Thread by @PSUIMReport

1/6 #IMpearls
56yoF with obesity and T2DM presents to the ED with lethargy and AMS. ROS + for weight loss and polydipsia
Labs: Na 128, glucose 720, serum osm 322
U/A: 3+ glucose and mild ketonuria
ABG: pH 7.32, bicarb 23. VS stable.

What is the dx and best initial treatment?

2/6 Mild ketonuria does not necessarily mean DKA! According to the @AmDiabetesAssn the diagnostic criteria for DKA includes:
- pH < 7.30
- Bicarbonate < 18 and
- Glucose > 250
The key differentiating feature is the 𝗽𝗿𝗲𝘀𝗲𝗻𝗰𝗲/𝗮𝗯𝘀𝗲𝗻𝗰𝗲 𝗼𝗳 𝗸𝗲𝘁𝗼𝗮𝗰𝗶𝗱𝗼𝘀𝗶𝘀.

3/6 This patient has hyperosmolar hyperglycemia syndrome (HHS) which commonly causes significant mental status changes as seen in the case.
👇 chart from UpToDate 👇

4/6 The best initial tx for DKA and HHS is fluid resuscitation with 0.9% NaCl, which should be initiated while additional workup is completed.
Correction of K+ deficits and IV reg. insulin should follow
✨ Even if K+ is elevated in the blood, total body K+ is likely depleted ✨

5/6 What about their hyponatremia of 128? Don’t be fooled! Serum sodium is falsely lowered by 1.6-2.4 mEq per 100 mg/dL increase in blood glucose. This must be corrected for an accurate assessment of sodium level. MDCalc provides an easy way to do this.

6/6
Students - can you describe the major physiologic differences between DKA and HHS? Why does DKA lead to significant acidosis while HHS does not?

Educators, feel free to add your own pearls!
#IMPearls #MedEd #MedTwitter
@NickDuca57 @BMcGillenMD @NaziaRajaKhan @davidshoremd