Hyperosmolar hyperglycemic state differential diagnosis: Difference between revisions

	Hyperosmolar hyperglycemic state Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Hyperosmolar hyperglycemic state from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic study of choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Hyperosmolar hyperglycemic state differential diagnosis On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Hyperosmolar hyperglycemic state differential diagnosis All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Hyperosmolar hyperglycemic state differential diagnosis
CDC on Hyperosmolar hyperglycemic state differential diagnosis
Hyperosmolar hyperglycemic state differential diagnosis in the news
Blogs on Hyperosmolar hyperglycemic state differential diagnosis
Directions to Hospitals Treating Psoriasis
Risk calculators and risk factors for Hyperosmolar hyperglycemic state differential diagnosis

VisualWikitext

Revision as of 16:40, 5 September 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Differentiating Hyperosmolar hyperglycemic state from other Diseases

Hyperosmolar hyperglycemic state must be differentiated from other diseases that cause hyperglycemia, hyperosmolarity, and altered state of conciousness.^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]

Other conditions causing hyperglycemia
Other conditions causing hyperosmolarity
Other conditions causing altered state of conciousness

Characteristic Common to Hyperosmolar hyperglycemic state	Condition	History Findings	Clinical Features	Lab abnormalities
Hyperglycemia	Diabetes mellitus	Family history of diabetes Obesity (BMI >25 kg/m2) Stress Sedentary lifestyle History of gestational diabetes Polycystic ovarian syndrome Acanthosis nigricans Hypertension (Blood pressure >140/90 mmHg)	Polyuria Polydipsia Polyphagia Weight loss Central obesity Autonomic and peripheral neuropathy Vascular occlusion secondary to atherosclerosis (Stroke, myocardial infarction) Renal impairment (microalbuminuria leading to renal failure) Decreased visual acuity (diabetic retinopathy) Increased susceptibility to infections Charcot's joints	Hyperglycemia: Fasting blood glucose level: >126 mg/dl Random blood glucose level: >200 mg/dl HbA1C: >6.5 % Urinanalysis may show: Proteinuria Glucosuria Positive antibodies:(Type 1 diabetes) Anti-glutamic acid decarboxylase Anti-islet cell Anti-insulin
	Diabetic ketoacidosis	Younger age with type 1 diabetes mellitus Undiagnosed type 1 diabetes mellitus Prolonged hyperglycemia	May have all clinical features of diabetes mellitus plus: Hypotension Dehydration Tachycardia
	Impaired glucose tolerance	Family history of diabetes Obesity (BMI >25 kg/m2) Stress Sedentary lifestyle History of gestational diabetes Acanthosis nigricans	May have all clinical features of diabetes mellitus	Hyperglycemia: Fasting blood glucose level: 100-125 mg/dl Oral glucose tolerance test: 140-200 mg/dl
Hyperosmolarity	Central diabetes inspidus
Hyperosmolarity	Hyperaldosteronism
Altered state of conciousness	CNS infections
	Hypoglycemia
	Stroke
	Uremia

Use if the above table can not be made


Differential Diagnosis	Similar Features	Differentiating Features

Differential 1	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 2	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 3	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 4	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 5	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].

References

↑ "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".
↑ Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.
↑ Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, Beauregard H, Ekoé JM, Fournier H, Havrankova J (2003). "Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state". CMAJ. 168 (7): 859–66. PMC 151994. PMID 12668546.
↑ Joseph F, Anderson L, Goenka N, Vora J (2009). "Starvation-induced true diabetic euglycemic ketoacidosis in severe depression". J Gen Intern Med. 24 (1): 129–31. doi:10.1007/s11606-008-0829-0. PMC 2607495. PMID 18975036.
↑ Williams HE (1984). "Alcoholic hypoglycemia and ketoacidosis". Med. Clin. North Am. 68 (1): 33–8. PMID 6361416.
↑ Durnas C, Cusack BJ (1992). "Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it". Drugs Aging. 2 (1): 20–34. PMID 1554971.
↑ Gokel Y, Paydas S, Koseoglu Z, Alparslan N, Seydaoglu G (2000). "Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room". Am. J. Nephrol. 20 (4): 319–23. doi:13607 Check |doi= value (help). PMID 10970986.
↑ Brinkmann B, Fechner G, Karger B, DuChesne A (1998). "Ketoacidosis and lactic acidosis--frequent causes of death in chronic alcoholics?". Int. J. Legal Med. 111 (3): 115–9. PMID 9587792.

