Hyperosmolar hyperglycemic state Quiz: Ace Your Exams
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A 66-year-old man presents to the emergency department for evaluation of altered mental status. The patient's partner reports that they found him unresponsive in bed this morning and that he was suffering from an upper respiratory illness all week. The patient's partner states he has not seen a physician in several years and is not adherent with his medications. He has a past medical history of type 2 diabetes mellitus, hypertension, and hyperlipidemia for which he is prescribed metformin, atenolol, and atorvastatin. Temperature is 36°C (96.8°F), blood pressure is 95/60 mmHg, pulse is 123/min, respiratory rate is 22/min, and oxygen saturation is 95% on room air. The patient appears ill, lethargic, and is unable to provide a clinical history. Physical examination demonstrates dry mucous membranes and eye exam shows normal pupil exam. Fingerstick blood glucose is >600 mg/dL and venous pH is 7.4. Additional laboratory findings are shown below. Which of the following is the best next step in management?
| Laboratory value | Result |
| Serum chemistry | |
| Sodium | 129 mEq/L |
| Potassium | 4.5 mEq/L |
| Chloride | 97 mEq/L |
| Creatinine | 1.4 mg/dL (baseline 1.1 mg/dL) |
| HCO3 | 19 mEq/L |
| Glucose | > 600 mg/dL |
| BUN | 25 |
| Serum Osm | 440 mOsm/kg |
| 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 | Few |
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