Next patient is geraldine matthews dfordelta 052054 78 year old lady presenting complaint is hypoglycemia past medical history type 1 diabetes mellitus since 1986 with diabetic nephropathy ckd 4 high risk diabetic heat bilaterally background diabetic retinopathy and chronic venous insufficiency as well as diabetic neuropathy also has copd hypertension an episode of diabetic ketoacidosis in 2017 cystectomy and formation of ileal conduit 2009 for neuropathic bladder secondary to diabetes copd was from 02/2007 osteoarthritis 02/2002 medications list lanzoxyl 30 mg in the morning hydroxycobalamin 1 mg administered by injection salmeterol 25 microgram per dose 2 puffs twice a day loperamide 2 mg 3 times a day as required for diarrhea stexoril d 3 1000 units once a day frizamide 20 40 mg 20 to 40 mg per day lantus insulin I'll clarify the units later novorapid insulin I'll clarify the units later salbutamol 100 micrograms 2 puffs to inhale 4 times a day when required observations respiratory 18 sat's 96% on air blood pressure a 133 over 46 pulse 81 temperature 35 36.5 she's been afebrile since presentation investigations list crp 12 with white cells 13.3 and neutrophils 12.4 potassium 5.5 with creatinine 202 and urea 28.5 most recent creatinine 215 in may 2025 but a 148 in january 2025 alp 280 statically raised but increasing bloods from may demonstrate low ferritin with anemia blood gases on presentation ph 7.15 with glucose 5.4 at that time and low carbon dioxide open brackets metabolic acidosis with respiratory compensation close brackets subsequent blood gases demonstrate ph 7.19 with glucose 14.8 and ph 7.17 with glucose 26 information from a and e team sudden onset of epigastric pain with nausea patient checked capillary blood glucose was 2.3 and gave herself a hypo treatment was unable to raise her levels drowsy and on the crew arrival administered 10% 100 mil glucose led to capillary glycosylase being 7 so she had intravenous glucose with the ambulance crew and symptoms resolved by the time she arrived in the emergency department she also had antiemesis drug allergies curmox clav and flucoxibin so she's allergic to penicillin type antibiotics can add to the investigations list chest x-ray clear lung fields actually yeah clear lung fields I read about that yeah you were lucky bladder wasn't it no and are you a conduit yeah yeah I'm rob I'm 1 of the medical nurse friends it's nice to meet you how are you I'm fine I'm fine fine here a fair while by the looks of things been here since about midnight or so yeah before that and I want to go out to my of course cpap sorry men have missed it so was just getting off this is the switchboard someone's coming from outside to talk please how's that going hey yeah gotcha not long hi again sorry about that we we were talking a little bit about what you what brought you into hospital mhmm I understand you had been vomiting is that right mhmm tell me about that how long have you been sick for only the evening only 1 evening 1 evening and then a few weeks before that I had sleep okay and what comes up well I said I've got a headache with a heartbeat a bit of right a bit of a bit of in my neck think it's to me but yeah and then the vomiting what comes up when you vomit when do you vomit I was just feeling so bad was so bad for tea is it and it was that yesterday evening and then evening a week ago mhmm and any time before that sorry I'm trying to distract you but you don't have to talk to me if you want to no fine I I haven't been sick for about 6 hours I know yeah I've been on warms and it's just a few weeks a few weeks okay just take your knees and hands I didn't fall back are you okay yeah no I don't know the only reason I ask is because you've obviously had diabetes for some time and it affects all parts of your body as you know it's affected your eyes it's affected the vessels in your legs it's affected your kidneys it can also affect the nerves in the gut really movement of your stomach which can cause vomiting usually people will vomit every year fine I suppose it's just once or twice which is why I was asked for so much about it oh yeah but I doubt very much that's what you have I think you're vomiting for another reason for that I used to have a lot of stuff I read it last summer mhmm and they said it was more of the now like they're all exactly it's the same stuff the nerves that supply the gut can be affected yeah so you had an episode of vomiting last week right 1 episode but did you did you become hypoglycemic after that a little bit a little bit but I I took some insulin yeah so your blood sugars were high after that yeah not low they were high you had some insulin some novorapid okay and then and then yesterday you vomited but your blood sugars went low instead is that right yeah it was low before low before mhmm on the level you get a nip back there never heard of before and I've had I get hit people some days mhmm to manage the to get the sugars in the right level yeah yeah I understand I know you've had diabetes for a while and and how has it been controlled in the last sort of 6 months that you've been doing I do a lot of times yeah okay yeah I know what it's up to mhmm yeah and then I just inject yeah you use novorapid mhmm and you take your long acting insulin as well yeah did you take your long acting insulin yesterday no okay because your blood sugars were low because they can't pick me up yeah and that's probably where things have gone slightly wrong yeah because the long act you need the long acting insulin in the background to keep your body moving sugar through and then what's happened is over the course of the night your blood sugars have started to come up but actually your blood was always quite acidic when you came