Template:WH Template:WS

[urlDiabetic_Ketoacidosis:_Evaluation_and_Treatment_-_American_Family_Physician-1] "Diabetic Ketoacidosis: Evaluation and Treatment - American Family Physician".

[pmid19564476-2] Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.

[pmid12668546-3] Chiasson JL, Aris-Jilwan N, Bélanger R, Bertrand S, Beauregard H, Ekoé JM, Fournier H, Havrankova J (2003). "Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state". CMAJ. 168 (7): 859–66. PMC 151994. PMID 12668546.

[pmid18975036-4] Joseph F, Anderson L, Goenka N, Vora J (2009). "Starvation-induced true diabetic euglycemic ketoacidosis in severe depression". J Gen Intern Med. 24 (1): 129–31. doi:10.1007/s11606-008-0829-0. PMC 2607495. PMID 18975036.

[pmid6361416-5] Williams HE (1984). "Alcoholic hypoglycemia and ketoacidosis". Med. Clin. North Am. 68 (1): 33–8. PMID 6361416.

[pmid1554971-6] Durnas C, Cusack BJ (1992). "Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it". Drugs Aging. 2 (1): 20–34. PMID 1554971.

[pmid10970986-7] Gokel Y, Paydas S, Koseoglu Z, Alparslan N, Seydaoglu G (2000). "Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room". Am. J. Nephrol. 20 (4): 319–23. doi:13607 Check |doi= value (help). PMID 10970986.

[pmid9587792-8] Brinkmann B, Fechner G, Karger B, DuChesne A (1998). "Ketoacidosis and lactic acidosis--frequent causes of death in chronic alcoholics?". Int. J. Legal Med. 111 (3): 115–9. PMID 9587792.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

