Who you are:
You are an FY2 in emergency department.Who the patient is:
30-year-old Pauline Lynn has been brought by an ambulance to the A&E with history of abdominal pain. She has been diagnosed with Type 1 diabetes. She is Insulin dependent. The blood test has been done and she has been diagnosed with DKA. She is not willing to stay in the hospitalAdditional information:
Vitals:-
BP: 90/60 mmHg
Pulse: 110
02 Sat: 95
RR: 17
TEMP: 37Special note:
Patient is refusing admissionWhat you should do:
Take focused history, discuss the appropriate plan of management.
D: Hello I’m one of the doctors here in the emergency department. Is it
Pauline?
P: Yes.
D: Can I get your full name and date of birth please.
P: (She confirms details)
D: I can see you are in distress Pauline, what is going on? /What brought you here today?
P: I just want to go home; I don’t want to stay here.
D: Well it is your right to go if you want, but how about I ask you some questions first and if everything is fine, then we can send you home.?
P: No doctor it is just some tummy ache. Don’t bother, I need to go home.
D: Pauline it’s our duty to make sure you’re safe and we wouldn’t want to miss anything serious before we are able to discharge you, right? Can you please describe more about this ache?
P: Okay doctor. (OR) Doctor I am fine please send me home !!
Start Refusal structure
(It is unlikely that the patient will be that stubborn with the Hx so she will probably answer but will strongly refuse admission later in management. Depending on the patient you can start your refusal structure here or later)
Why ---- Address — Benefit — Warn
P: Like I said doctor I felt sick, and I had tummy pain. Explore pain
(SCOCRATES) and sickness briefly as it is already diagnosed DKA.
D: Can you tell me more?
P: I have had pain all over my tummy, (points towards her abdomen) for the last few hours and it is getting worse.
D: How did it start?
P: Suddenly.
D: What about the sickness?
P: It started at the same time with my belly discomfort.
D: Is there anything that makes you feel better or worse?
P: No.
D: Can you grade the pain for me from 1 to 10 with one being the least and ten being the most severe pain?
P: 7.
D: Have you had anything else apart from these?
P: No.
DDx (1 or 2 tops) (Make sure don’t spend a lot of time on DDs of tummy pain as it is DM station)
D: How are your bowels?
P: Nothing new.
D: Any vomiting?
P: No.
P4: D: How are your periods? When was the last? Are you on any contraception?
Don’t forget Ectopic pregnancy (Important)
DM Sx
D: Any problems with your water works, like going to the loo more often?
P: Yes/No
D: Have you been feeling excessively thirsty?
P: Yes/No.
DKA Sx (dehydration Sx)
D: Is your mouth dry? Not going to the toilet?
P: No.
D: Have you been breathing faster or deeper than usual?
P: Yes/No
D: Have you noticed or been told that your breath smells funny or maybe fruity?
P: Yes/No.
D: Do you feel like you are a bit confused or dizzy and about to faint?
P: No.
D: Do you feel tired or drowsy?
P: No.
D: Any fever, flu-like symptoms recently? (Viral infection most common exacerbating factor)
P: No.
P2
D: Have you had similar problems in the past?
P: No.
D: I understand that you have diabetes, can you tell me more about it?
Explore like before:
P: I have had diabetes for the last 10 years, since I was a teenager.
D: How is it controlled?
P: I take insulin Actrapid and some other one I can’t really recall.
D: How many times a day are you taking it?
P: I take it once at night and 2-3 times during the day.
D: Do you take it regularly?
P: Usually I do. But I didn’t take it for the past 5 days.
D: May I ask why?
P: I have a wedding in 4 weeks time and I want to look beautiful in the dress I bought. I stopped my insulin as I didn’t eat much in the last 5 days trying to lose some
weight so I can fit into my dress.
D: I understand. I just want to ask a few more questions to assess if it’s safe to send you home.
P: Okay.
