History and exam

Key diagnostic factors

common

altered mental status

Altered mental status is frequently present on admission, and correlates with the severity of hyperglycemia and serum osmolality.[1]​​​

Coma is a very rare presentation of hyperosmolar hyperglycemic state. Typically, coma is associated with serum osmolality levels >340 mOsm/kg.[3]

Other diagnostic factors

common

polyuria

Symptom of hyperglycemia, may develop over days to weeks.[4]

polydipsia

Symptom of hyperglycemia, may develop over days to weeks.[4]

weight loss

Symptom of hyperglycemia.

weakness

Symptom of hyperglycemia.

dry mucous membranes

Sign of volume depletion.

poor skin turgor

Sign of volume depletion. Volume depletion may be difficult to assess in the form of poor skin turgor in older patients.

Assessment of the buccal mucosa for dryness is more informative in these patients.​[8]

tachycardia

Sign of volume depletion.

hypotension

Sign of volume depletion.

seizures

Seizures are seen in up to 25% of patients and can be either focal or generalized.

Epilepsia partialis continua is an unusual form of seizure that is present in 6% of patients with hyperosmolar hyperglycemic state (HHS) in the early phase of HHS.[49]

Seizures related to hyperglycemia in HHS are usually resistant to anticonvulsive therapy and phenytoin may further exacerbate HHS.[8]

uncommon

hypothermia

Although concomitant infection is common in hyperosmolar hyperglycemic state, patients are usually normothermic or hypothermic owing to peripheral vasodilation.[46]

Severe hypothermia is a poor prognostic sign.​[8][46]

shock

Sign of volume depletion.

abdominal pain

Abdominal pain is uncommon in hyperosmolar hyperglycemic state (HHS) but frequent (>50%) in diabetic ketoacidosis (DKA).[1]​​[12]​​ Therefore, in patients with hyperglycemic emergencies, the presence of unexplained abdominal pain should guide the clinician toward a diagnosis of DKA over HHS.[12]

focal neurologic signs

Focal neurologic signs in hyperosmolar hyperglycemic state (HHS) can be in the form of hemianopia or hemiparesis at presentation.​​[8][12][46]

This presentation can be mistaken for acute stroke. However, correction of hyperglycemia with fluid and insulin therapy leads to rapid resolution of these signs in HHS.​[8][12]

Use of this content is subject to our disclaimer