I'm talking enough it's just the bed spinning I was wanting to set up this sliding scale so impression is left basal pneumonia leading to infectious exacerbation of copd leading to decompensation in and hyperglycemia with hyperosmolar state but not meeting criteria for hhs plan manage as hhs with hhs protocol antibiotics and steroids to treat for exact infection exacerbation of copd yeah sorry doctor

Medical ST5 Miller Clerking

Presenting Complaint:
Shortness of breath and hyperglycaemia

History of Presenting Complaint:
Patient presented to ED with acute shortness of breath and feeling dizzy. Describes being unable to breathe, coughing up blood, and having to breathe through both mouth and nose. Symptoms started earlier today but similar episode occurred 5 days ago. Blood glucose levels have been persistently elevated for 4 days, checking 4-5 times daily with consistently high readings.

Patient has intentionally stopped taking Tresiba insulin. When questioned, admits this was deliberate and related to low mood and suicidal ideation. Has history of stockpiling insulin with intention to overdose. Previously asked diabetic nurse what would happen if he injected all 3 insulin pens, receiving response that it "would be the end". Subsequently attempted overdoses with 10 units, then 30 units.

Background of recurrent hospital admissions to Forest Ward, mostly under endocrinology team. Multiple previous suicide attempts including overdoses of fluoxetine, pregabalin, diazepam, paracetamol, and zopiclone. Most recent overdose August 2025 during mental health crisis.

Mental health history includes paranoid schizophrenia diagnosed 2018, multiple personality disorders, and history of violence. Detained under Section 136 Mental Health Act July 2023. Recently changed from fluoxetine (38 years duration) to mirtazapine 15mg with plan to increase to 30mg next week then 45mg. Patient expresses feeling unable to cope with life pressures and describes pervasive feelings of being taken advantage of by others.

Significant social stressors include relationship with boyfriend of 5 years who has agoraphobia, received 2-year suspended sentence for domestic violence, and requires significant support. Boyfriend has support worker called Tally but patient describes feeling overwhelmed by caring responsibilities.

Recent substance misuse includes crack cocaine (stopped 2 weeks ago) and ongoing cocaine use. Long-term cannabis abuse. Current smoker 40-60 cigarettes daily.

Clinically appears dehydrated. No chest pain. No urinary symptoms. No abdominal pain. Cough productive of blood.

Past Medical History:
• Paranoid schizophrenia (2018)
• Type 2 diabetes mellitus
• Metabolic-associated fatty liver disease
• COPD
• Hypertension
• Paranoid psychosis (2017)
• Cannabis abuse (October 2024)
• Cocaine abuse (October 2024)
• Previous hyponatraemia - lowest 124 mmol/L (August 2024)
• Detained under Section 136 Mental Health Act (July 2023)
• Multiple previous overdoses (2025, 2020) including intentional self-harm, diazepam, zopiclone, paracetamol

Drug History:
• Amisulpride 500mg PO BD
• Tresiba insulin according to requirements (not currently taking)
• Pregabalin 200mg PO mane and 175mg PO nocte
• Diazepam 3mg PO mane, 3mg lunchtime, 2mg evening, 2mg nocte (total 10mg daily)
• Clopidogrel 75mg PO OD
• Canagliflozin 100mg PO OD
• Metformin 1g PO BD
• Lisinopril 5mg PO OD
• Lansoprazole 30mg PO BD
• Fluoxetine 60mg PO mane
• Mirtazapine 15mg (recently commenced, plan to increase to 30mg)

Recently Stopped Medications:
• Fluoxetine - changed to mirtazapine approximately 1 month ago

Allergy History:
Not documented

Social History:
Lives with girlfriend of 5 years and 2 dogs. Also has 2 cats, 4 scorpions, and 2 grandchildren. Boyfriend has significant mental health issues including agoraphobia and is supported by mental health worker. Patient provides substantial care and support. Current smoker 40-60 cigarettes daily. Recent crack cocaine use (stopped 2 weeks ago). Ongoing cocaine use. History of cannabis abuse. Not currently working.

On Examination:
General Appearance: Alert, appears unwell and dehydrated
Observations: Not documented
• Respiratory: Clinical signs consistent with left basal pneumonia
• Other systems: Not documented in detail

Investigations:
• Serum glucose: 41.2 mmol/L
• White cell count: 10.8 (neutrophils 7.15)
• INR: 0.9
• Sodium: 129 (previous hyponatraemia 124 in August 2024)
• Creatinine: 56 (patient's baseline)
• Potassium: 4
• ALP: 132
• CRP: 39 (previously 15)
• Urea: 5
• AST: Normal
• Venous blood gas: pH 7.36, ionized calcium normal, lactate 2.9, base excess 1.7
• Chest X-ray: Pending

Impression:
Left basal pneumonia leading to infective exacerbation of COPD leading to decompensation and severe hyperglycaemia with hyperosmolar state (not meeting full criteria for HHS)

Secondary issues: Chronic non-compliance with insulin due to severe mental health issues and suicidal ideation. Acute on chronic dehydration. Active substance misuse.

Management Plan:
1. Manage as HHS with HHS protocol - aggressive IV fluid resuscitation and insulin sliding scale
2. Stop canagliflozin and metformin during admission
3. Antibiotics and steroids for infective exacerbation of COPD and pneumonia
4. Await chest X-ray to confirm pneumonia
5. Obtain urine sample to exclude urinary tract infection
6. Urgent mental health team review given ongoing suicidal ideation and non-compliance with life-saving medication
7. Respiratory bed
8. Resuscitation status discussed - patient initially reluctant but agreed to full resuscitation following discussion. For CPR and escalation to ITU if required.

Summary

Investigations

Plans