@@ Line 73: / Line 73: @@
 ** Anti-[[insulin]]
 |-
-|[[Hyperosmolar hyperglycemic state|Non-ketotic hyperosmolar state]]
+|Diabetic ketoacidosis
 |
-* Elderly with [[type 2 diabetes mellitus]]
+* Younger age with [[Diabetes mellitus type 2|type 1 diabetes mellitus]]
-* Undiagnosed [[Diabetes mellitus type 2|type 2 diabetes]]
+* Undiagnosed [[Diabetes mellitus type 2|type 1 diabetes mellitus]]
 * Prolonged [[hyperglycemia]]
 |
@@ Line 83: / Line 83: @@
 ** [[Dehydration]]
 ** [[Tachycardia]]
-** Decreased mentation
+**
-** Focal [[neurological]] abnormalities
+**
 |
-* [[Hyperglycemia]] (600-2000 mg/dl)
+*
-* Increased [[serum]] [[osmolarity]] (330-380 mOsm/kg)
-* [[Arterial]] [[pH]] >7.3
-* [[Anion gap]] normal
-* No [[ketosis]]
 |-
 |[[Impaired glucose tolerance]]
@@ Line 107: / Line 103: @@
 ** [[Oral glucose tolerance test]]: 140-200 mg/dl
 |-
-| rowspan="2" |Ketosis
+| rowspan="2" |Hyperosmolarity
-|Alcoholic [[ketosis]]
+|Central diabetes inspidus
 |
-* Non-diabetic chronic [[alcohol]] user
+*
-* [[Binge drinking]] history
-* Fasting for 1-2 days after [[binge drinking]]
 |
-* [[Nausea]]
+*
-* [[Vomiting]]
+|
-* Diffuse [[abdominal]] pain
+*
+|-
-* [[Dehydration]]
+|Hyperaldosteronism
-* Stress
+|
-* [[Anorexia]]
+*
+*
+|
+*
 |
-* [[Serum]] [[glucose]] normal (only 10% with [[serum]] [[glucose]] >250 mg/dl)
+*
-* [[Serum]] [[bicarbonate]] < 18 mEq/L
-* [[Arterial]] [[pH]] may show acidosis or may be [[Alkalosis|alkalotic]] due to [[respiratory alkalosis]]
-* Increased [[anion gap]]
-* [[Acetoacetate]] and beta hydroxybutyrate elevated
 |-
-|Starvation [[ketosis]]
+| rowspan="4" |Altered state of conciousness
+|CNS infections
 |
-* Several weeks of low [[Calories|caloric]] intake
+*
-* [[Malnourishment]]
 |
-* [[Halitosis]]
+*
-* [[Dehydration]]
-* Dry coated [[tongue]]
-* [[Confusion]]
-* [[Drowsiness]]
-* Cold [[extremities]]
-* [[Hypotension]] (postural or supine)
-* [[Leg cramps]]
 |
-* [[Serum]] [[glucose]] normal or [[hypoglycemia]]
+*
-* [[Serum]] [[bicarbonate]] > 18 mEq/L
-* [[Arterial]] [[pH]] may show [[acidosis]]
-* Increased [[anion gap]]
 |-
-| rowspan="4" |[[Metabolic acidosis]]
+|Hypoglycemia
-|[[Lactic acidosis]]
 |
-* [[Hypermetabolic]] states:
+**
-** [[Trauma]]
-** [[Burns]]
-** [[Sepsis]]
-* [[Hypoxia]]
-* [[Short bowel syndrome]]
-* [[Jejuno-ileal bypass|Jejuno-ileal bypass surgery]]
-* [[Chronic pancreatitis|Chronic pancreatic insufficiency]]
-* [[Chronic renal insufficiency]]
-* Large [[carbohydrate]] intake
-* [[Carbon monoxide poisoning]]
-* Drug intake:
-** [[Cyanide]]
-** [[Salicylates]]
-** Biaguanides
-** [[Isoniazid|INH]]
-** [[AIDS antiretroviral drugs|Anti-retroviral agents]]
-** [[Valproic acid]]
-* [[Chronic obstructive pulmonary disease|COPD]]
-* [[Asthma]]
-* [[Mesenteric ischemia]]
 |
-* [[Neurological]]:
+**
-** [[Confusion]]
-** [[Stupor]]
-* [[Slurred speech]]
-* [[Nausea]]
-* [[Vomiting]]
-* Warm [[extremities]]
-* [[Dyspnea]]
-* [[Cough]]
-* [[Tachycardia]]
-* [[Weakness]]
-* [[Fatigue]]
 |
-* [[Arterial]] [[pH]] <7.3
+*
-* Increased [[anion gap]]
-* Increased [[blood]] [[lactate]]
 |-
-|[[Salicylic acid]] [[ingestion]]
+|Stroke
 |
-* Acute [[overdose]]:
+**
-** Young individuals or [[infants]]
-** Intentional
-** [[Suicidal]]
-** Rapid progression of [[signs]] and [[symptoms]]
-* Chronic [[overdose]]:
-** Therapeutic misadventures
-** Chronic pain disorders
-** Acute [[lung]] injury
 |
-* Early [[symptoms]]:
+*
-** [[Nausea]]
-** [[Vomiting]]
-** [[Anorexia]]
-** [[Diaphoresis]]
-** [[Tinnitus]]
-** [[Hyperventilation]]
-** [[Tachycardia]]
-* Late symptoms:
-** [[Drowsiness]]
-** [[Fatigue]]
-** [[Dizziness]]
-** [[Confusion]]
-** [[Delirium]]
-** [[Hallucinations]]
-** [[Seizures]]
-** [[Hyperthermia]]
 |
-* Mixed [[respiratory alkalosis]] and [[metabolic acidosis]]
+*
-* Increased [[anion gap]]
