Cases/Urgent & Unscheduled care

Type 1 Diabetes and A Stomach Bug — Free SCA Practice Case

Woman with type 1 diabetes and a stomach bug

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Briony Ledgard

Age

24 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day call booked by the patient.

Reason for Encounter

"I've been ill since last night and my sugars are high."

Medical Records

●PMH: Type 1 diabetes since age 17 (diagnosed after presenting in diabetic ketoacidosis). HbA1c 62 mmol/mol four months ago. Eczema.
●Medications: Insulin glargine at night, insulin aspart with meals (carbohydrate counting). Progestogen only implant. Emollients.
●Allergies: NKDA.
●Social: Data analyst. Shares a flat. Non smoker.

Patient Script

For the friend playing the patient role

Character Overview: You are Briony Ledgard, a 24 year old data analyst at an energy company. You share a flat with your flatmate Dani, who works long shifts as a care assistant and is out until late tonight. Your mum lives about 40 minutes away by car. You do not drive and have no car. You have had type 1 diabetes since you were 17 and mostly cope well. You phoned because you are not sure what to do. You are tired, dry mouthed and a little wobbly, but fully alert and able to talk clearly. Your tone is polite, slightly sheepish, and quick to defend yourself when you feel told off. You get quieter and more anxious when hospital comes up.

Opening Sentence: "Hello, doctor. I've been sick since last night and I've got diarrhoea too, and my sugar's gone up to 19. I'm not eating anything so I've left my insulin, but I wasn't sure if that was right."

History if Asked (Data Gathering Phase)

●How it started: "My stomach started cramping about ten last night and the diarrhoea started soon after. I was first sick around one in the morning. Dani had the same bug three days ago, so I think I've caught it from her."
●Vomiting and diarrhoea: "I've been sick about six times. The last time was about forty five minutes ago. There was no blood and it was just fluid and bile. The diarrhoea is watery, maybe seven times, with no blood or black stools."
●Drinking: "I tried sips of water and some weak squash this morning. The first few stayed down. The last two lots came straight back up within minutes. I haven't kept anything down for about four hours."
●Eating: "Nothing since lunch yesterday. I tried a cracker this morning and it came straight back."
●Hydration: "I'm really thirsty and my mouth is dry. I was passing loads of urine in the night, but this morning I've only been twice and it was dark. I feel light headed when I stand up."
●Tummy pain: "It's crampy and across the middle, about three out of ten, and it comes and goes with the diarrhoea. It isn't in one spot and it isn't getting worse."
●Breathing and alertness: "My breathing feels normal, I'm not short of breath. I'm very tired and a bit woozy but I'm thinking clearly. My heart feels like it's racing a bit when I stand up."
●Temperature and other symptoms: "No fever that I know of. No cough, no sore throat, no burning when I pass urine."
●Insulin taken: "I haven't taken any since yesterday lunchtime. My last mealtime dose was with that lunch. I skipped my long acting at bedtime last night, so the last one I had was the night before. I take twenty two units of the long acting at night and a mealtime dose worked out from my carbs. I usually take one unit for every ten grams."
●Why she stopped: "Last year I had a stomach bug and carried on with my normal insulin. I dropped to 2.6 at four in the morning and Dani had to wake me and give me juice. It scared me. I thought if I'm not eating, insulin will send me low again."
●Glucose readings: "I checked at midnight and it was 11.8. At seven this morning it was 16.4, and about an hour ago it was 19. I haven't checked since."
●Ketones: "I do have a blood ketone meter and strips from the diabetes nurse, but I've never used them when ill. I don't have urine sticks." Gating note: If the doctor asks her to check, she goes to find the meter, and returns saying "it says 2.4". She gives no ketone result unless asked to test.
●Sick day knowledge: "I did an education course a few years ago. There's a sick day sheet in a drawer somewhere but I haven't looked at it."
●Previous problems: "I was in hospital for four days when I was diagnosed because my blood was too acidic, and I hated every minute. No other admissions since."

Ideas, Concerns, Expectations

Gating note: Briony does not raise any of these herself. Each part comes out only when the doctor asks what she thinks is happening, what is worrying her, or what she was hoping for.

