Clinical Case Study: Managing Diabetic Ketoacidosis (DKA)
Stepping onto the admissions unit and seeing a patient in DKA can feel overwhelming — this is a true medical emergency. But with clear understanding, structured escalation, and genuine compassion, you become the steady presence they need. This case builds your confidence in recognising the signs, acting fast, and supporting someone through metabolic crisis.
📋 How to Use This Case Study
- Read through Chloe’s story carefully — this is your handover.
- Write down your answers to all 4 questions before clicking anything. What do you see first? Who do you call?
- Click “Reveal Answer & Rationale” to compare your reasoning against evidence‑based practice.
Patient Background & Clinical Narrative
Patient: Chloe Evans, 22 years old
Background: Type 1 Diabetes since age 10. Started university recently — missed a few basal insulin doses over 48 hours due to busy schedule + mild viral throat infection.
What You See: Mid‑afternoon admissions. Exhausted, flushed, distressed. Distinct fruity/acetone breath — pear drops or nail polish remover. Breathing deep, fast, sighing. Severe central abdominal pain, nausea. Excessive thirst + frequent large‑volume urination all day.
Assessment & Key Findings
- Respiratory Rate: 28/min — deep, sighing → Kussmaul breathing
- SpO₂: 98% on room air
- BP: 102/64 mmHg
- Heart Rate: 116 bpm — tachycardic
- Temp: 37.8°C
- Blood Glucose: 18.5 mmol/L
- Blood Ketones: 5.8 mmol/L — significantly elevated
- Conscious Level: Alert, anxious, oriented ×3
NEWS2 Score: 6 — Medium‑High Risk → Urgent Escalation
Question 1: Kussmaul Breathing — Why It Happens
Chloe is breathing deeply and rapidly at 28 breaths/min. What drives this specific pattern in DKA?
Answer: Kussmaul breathing is the body’s compensatory mechanism for severe metabolic acidosis.
Rationale: Insulin deficiency → body burns fat for energy → produces acidic ketone bodies → blood pH drops. Deep, fast breathing blows off CO₂ (a volatile acid) to try and raise pH. This is not “anxiety breathing” — it’s a physiological response to chemical imbalance.
Question 2: Dehydration, Pain & Polyuria — The Chain Reaction
Thirst, constant urination, dehydration, and severe stomach pain — how do these all connect?
Answer: Hyperglycaemia → osmotic diuresis pulls water + electrolytes out → massive fluid loss → dehydration. Ketones + electrolyte shifts irritate the gut lining → severe abdominal pain that mimics a surgical emergency.
Rationale: Glucose in the urine acts like a sponge — drags litres of water with it. That’s why patients are thirsty and passing large volumes. The pain is real, visceral, and often mistaken for appendicitis — always check blood glucose + ketones first.
Guidance: Diabetes UK — Sick Day Rules & Monitoring.
Question 3: Urgent SBAR Handover
Call the medical registrar NOW. Deliver your SBAR — say “DKA” to trigger priority.
Key point: State the ketone level — it’s the single clearest marker of severity. Mention “DKA pathway” — shows you know the protocol.
Question 4: Compassion — “It’s All My Fault”
Chloe is crying, terrified, and feels guilty for missing doses. How do you respond while working fast?
Answer: Validate, normalise, remove blame — keep moving calmly:
“This is frightening — I’d be worried too. Missing doses when you’re unwell is incredibly common. Your body is under extra stress right now and that’s what’s pushed this. We see this often and we know exactly how to help you. You haven’t failed — you’re here, and we’re going to get you better.”
Rationale: Guilt + fear raise adrenaline → raises glucose → worsens DKA. Reassurance isn’t “soft” — it’s therapeutic. Patients who feel safe cooperate better, recover faster, and come back sooner if they know it’s not their fault.
Further reading: Diabetes UK — Emotional & Psychological Support.