Personal Details:

Name: Jessica

Age: 24

Medical Record:

Past medical history: Newly diagnosed with Type 1 Diabetes Mellitus.

Notes:

Coming with nausea, abdominal pain, and vomiting

Task:

1. Talk to the patient and understand why she wants to leave.

2. Discuss the management plan

Urine dip has been done by the nurse: glucose +++, ketone +++

Blood sugar 78 mmol/L

Observation: HR 105, RR 24, T 36.8, BP 100/70 

Abdomen examination: diffuse abdominal tenderness, no guarding or rigidity, no lumps or swelling.

Opening Sentence: “Doctor, I’m feeling a bit better. Can I go home? ”

Open History (to give freely): “I’ve had this awful stomach pain and vomiting for days. But I really want to go home.”

Cues to give: “Can’t you just give me some tablets and I can go?

ICE (Ideas, Concerns, Expectations):

Ideas: “I think now that I know it’s diabetes, I can just be careful with what I eat. I feel a bit better than I did this morning.”

Concerns: “You want to go home as you have your wedding in two weeks.”

Expectation: “I expect you to understand and let me go home. I’ll come back after the wedding if I’m not better.”

How to Act: You are stressed, anxious about your wedding, and underestimating the severity of your illness. You are determined to leave at the beginning of the consultation, but after the doctor explains the seriousness of the condition, you agree to stay for treatment.

More History (only if asked): You are still feeling nauseous and weak. You don’t really understand what DKA is.

Questions to ask:

What is DKA anyway? Is it really that serious?

So what will happen if I just walk out?

Opening & Exploring Her Request:

Hi Jessica, I hear you want to go home. Can you tell me why you feel you need to leave right now?

Do you have any pain at the moment? Are you still vomiting? Do you feel thirstier? Are you passing urine okay? Have you had any fever?

Explain the situation, the likely diagnosis:

Jessica, I understand you’re feeling a bit better and that you have a huge amount to do for your wedding. It must be an incredibly stressful time. However, I need to talk to you very seriously about your health. You are currently very unwell. The condition you have, Diabetic Ketoacidosis or DKA, is a life-threatening medical emergency.

Addressing and answering the patient’s ICE:

You asked if it’s really that serious. Yes, it is. Because your body hasn’t been able to use sugar for energy, and acids are building up in your bloodstream, which is essentially poisoning your system. This is why you have had the abdominal pain and vomiting. Although you feel a little better, your blood tests show that you are still in DKA.

Next Steps:

“We cannot treat this with tablets. The only treatment is to give you insulin and fluids through a drip, directly into your vein. We need to do this in a monitored setting in the hospital, checking your blood every hour, to bring the acid level down safely. If you were to leave now, the DKA would get worse. You would become more dehydrated, your blood acid level would rise, and you could fall into a coma. People can die from DKA if it is not treated in a hospital.”

I know how important your wedding is. Our goal is to get you well enough so that you can attend your wedding and enjoy it. If you stay with us for the next 24-48 hours, we can get the DKA under control. Then, our specialist diabetes nurses will teach you how to manage your insulin injections yourself. If we can get you stable and confident with your insulin, you will be able to go home in a few days and continue your wedding preparations.”

Think of it this way: staying in the hospital for a couple more days will ensure you are well for your big day. Leaving now puts everything, including your life and your wedding, at risk. We can help you with practical things. We can allow your fiancé to visit, and we can give you access to a phone or Wi-Fi so you can try to sort things out from here. Please, let us help you get well.

Addressing ideas, concerns, and expectations: Clearly and starkly explain the life-threatening nature of DKA. Explain the treatment pathway in the hospital, including IV fluid, insulin, etc.