-* [[Hyperkalemia]]
-* Increased [[bleeding time]], normal [[Prothrombin time (PT)|prothrombin time]] ([[Prothrombin time|PT]]) and [[activated partial thromboplastin time]] ([[Partial thromboplastin time|aPTT]])
 |-
-|[[Uremia|Uremic acidosis]]
+|Uremia
 |
-* [[Renal failure]]
+**
-** Pre-renal: [[Dehydration]] due to [[gastroenteritis]], [[diarrhea]], [[hemorrhage]], [[hypovolemia]], [[cardiac failure]]
-** Renal: [[Hemolytic-uremic syndrome|Hemolytic uremic syndrome]], acute [[glomerulonephritis]], [[Renal papillary necrosis|renal necrosis]], [[drugs]], [[sepsis]], [[shock]]
-** Post-renal: [[Renal stones]], [[renal]] [[tumors]], [[Posterior urethral valves|posterior ureteric valves]], [[renal]] [[trauma]], [[renal vein thrombosis]]
 |
-* [[Neurological]]:
+*
-** [[Tendon reflex|Delayed tendon reflexes]]
-** [[Confusion]]
-** [[Headache]]
-** [[Seizures]]
-** [[Peripheral neuropathy]]
-* [[Uremic frost]]
-* [[Uremia|Uremic]] fetor
-* [[Hypertension]]
-* [[Osteomalacia]]
-* [[Muscular weakness]]
-* [[Cardiac arrhythmia|Cardiac arrythmias]]
-* [[Gout]] (podagra)
-* [[Kussmaul breathing]]
-* [[Nausea]]
-* [[Vomiting]]
 |
-* [[Arterial]] pH < 7.3
+*
-* Increased [[anion gap]]
-* [[Hyperkalemia]]
-* [[Hypocalcemia]]
-* [[Hyperphosphatemia]]
-* [[Secondary hyperparathyroidism]]
-* [[Hyperuricemia]]
-* [[Hypermagnesemia]]
 |-
-|Drug-induced [[acidosis]]
 |
-* [[Drug]] intake:
-** [[Potassium-sparing diuretic|Potassium sparing diuretics]] ([[amiloride]], [[triamterene]], [[spironolactone]]
-** [[Trimethoprim]]
-** [[Pentamidine]]
-** [[ACE inhibitor|ACE inhibitors]]
-** [[Angiotensin II receptor antagonist|ARBs]]
-** [[Non-steroidal anti-inflammatory drug|NSAIDs]]
-** [[Cyclosporine]]
-** [[Tacrolimus]]
-** [[Aspirin]]
-** [[Amphotericin B]]
-** [[Opiates]]
-** [[Anaesthetics]]
-** [[Phenobarbital]]
 |
-* [[Neurological]]:
-** [[Confusion]]
-** [[Seizures]]
-* [[Nausea]]
-* [[Vomiting]]
-* [[Chest]] discomfort
-* [[Cardiac arrhythmia|Cardiac arrythmias]]
-* [[Abdominal]] pain
 |
-* [[Arterial]] [[pH]] < 7.3
+|
+|
-* Normal [[anion gap]]
-* Increased [[hepatic transaminases]] ([[Aspartate transaminase|aspartate aminotrasnferase]], [[alanine aminotransferase]])
-* [[Hyperkalemia]] ([[ACE inhibitor|ACE inhibitors]], [[ARBs]], [[NSAIDs]], [[trimethoprim]], [[Potassium-sparing diuretic|potassium sparing diuretics]])
-* Increased [[Blood urea nitrogen|BUN]], [[creatinine]]
 |}
 ===Use if the above table can not be made===
-{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align=center
+{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"
-|valign=top|
+| valign="top" |
 |+
 ! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
@@ Line 304: / Line 169: @@
 ! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
 |-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 1
+| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 1
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
 |-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 2
+| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 2
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
 |-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 3
+| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 3
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
 |-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 4
+| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 4
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
 |-
-| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;"|Differential 5
+| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 5
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
-| style="padding: 5px 5px; background: #F5F5F5;"|
+| style="padding: 5px 5px; background: #F5F5F5;" |
 * On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
 |}