●Ideas: She thinks it is an ordinary stomach bug, and that the high sugar is just the illness and stress. She believes insulin without food is what puts you in danger. She thinks the really serious sugar problem only happens if you leave insulin out for days. "I've only missed a day. I thought the dangerous stuff takes longer."
●Concerns: She is frightened of going into hospital. She remembers the drip, the cannulas and the four days at diagnosis. She also worries about going low if she takes insulin, and she does not want her mum to panic. "I don't want to end up back on a drip. And Mum will go into a state."
●Expectations: She hoped to be told how much insulin to take, and for something to stop the vomiting so that she can sleep it off at home. "Can you give me something for the sickness? If I can keep fluids down I'll be fine."

If Asked: Medical History and Medications

Gating note: Briony answers each of these plainly when the doctor asks about it.

●Other health problems: "Just the diabetes and a bit of eczema. No thyroid problems that I know of."
●Medicines: "Long acting insulin at night, mealtime insulin with food, the implant in my arm, and emollient for my eczema. I haven't taken anything for the sickness. No ibuprofen or anything like that."
●Allergies: "None."
●Pregnancy: "I've had the implant for two years and my last period was about three weeks ago. I'm not pregnant."
●Hypoglycaemia awareness: "I usually feel lows coming, the shaking and sweating. The one last year was the only really bad one."
●Supplies: "I have glucose tablets and a spare pen of each insulin. I don't have a glucagon kit."

Social History and Lifestyle Impact

●Home: Lives in a shared flat with Dani. Dani is at work until about midnight, and Briony can phone her but she cannot leave work easily.
●Family: Her mum lives about 40 minutes away and would come if asked, but Briony does not want to worry her. Her dad lives abroad.
●Transport: Does not drive and has no car. She feels too dizzy and sick to take a bus.
●Smoking and alcohol: Non smoker. A couple of drinks on a weekend out, nothing this week.
●Availability to be seen: She says she would rather not travel on public transport feeling like this, but would come to the surgery if there was nothing else.

If Asked: Associated Symptoms

Gating note: Briony answers these only when asked. Every one is negative unless stated.

●If asked about pain in the right lower abdomen, a rigid abdomen or pain getting worse: "No, it's just crampy and comes and goes."
●If asked about fast or deep breathing, chest pain or a fruity smell on her breath: "No, and nobody's said anything about my breath."
●If asked about confusion, drowsiness or blurred vision: "I'm tired but I'm thinking fine. My vision's normal."
●If asked about recent antibiotics or other illness at home or work: "No, only Dani."

Responses to Management (The Negotiation Phase)

