Question

A 53 year old female with type II diabetes presents is brought to the physician by her husband because of lethargy, fatigue, and decreased responsiveness. She had been feeling well until two days ago, when she developed myalgias and upper respiratory congestion. Medications include glipizide, metformin, lisinopril, and atorvastatin. On physical examination, the patient is somnolent but arousable. Vital signs include temperature 36.7 C (98.6 F), pulse 130, blood pressure 102/64, respirations 15/min. There is no nuchal rigidity. There is poor skin turgor and the patient's mucous membranes are dry. Laboratory evaluation shows the following: Na+ 124, K+ 4.0, Cl- 92, HCO3- 24, BUN 70, creatinine 2.1, glucose 965, total protein 6.1 g/dL, albumin 4.5 g/dL, AST 12 U/L, ALT 17 U/L, Alk. Phosphatase 110 U/L, total bilirubin 0.7 mg/dL. Which of the following is the most likely diagnosis in this patient?

A. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
B. Diabetic ketoacidosis
C. Bacterial meningitis
D. Nonketotic hyperosmolar coma
E. Acute sinusitis

Answer 1

The patient is most likely experiencing Nonketotic hyperosmolar coma, a serious complication of type II diabetes characterized by extremely high blood glucose levels, altered mental status, and signs of dehydration, without significant ketosis or acidosis.

Step-by-step explanation:

The most likely diagnosis for this patient, given the presentation and laboratory findings, is Nonketotic hyperosmolar coma (D). This condition is characterized by severe hyperglycemia (elevated blood glucose levels) without significant ketosis, often occurring in patients with type II diabetes. The patient's high blood glucose level of 965 mg/dL along with altered mental status (somnolent but arousable), and evidence of dehydration (poor skin turgor and dry mucous membranes) fit the typical presentation of nonketotic hyperosmolar coma. Additionally, her normal blood pH (indicated by a normal HCO3− level) and absence of urinary ketones would suggest that ketoacidosis is less likely and support the diagnosis of nonketotic hyperosmolar state.