in you probably had dka ketoacidosis when you came in even though your sugars were normal and do you take when's the last time you took your long acting routine the night before the night before you did take it then 5 and how many units of lantus do you take about 15 15 units 1 5 is fine and then the novorefort how do you dose that often put my sugars on mhmm I don't take between 8 and a day 8 and 10 units 3 times a day yeah mhmm yeah just noticing alright so you normally use your insulin it's normally reasonably controlled yeah then you had this episode of vomiting which is throwing things off a little bit yeah and then as I explained your blood your bloods were quite acidic when you came in and then they got slightly worse you now you're in tk you need to treat that so stop some treatment for that have you been feeling unwell in any way in the last few days very tired very tired I've got a bit of kidney problems I'm under a bit conscious mhmm mhmm yeah and any infective symptoms any symptoms of fever feeling hot and cold shivering or shaky I get shakes when I'm tired so I don't lose take a lot of notes okay so you haven't had any fevers any tummy pain yeah okay tell me about your tummy pain an obvious suggestion mhmm mhmm and I I'm on the medication for reflux yeah know right and what's been busy I've got I've got it here that's it I've got I've got all your medicines so don't worry yeah yeah yeah fine so you've had some tummy pain you get bad indigestion any pain passing water of course because you've got the ileal chondrium silly me sorry for asking fine any shortness of breath on top the time maternity cardiac the cord mhmm not all the time no okay but sometimes and not particularly over the last few days or particularly over the last few days sometimes sometimes in the mornings mhmm okay but not yeah okay fine any cough I love to a bit in the mornings when I get up okay k and tell me about your life more generally who do you live with at home myself mhmm and you've got your pussy cat of course do you drink alcohol no no smoke cigarettes I'm sort of sorry I don't know when I'm smoker I smoke about 2 or a day 2 a day fine how long have you smoked for over 6 years yeah fine since you're 16 kind of thing yeah since you're not and and that time have you ever been up to a pack a day or more than that no yeah no no you're always a kinda 10 a day kind of person and then bringing it down is that fair to say it's if everybody wants me up I'll go outside so you'll go and have a cigarette now just joking is that pillow comfortable for you is that okay yeah okay good I want a drink of water yeah I will get you a drink of water yeah yeah breathe yourself at times all your chest is nice and clear which is good don't think you've got chest infection sorry pretty swelling on the legs I see oh yeah so I'm trying to be gentle sorry you look up to the hips on both sides fine and you take a bit of fruzilide I understand is that right yeah yes I don't want me to take it anymore just suspend it slightly at the moment exactly just because you're having fluid anyway so yeah can I see your tongue is that alright that's fine it makes it quite dry isn't it have a look at this vein in your neck can you just say there's that side of it no I can't see that vein in your neck it's quite low okay is that alright right can I touch your tummy sore at all no k lovely so on the monitor your it doesn't look like heart's going in an irregular rhythm as you've heard before your rate's lovely 86 saturation is good 97% blood pressure is lovely can you repeat your 1 over 52 and your respiratory rate 58 great so all looking really good we're gonna get that blood test which we'll have a look at in a okay to see how you're how is it looking so ph is still 7.3 c o 2 is 3.16 so it's about a dose of iron so yeah potassium is 5.2 so glucose is still high it's got better yeah and then the ketones are 2.6? Ketones coming up but ph coming coming up as well so that's good yeah and then yeah I think you can choose this week me kind yeah yeah but we'll we'll stop 10 so perfect yeah so we'll give you this bridge to treat your diabetic ketoacidosis yeah I'll ask the diabetic nurses to come and see you as well as the endocrinology team they're the experts in managing this condition alright they come to see you we'll carry on all the fluids and this is just hold your diuretic your water tablet for a bit because you're quite dehydrated in detail so you need a bit of a top up and then we can restart that before you go there yeah and we'll give you your long acting insulin as before the lantus that we talked about that alright yeah any questions acne insulin yeah I'll get you some water in the next insulin now but you can have your long acting alongside that that'll be good probably and no rashes on your legs so that's fine cool I'll I'll ask to take a sample of your urine just to make sure that there's no infection in it mhmm and I'll take a swab at the back of your throat just to see if you haven't got a viral infection they're going around a bit at the moment I hope that's okay yeah bruh okay we should talk to everyone that comes in the hospital about resuscitation about what they'd want if they were to deteriorate in hospital but from my perspective medically everything people should do everything they'll drop them down in your chest and take you to intensive care as required are you okay with that yeah okay okay maybe something you haven't thought about but no it was good for me to inquire about it just so that just for teens that might see you in the future yeah yeah we're not expecting that to happen certainly okay great well it's your meeting nice to meet you it's okay too young I'll sit back and look back and talk to you soon