●
If the doctor tells her not to stop her insulin:
- ●Reaction: Uneasy. "But I'm not eating. Last time I went to 2.6 doing exactly that." If the doctor explains that the long acting insulin is needed even when she is not eating, that the plan will include checking her glucose, and that the hospital team will watch her, she accepts and asks "so how much do I take?" If told to take her usual long acting dose, she agrees. If told to seek advice about the mealtime doses, she is fine with that.
●
If the doctor asks her to check her ketones or discusses the result:
- ●Reaction: Curious. She gives 2.4 if asked to test. "Is that bad? The nurse said something about a number, but I can't remember which." If told what it means, she becomes anxious: "So I'm in trouble, then?"
●
If the doctor advises going to hospital:
- ●Reaction: Reluctant at first. "Can't I just stay home and sip fluids? I'll check my sugars every hour, I promise." If the doctor explains clearly why home is not safe, that she cannot keep fluids down, her ketones are raised and she may need fluids and insulin through a drip, she says "okay, I don't want to get worse." She then asks how she is going to get there, because Dani is at work, her mum is 40 minutes away and she cannot drive. If told to drive herself or take the bus, she says she is too dizzy. If an ambulance is suggested she says "isn't that a waste of an ambulance?" and agrees if reassured. If asked to phone her mum, she agrees with "she'll panic but I'll tell her to stay calm".
●
If the doctor offers or declines anti sickness tablets:
- ●Reaction: She wants them. "Surely a tablet to stop me being sick would do it?" If told the hospital will treat the vomiting and that the tablets alone won't make home safe, she accepts: "Fair enough, I just want it to stop."
●
If the doctor talks about what to bring and what to watch for:
- ●Reaction: Practical. She repeats back: "Pens, meter, ketone strips and my readings." If safety netting is vague, she asks "what counts as getting worse?" She wants to know if the hospital will be warned. "Will you ring ahead so I don't wait for hours?"
●
If the doctor explains what to do next time she is ill:
- ●Reaction: Receptive. "Nobody ever really went through it properly. Can I get it written down?" She is glad to hear the diabetes nurse can see her afterwards.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Briony is a 24 year old with type 1 diabetes, about a day of vomiting and diarrhoea, a glucose of 19 mmol/L and no insulin since yesterday's lunch. She believes the problem is a stomach bug and that insulin is unsafe if she is not eating. She has a blood ketone meter, and the result she gives when asked (2.4 mmol/L) decides the disposal. The station tests whether the candidate finds the ketone level, applies the thresholds and sends her for emergency assessment without being talked out of it by her reluctance, while correcting the dangerous belief about insulin.
●The model plan has five parts. Take a focused history of the illness, the hydration, the exact insulin missed and why. Ask her to check blood ketones now. Recognise that a ketone level of 1.5 to 2.9 mmol/L in a person who cannot eat or drink needs emergency hospital assessment today, arranged safely (not driving herself) with a phone call ahead. Tell her not to stop insulin, and to take her long acting insulin. Give interim and safety net advice, and arrange follow up and sick day education after she has recovered.
●Acceptable alternatives: an ambulance, or a lift from her mum, are both acceptable if the journey is safe and prompt. Telling her to take her usual long acting dose before leaving, letting the hospital team give the background insulin promptly under supervision, or advising her to seek the diabetes team's advice about the mealtime doses, are both acceptable. Sick day education during the call or after discharge are both acceptable, provided the immediate decision is not delayed.

Why Insulin Must Not Be Stopped

●NICE Clinical Knowledge Summaries (CKS) Diabetes type 1 (revised June 2026) advise: never stop or omit insulin therapy during illness. The dose may need to be altered, and the person should seek advice from the diabetes team if unsure how to adjust it.
●The background insulin keeps the body from breaking down fat for fuel. Without it, ketones are made even when the glucose is only moderately raised, and the blood becomes acidic. Taking insulin when not eating is not the same as taking a full mealtime dose without food: the background dose is still required.
●Gastroenteritis can lower glucose, and she has had a hypoglycaemic episode at 2.6 mmol/L when she carried on unchanged. A good consultation validates the fear and explains that the answer is more monitoring with a supervised plan, not stopping insulin.
●No dose needs to be stated. A reasonable answer is her usual long acting insulin, leaving mealtime and correction doses to the assessing team unless she is clear how to adjust them.

Ketones and the Thresholds That Matter

●CKS advises that ketones are high above 2+ in urine or above 3 mmol/L in blood, and that urgent medical advice is needed in that situation. CKS advises that emergency hospital admission should be arranged where there is moderate ketonuria (2+) or ketonaemia of 1.5 to 2.9 mmol/L, with or without hyperglycaemia, and the person cannot eat or drink, because of the risk of ketoacidosis.
●NICE guideline NG17 (Type 1 diabetes in adults) recommends considering ketone monitoring, blood or urine, as part of sick day rules (recommendation 1.10.1). CKS notes that blood ketone measurement is preferred over urine, and that blood ketones can be raised in gastrointestinal illness or starvation even if the glucose is low or normal.
●Briony's ketone level of 2.4 mmol/L, together with vomiting that has prevented her keeping fluids down for hours, falls into the emergency admission category. Her glucose of 19 mmol/L is above the 11 mmol/L that CKS uses to raise suspicion of ketoacidosis when associated with nausea or vomiting.
●A candidate who does not obtain a ketone result can still reach a safe decision, because vomiting, dehydration, missed insulin and a glucose above 11 are enough to arrange assessment. The result makes the decision explicit and gives her a clear reason.

