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Your next patient in an emergency department is a 74

year old Mr. McGee who had been unwell for about 2
days without specific symptoms although his wife
thought he was slightly confused over the last 24
hours and she could not get an appointment with the
GP so she called the ambulance and he was brought
to the hospital.
Yours tasks are to:
1. take a relevant history
2. perform a physical examination
3. order appropriate investigations
4. discuss your diagnosis and management with the

HOPC: Mr. McGee has been in quite good health although he has suffered from NIDDM
for the last 10 years but usually well controlled. Over the last week he had a flu and for
two days he has been increasingly chesty with cough and some yellowish sputum.
Yesterday his wife noticed that he was slightly confused to time and place. Today he
vomited twice in the morning. She tried to make an appointment with the local doctor but
could not get one and therefore she called the ambulance. He has passed a lot of urine.
Otherwise no remarkable symptoms.

PHx: appendicectomy age 20, cholecystectomy age 43, NIDDM for 10 years on
diamicron (gliclazide) 80 mg daily.
FHx.: unremarkable
SHx.: married, retired accountant, 3 children, no problems, non smoker, very little
alcohol, NKA
Examination: solidly built 74 year old man, no distress, mildly confused to time and
Vital signs: BP 115/75, P 80 + reg., RR 20, T 37 dgrees Celsius.
Moderate dehydration with reduced skin turgor and dry mucous membranes.
Lungs: slightly bronchial breathsounds over right middle lobe with few crackles.
The rest of the physical examination is normal.
BSL > 50 mmol/L
WCC 11,000 ( left shift)
Serum osmolarity 310 mOsm/L, Na 146, K 3.2, ABGs and renal function normal!
CXR suggestive of mild infective changes in RML
Urine and blood cultures.
DIAGNOSIS: hyperosmolar hyperglycaemic non-ketotic state (HHNS)!!!
Occurs mainly in older patients with NIDDM, characterized by relative insulin deficiency
(insulin levels sufficient to prevent lipolysis and ketoacidosis but insufficient to prevent
hyperglycaemia!) leading to hyperglycaemia, hyperosmolarity and dehydration with little
or no acidosis! Usually precipitated by infection, non compliance, cardiovascular events,
renal failure etc.!
1. FLUIDS: colloids if hypotensive or N-saline in 500 ml boluses until blood
pressure and tissue perfusion restored. Once the BSL falls and urinary output is
established (>1ml/kg/h), continue slowly with fluid replacement using 0.45%
saline +/- 2.5% dextrose. CVP monitoring may be necessary.
2. INSULIN: insulin infusion should be started at 0.05 units/kg /hr to achieve a fall
in BSL of 3-5 mmol/hr!
3. ELECTROLYTES: potassium is usually added to iv fluids in the second hour of
resuscitation once the K < 5.0! Rate is 10-20 mmol K/hour
4. Treatment of underlying cause (chestinfection)