CC:

Blurred vision, numbness

HPI:

56 year-old male with a history of DM, questionable HTN presenting with blurred vision, numbness of fingertips/toes for 2wks. Associated symptoms include dry mouth, polydipsia/polyuria. He states that these symptoms coincide with elevated measurements of blood glucose at home (>500). He ran out of his diabetes medication (metformin) 8mo ago but states his BG was typically between 100-200 with diet/exercise until 2wks ago. He reports recent dietary indiscretions on a trip to Las Vegas.

He denies fevers/chills, CP/SOB, cough, abdominal pain, N/V, or dysuria.

Physical Exam:

VS:	T 37.8 HR 60 RR 14 BP 165/90 O2 99% RA
Gen:	Well-appearing, no acute distress, obese
HEENT:	PERRL, EOMI, optic discs sharp b/l, no abnormalities visualized
CV:	RRR, normal S1/S2, no M/R/G, no additional heart sounds
Lungs:	CTAB, no wheezes/crackles
Abd:	+BS, soft, NT/ND, no rebound/guarding
Ext:	Warm, well-perfused, 2+ pulses, no clubbing/cyanosis/edema
Neuro:	AAOx3, CN II-XII intact

Labs/Studies:

• BMP: 135/3.8/102/24/18/1.1/378
• CBC: 7.4/14.1/42.0/403
• UA: + glucose, – ketones

Assessment/Plan:

56M, hx DM with poor medication adherence presenting with vision changes and stocking/glove paresthesias for 2wks after reported dietary indiscretion found to be hyperglycemic. DKA/HHS unlikely given stable vital signs, normal metabolic panel with exception of isolated hyperglycemia (slight hyponatremia likely related to osmotic effect of elevated serum glucose). Also, no evidence of concerning precipitates for hyperglycemic crisis (no CP/SOB, no F/C, no cough, no abdominal pain, no change in mental status). Patient was discharged home with education on importance of medication adherence, refill of metformin, and follow-up with primary care physician for further management of DM and possible hypertension.

Evaluation of hyperglycemic crises in patients with diabetes:^1,2

Key signs/symptoms of HHS/DKA:

• Both: Polyuria, polydipsia, weight loss, hypovolemia (dry MM, skin turgor, tachycardia, hypotension)
• DKA: Short course (<24h), N/V, diffuse abdominal pain, Kussmaul respirations
• HHS: Longer course (days/weeks), altered mental status (lethargy, coma, seizure)

Admission Laboratory Data of Patients with HHS vs. DKA:¹

	DKA	HHS
Glucose (mg/dl)	616	930
pH	7.12	7.30
3-β-hydroxybutyrate (mmol/l)	9.1	1.0
Serum osmolality	323	380
Delta gap (AG-12)	17	11
Na (mEq/l)	134	149
K (mEq/l)	4.5	3.9
Bicarbonate (mEq/l)	9	18

References:

1. Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic crises in adult patients with diabetes. Diabetes care, 32(7), 1335–1343. doi:10.2337/dc09-9032
2. De Beer, K., Michael, S., Thacker, M., Wynne, E., Pattni, C., Gomm, M., Ball, C., et al. (2008). Diabetic ketoacidosis and hyperglycaemic hyperosmolar syndrome – clinical guidelines. Nursing in critical care, 13(1), 5–11. doi:10.1111/j.1478-5153.2007.00259.x
3. Stoner, G. D. (2005). Hyperosmolar hyperglycemic state. American family physician, 71(9), 1723–1730.