D: Have you ever skipped your dose of insulin before?
P: Yes. I did it when I was 16 and there was no problem.
D: Do you check your blood sugar regularly?
P: Not really.
D: When was the last time you checked it?
P: When I came to the hospital.
D: And what was the reading?
P: 22.
D: Do you attend your GP and annual review regularly?
P: Yes.
D: When was the last time you went to the GP?
P: A year ago.
D: Have you been diagnosed with any other medical conditions?
P: No.
MAFTOSA
As before, especially MAF
DESA:
Acute setting so no need (you can say we will book another appointment to discuss lifestyle modifications.)
Examination:
Thank you, Pauline, for being so cooperative. I would like to check your vitals and examine your heart, chest and tummy now, would that be okay?
Risk factors & DKA
• Infection (chest & urine) v. important
• Not taking medications?
Complications of DM (DKA):
(dehydration questions)
− Dry mouth
− Feeling thirsty
− Not passing enough urine
− Drowsy
− Dizzy
In any case of DKA you must remember:
− DM hx
− Infection as a cause
− Dehydration as a complication
I would also like to send for some initial investigations including routine blood tests and your blood sugar level.
The examiner or the role player will say:
All the investigations are on the table.
Provisional Diagnosis:
I am well aware that you really want to go home, but how about you give me the chance to explain what might be going on here, and then I will let you decide because it could be serious.
P: Please let me go home doctor. I feel fine and I have got so much to do. And I swear I will start eating and taking my medications regularly.
D: I understand your frustration, Pauline. I am afraid your condition might be very serious now. What you have is called Diabetic Keto Acidosis, where blood sugar goes very high along with other bad chemicals called Ketone bodies. It’s a serious diabetic complication and life threatening if we don’t treat immediately, so it is better to admit you. I’m sorry to say it!
P: Oh doctor I want to go home please don’t admit me I am fine.
- D: May I ask why you want to go home Pauline?
- P: Because I have so many arrangements to do before the wedding.
- Address the concern: How about you get some help from any of your family or friends?
P: They are doing so much already doctor.
D: Why don’t you hire a wedding planner and she can help you with all the arrangements, at least until you’re well enough to carry on. - Benefits If you stay in the hospital we can provide the suitable management that will help you with the pain, run some tests and make sure that you are recovering and then after that we can send you home.
- Warn her of risks Ultimate risk — DEATH
P: Okay doctor It seems really dangerous, I will stay and will talk to my family about the preparations.
Management:
Admit
Senior
Investigations
(DM/infection/ dehydration) Verbalise what has not been requested yet to help you exclude any DDx that you may have missed with your history. Always a good strategy to mention the investigations if you are cutting the history short.
− Blood (RBS/ ESR- CRP/ cholesterol/ ABG/ KFT)
− Urine (dipstick culture + ketone bodies)
− CXR: chest infection
− Erect abdominal x ray to exclude perforation
Findings will be on the table: RBG (30 mmol), ABG (metabolic acidosis), ketonemia and ketonuria.
Treatment:
Symptomatic:
− For DM (insulin injections into your veins on a drip to decrease sugar levels)
− For dehydration (fluids through your veins)
− For infections (antibiotic) / paracetamol for fever.
Lifestyle: if there is a problem in DESA or (advise about the cause of DKA)
Verbalize booking follow up appointments to discuss it.
− Even if you’re busy, you must still take your insulin.
− You must go for your regular follow-ups.
− If you have fever or signs of infection you must see your GP
Safety netting: About Driving and Hypoglycaemia and DKA.
Another scenario of DKA
You are an FY2 in emergency department.
Alicia, 16 yrs old, with abdominal pain & weight loss.
She has come with her mum
(ask the patient if it’s OK for her mum to stay)
Make sure it’s not anorexia nervosa station, it’s a case of undiagnosed DM with DKA
first presentation, so ask her about (polydipsia/ polyuria/ weight loss)