Why Hospital and Not Home

●CKS lists reasons to arrange emergency admission: an immediate risk of ketoacidosis, moderate ketones with an inability to eat or drink, and failure to improve rapidly with insulin. It also lists reasons to consider admission or seeking specialist advice: unclear underlying condition, dehydration or risk of dehydration, vomiting beyond two hours, difficulty keeping glucose above 3.9 mmol/L and exhaustion of the person or carers.
●Briony meets several of these. She has been vomiting for about 12 hours, she is dehydrated with a racing heart when she stands, she lives alone for most of today, and she has already omitted background insulin for a day. Managing at home with anti sickness tablets and hourly checks is not safe, because she needs intravenous fluids, supervised insulin and monitoring that a telephone plan cannot provide.
●A same day assessment in an emergency department or acute medical unit is the standard route. An in person assessment at the surgery with a point of care ketone test is a reasonable first step only if it is immediate, and it must lead directly to hospital transfer. Any plan that leaves her at home overnight, or waiting for a call back, is not acceptable.
●Safe transport matters. She is dizzy, dehydrated and vomiting, so she should not drive. A lift from her mum is acceptable if quick and she is accompanied, and an ambulance is appropriate if no lift is available or she worsens. Phoning ahead helps avoid delay.

Assessing Severity on the Phone

●Features that point to ketoacidosis include nausea or vomiting, abdominal pain, fast or deep sighing breathing, dehydration and reduced consciousness (CKS: suspecting diabetic ketoacidosis). Briony has vomiting and dehydration and a racing heart on standing, but normal breathing and alertness, and mild non focal cramps, so she is not yet in severe ketoacidosis.
●A telephone candidate should still screen for breathing pattern, drowsiness, abdominal pain, fever and other causes, such as urinary infection or alcohol, because these change urgency and give the receiving team a better handover. Pregnancy should be considered in a woman of reproductive age with vomiting, although the implant makes it unlikely here.

Advice While She Waits

●Small frequent sips of sugar free fluid if tolerated, glucose checks every one to two hours (CKS), and repeat ketones are all reasonable. If glucose is low, she should take carbohydrate containing drinks or fast acting carbohydrate. CKS advises avoiding carbonated drinks.
●The candidate should tell her to ask her mum or Dani to be with her, and should say clearly when to dial 999: drowsiness, confusion, fast or deep breathing, worsening abdominal pain, collapse, or if she cannot travel.
●Anti sickness tablets are not an alternative to assessment. They may be given by the hospital team as part of treatment. Prescribing them and sending her home to see how she gets on is the unsafe path.

Sick Day Rules for the Future

●CKS advises that people with type 1 diabetes should have written sick day rules, with contact details for the healthcare team, easily digestible food and carbohydrate containing drinks, oral rehydration therapy, additional supplies of insulin, and glucose tablets or gel and, where appropriate, glucagon.
●The rules are to never stop insulin, check glucose every one to two hours including overnight, check ketones every three to four hours (more often depending on results), keep drinking at least 3 litres a day if possible, replace meals with carbohydrate containing drinks if not eating, and seek urgent advice if ketones are above 3 mmol/L (urine above 2+), if vomiting, unable to drink, or if there are signs of severe dehydration.
●These rules should be offered when she is well enough to take them in. Offering a short version in the call is good practice, but the priority at the time is the disposal. Spending most of the call teaching while delaying care misjudges the priority.

Follow Up and Prevention

●After discharge, arrange contact with the diabetes specialist team, who can repeat the education, review her insulin regimen and explore her fear of hypoglycaemia. Education should include how to adjust insulin during illness.
●Check she has in date blood ketone strips and glucose tablets, and discuss a glucagon kit given her previous low. A GP review soon after discharge is reasonable.

Common Mistakes in This Station

●Not asking for a ketone result, or accepting the glucose alone as reassuring.
●Telling her to omit insulin until she is eating, or giving her a full mealtime dose without considering the effect of no food.
●Agreeing to manage her at home with anti sickness tablets and hourly checks because she is reluctant to go to hospital.
●Telling her to drive herself or take the bus, or leaving her to arrange the journey without checking it is possible.
●Safety netting with "ring back if it gets worse" and no named symptoms.
●Lecturing her about missing insulin instead of acknowledging her fear of a low.
●Using words such as "ketoacidosis" without explaining them.

Mapped to the RCGP curriculum topic: Urgent & Unscheduled care.

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