PUID: 63 || PLAB 2 Mock 5 :: AdmissionRefusalOrLAMA1: DKA Refusing Admission

Practice a case with the AI patient 🤖

📝 Summary

This scenario involves a patient with poorly controlled diabetes presenting with abdominal pain and UTI symptoms, diagnosed with DKA but reluctant to stay in hospital. The key challenge is systematic clinical reasoning and effective communication to ensure safe admission.

Key Points

Data Gathering & Clinical Recognition

• Abdominal pain, nausea, vomiting → think DKA

• Burning micturition → trigger for UTI

• DKA is often multifactorial:

  • Missed insulin doses

  • Infection (e.g., UTI)

• Use open-ended questions first:

  • “Have you had any other symptoms?”

• Always explore:

  • Medication adherence (insulin use)

  • Triggers (infection, stress, lifestyle)

Investigations (Crucial in PLAB 2)

• ⚠️ Investigations must be explicitly requested

• Essential tests:

  • Urine dipstick (trigger: burning urine)

  • Blood glucose

  • Blood ketones

  • ABG (metabolic acidosis)

  • Full Blood Count (infection)

• Key learning:

  • If you don’t ask → you won’t get results

Examination

• General physical examination:

  • Signs of dehydration (dry mucosa, tachycardia)

• Focused abdominal exam:

  • For pain and complications

• Always link findings to severity

Clinical Reasoning & Prioritisation

• Recognise DKA as an emergency

• Identify:

  • Immediate risk: metabolic acidosis, coma, death

• Avoid missing the main issue (common PLAB error)

Information Delivery (Common Weak Area)

• Avoid overwhelming the patient

• Use a structured explanation:

  1. What was done (tests)

  2. What was found

  3. What it means

  4. Why it happened

  5. What needs to be done

Example structure:

• “Your blood test shows high acid levels → due to uncontrolled diabetes”

• “Your urine shows infection → this triggered the worsening”

• “This condition (DKA) can be life-threatening if untreated”

Important Considerations

• DKA complications:

  • Coma

  • Death

• Be clear and honest about risks (not exaggeration—clinical reality)

• Patients must make informed decisions

• Address social concerns:

  • Childcare

  • Family support

• Offer solutions:

  • Contact relatives

  • Support systems

Diagnostic Approach

1. Take focused history:

   • Symptoms (abdominal pain, vomiting, polyuria)

   • Infection symptoms (UTI)

2. Assess adherence:

   • Missed insulin doses

3. Identify triggers:

   • Infection, stress, lifestyle

4. Perform examination:

   • Dehydration + abdominal exam

5. Order investigations:

   • Blood glucose, ketones, ABG, urine dipstick

6. Confirm:

   • DKA + precipitating factor (UTI)

Management

Immediate (Emergency)

• Admit patient (DO NOT discharge)

• IV fluid resuscitation (correct dehydration)

• IV insulin infusion

• Electrolyte monitoring (especially potassium)

Treat Underlying Cause

• Antibiotics for UTI

Monitoring

• Blood glucose

• Ketones

• ABG

Education

• Importance of insulin adherence

• Sick day rules

Communication Skills

• Start by exploring concerns:

  • “I understand you want to go home—can you tell me why?”

• Use signposting:

  • “I’ll explain what we found”

• Avoid:

  • Information dumping

  • Medical jargon

• After each point:

  • Explain meaning clearly

• Emphasise severity:

  • “This can become life-threatening if untreated”

• Offer reassurance with solutions:

  • Social support arrangements

➡️ Communication must be clear, structured, and patient-centred 

Ethical Considerations

• Respect patient autonomy

• Ensure informed decision-making

• Explain risks clearly (capacity-based decision)

• Prioritise patient safety

• Work in partnership with patient

• Follow duty of care and communication standards 

📚 Additional Resources

• GMC Good Medical Practice

• NICE Guidelines: DKA management

• PLAB 2 Examiner Top Tips

• GMC PLAB 2 marking domains