Hyperosmolar Hyperglycaemic State – Clinical Case

Hyperosmolar Hyperglycaemic State – Clinical Case

A 56-year-old male attended ED with h/o progressive increase in fatigue and weakness over the past month. He felt so weak that he almost passed out. He also reported an increased fluid intake and an increase in urinary output. There was no pain on urination or history of urinary tract infection. He denied chest pain, vision problems, nausea, diarrhoea, and syncope. Family members were concerned that the patient was wobbly when he walked. While waiting in the emergency room, the patient experienced 2 tonic-clonic seizures.

PMH: Nephrolithiasis, hypertension, benign prostatic hypertrophy.

Current Medications: Lisinopril, Allopurinol, Flexeril.

Denies alcohol and tobacco use.

O/E: B.P: 71/36 mm Hg; pulse, 115; respiratory rate, 22; and temperature, 36.9 C. The patient was awake and responsive but not oriented. The skin was dry and turgor was poor. The oral mucosa was also dry. The abdominal exam revealed mid-epigastric tenderness. Neurologic exam was non-focal. Lung and cardiac exams were normal.

Investigations:

ABG

  • PH:           7.3 (7.387.42)
  • PCO2:      3.9 kPa (4.7 6 kPa)
  • PO2:         29.4 kPa (10.5 13.5 kPa)
  • HCO3:      8 (2426 mEq/L)

Biochemistry:

  • Na+:                 107 mEq/L (134144 mEq/L)
  • K+ :                  6.1 mEq/L (3.55.1 mEq/L)
  • Cl- :                  68 mEq/L (96108 mEq/L)
  • TCO2:              13 (2230 mEq/L)
  • Anion gap:        37 (414)
  • BUN:                11.4 mmol/L (2.5 7.8 mmol/L)
  • Creatinine:        282 mol/L (65 – 120 mol/L)
  • Glucose:            > 116 mmol/l (4 7.8 mmol/l)
  • C-peptide:          1.1 ng/mL (0.97.1 ng/mL)
  • Ionized Ca2+:    0.72 mmol/L (1.121.32 mmol/L)
  • Hb A1c :            12.4 (4.46.4)
  • Lactic acid:        9 mmol/L (0.22.0 mmol/L)
  • Lipase:              1485 units/L (857 units/L)
  • Amylase:           809 units/L (25115 units/L)

Haemetology:

  • White blood cells:         15.9 (4.011.0 K/mm3)
  • Red blood cells:             4 (4.505.90 K/mm3)
  • Hemoglobin:                  12.8 (13.018.0 g/dL)
  • MCV:                             103.3 (80.099.0 fL)

Plasma and Urine Ketones Negative.