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Diagnostic process - history, examination and investigation

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

diagnosis

Unlike diabetic ketoacidosis (DKA) which presents within hours of onset, HHS comes on over many days (1).

  • typical patient is an elderly person with undiagnosed diabetes or type 2 diabetes managed by diet and/or oral diabetic medication
  • history will reveal one or more of the precipitating factors (often medication) (1,2)

HHS patients may present with:

  • weakness
  • visual disturbance
  • leg cramps
  • nausea and vomiting - less frequent than in patients with DKA
  • neurological symptoms - degree of neurologic impairment correlates directly to the effective serum osmolarity
    • lethargy, confusion
    • hemiparesis (often misdiagnosed as cerebrovascular accident)
    • seizures - present in up to 25% of cases, can be generalized, focal, myoclonic jerking, or movement induced
    • coma (2)

Physical finding will reveal

  • signs of severe dehydration e.g. - poor tissue turgor, dry buccal mucosa membranes; soft, sunken eyeballs; cool extremities; and a rapid, thready pulse
  • low grade fever
  • abdominal distension - due to gastroparesis induced by hypertonicity (2)

Investigations

  • blood glucose - markedly raised (usually 30 mmol/L or more)
  • serum osmolarity - elevated >320 mmol/L (normal range is 290 ± 5 mmol/L)
    • serum osmolarity is useful, both as an indicator of severity and for monitoring the rate of change with treatment
    • if measurement of total osmolality is not available, osmolarity should be calculated as a surrogate using the formula 2(Na) + glucose + urea.
  • arterial blood gases
  • urinalysis
  • renal function tests and electrolytes
  • creatinine, blood urea nitrogen (BUN)

Reference:

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