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IV ½ NS
5%
4/85
IV NS
67%
57/85
IV D5W
2%
2/85
Subcutaneous insulin injection
4%
3/85
IV insulin
20%
17/85
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The patient in this vignette is most likely suffering from hyperosmolar hyperglycemic state (HHS). The first step in the management of this condition is the administration of IV NS. HHS is a complication of type 2 diabetes. The concentration of insulin required to prevent ketoacidosis is lower than the concentration required to adequately control glucose levels. Thus, the blood glucose may be very high, but ketoacidosis will be absent (unlike in type 1 DM). HHS is seen most commonly in older patients with concurrent cardiac and renal pathology. This conditon presents with symptoms and signs of shock. There is a high mortality with HHS, approximately 50%. Incorrect answers: Answer 1: IV ½ NS is not ideal solution for immediate volume resuscitation, as it will not stay intravascularly as well as NS. Answer 3: IV D5W would only give this patient more glucose which will exacerbate the NKHS. Answers 4 & 5: Insulin will be administered to this patient but only after volume resuscitation has begun.
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