Hyperosmolar hyperglycemic state Quiz: Ace Your Exams
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A 79-year-old woman presents to the emergency department for evaluation of lethargy and confusion. The patient's partner reports that she was unable to get the patient out of bed this morning and that she has been refusing all of her medications over the past several weeks. The patient has a past medical history of atrial fibrillation, hypothyroidism, coronary artery disease, type 2 diabetes mellitus, hypertension, and hyperlipidemia. Temperature is 36°C (96.8°F), blood pressure is 88/60 mmHg, pulse is 119/min, respiratory rate is 18/min, and oxygen saturation is 96% on room air. The patient appears ill and is unable to provide clinical history. Physical examination demonstrates dry mucous membranes, poor skin turgor, and delayed capillary refill. Initial fingerstick blood glucose is 680 mg/dL and serum osmolality is 380 mOsm/kg. Venous blood gas shows a pH of 7.37. The patient is given isotonic saline boluses followed by an infusion and intravenous insulin. The patient's initial laboratory findings are shown below, and repeat blood glucose at 1 hr is 550 mg/dL. Which of the following is the best next step in management?
| Laboratory value | Result |
| Serum chemistry | |
| Sodium | 129 mEq/L |
| Potassium | 3.2 mEq/L |
| Chloride | 97 mEq/L |
| Creatinine | 1.4 mg/dL |
| HCO3 | 19 mEq/L |
| BUN | 25 |
| Laboratory value | Result |
| Urinalysis | |
| Color | Dark |
| Specific gravity | 1.013 |
| Glucose | Large |
| Blood | Negative |
| Leukocyte esterase | Negative |
| Nitrites | Negative |
| Leukocytes | 1-2/hpf |
| Erythrocytes | 1-2/hpf |
| Dysmorphic RBCs | Absent |
| Casts | None |
| Ketones | None |
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