Clinical feature

Features of dehydration and acidosis: intense thirst, polyuria, nausea, vomiting, abdominal pain.

Objective examination

1. Level of consciousness is variable, patient with severe ketoacidosis may be conscious and alert, drowsiness is usual but coma is uncommon. Level of consciousness depends on serum osmolality, not on level of acidosis. When serum osmolality exceeds 320-330 mosm/L, CNS depression or coma develops (normal value is 280-300 mosm/L).

2. Dry tongue, inelastic skin, sunken eyes

3. Hypothermia

4. Kussmaul's respiration (rapid and deep breathing)

5. Hypotension

6. Rapid weak pulse

7. Fruity breath odor of acetone

8. Abdominal tenderness

Additional methods of examination

Determination of glucose: hyperglycemia (usually > 250mg/dl). The magnitude of hyperglycemia does not correlate with the severity of metabolic acidosis: moderate elevation of blood glucose may be associated with life-threatening ketoacidosis. In some cases hyperglycemia predominates with minimal acidosis.

Biochemical blood analysis. Metabolic acidosis (blood pH < 7.3, serum bicarbonate < 15 mEq/L). Hyperketonemia.

Clinical urine analysis: ketonuria (urinary ketones strongly positive ++++). There is ++++ glycosuria.

Comparison of Diabetic Ketoacidosis and Hyperosmolar (Nonketotic Syndrome)
Feature	Diabetic Ketoacidosis	Hyperosmolar Nonketotic Syndrome
Age of patient Duration of symptoms Plasma glucose Serum sodium Serum potassium Serum bicarbonate Ketone bodies pH Serum osmolarity Fluid deficit Cerebral edema Prognosis Subsequent course	Usually <40 yr Usually < 2 days Usually < 600 mg/dL Normal or low (130-140 mEq/L) Normal or high 15-6 mEq/L) < 15 mEq/L Positive at >1:2 dilution < 7.35 Usually < 320 mOsm/kg < 10% body weight Subclinical asymptomatic, rare clinically 3%-10% mortality (>20% for people >65 yr) Insulin therapy required in most cases	Usually >60 yr Usually >5 days Usually >600 mg/dL Normal or high (145-165 mEq/U) Normal (4-6 mEq/L) >15 mEq/L Negative at 1:2 dilution > 7.3 Usually >320 mOsm/kg < 15% body weight Very rare 10%-20% mortality Insulin therapy not usually required

Hyperosmolar non-ketotic coma

This condition, in which severe hyperglycemia develops without significant ketosis, is the metabolic emergency characteristic of uncontrolled type II diabetes. Patients present in middle or later life, often with mild or previously undiagnosed diabetes. Infection, myocardial infarction, stroke, or recent surgery is the precipitating factors.

Clinical features

Clinical features are dehydration and stupor or coma due to hyperosmolality. Nausea, vomiting and abdominal pain are much less common because there is no acidosis.

Additional methods of examination

• Severe hyperglycemia, blood sugar 600-2400mg/dl.

• Serum osmolality 330-340 mosm/L.

• Pre-renal azotemia with raised urea.

• ABGs show normal pH.