A 70-year-old male with type 2 diabetes presents with altered mental status, severe dehydration, blood glucose of 850 mg/dL, and serum osmolality of 345 mOsm/kg without significant ketosis. What is the diagnosis?

Answer and explanation

Correct answer: B. Hyperosmolar hyperglycemic state

  1. Step 1: Extreme hyperglycemia (>600 mg/dL), severe hyperosmolality (>320 mOsm/kg), and profound dehydration in the absence of significant ketoacidosis define hyperosmolar hyperglycemic state (HHS).
  2. Step 2: Residual endogenous insulin secretion in type 2 diabetes prevents significant lipolysis and ketogenesis while failing to prevent massive hyperglycemia and osmotic diuresis.
Answer
Hyperosmolar hyperglycemic state.
Why not the others: Diabetic ketoacidosis is characterized by significant ketonemia, high anion gap metabolic acidosis, and lower glucose elevations. Lactic acidosis presents with high anion gap acidosis and elevated blood lactate rather than severe hyperosmolar hyperglycemia. Diabetes insipidus produces hypernatremia from impaired vasopressin without severe hyperglycemia.

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