HONK

My most memorable patient this week came in with a HONK! That is, hyperosmolar non ketotic coma.
Direct from Wikipedia: "Nonketotic coma is usually precipitated by an infection,[2] myocardial infarction, stroke or another acute illness. A relative insulin deficiency leads to a serum glucose that is usually higher than 33 mmol/l (600 mg/dl), and a resulting serum osmolarity that is greater than 350 mOsm. This leads to polyuria (an osmotic diuresis), which, in turn, leads to volume depletion and hemoconcentration that causes a further increase in blood glucose level. Ketosis is absent because the presence of some insulin inhibits lipolysis, unlike diabetic ketoacidosis."
This gentleman had a blood glucose reading on admission in the 600s, and a Ha1c of 17. We all thought that was a mistake at first! He admits that he has not been paying attention to his diabetes, does not check his blood sugar much, and doesn't always take his Actos because he believes it makes him gain weight.
He also had a history or ESRD because of congenital kidney malformation and had a kidney transplant in 2001 after many years of dialysis. Since then he has been struggling with nephrotic syndrome which means he is leaking protein in to his urine and battling edema. I'm starting to see why he wasn't paying attention to his diabetes.
His HONK was probably precipitated by a large abcess on his back. I didn't see it, but read that they made a 3cm incision to drain it so it must have been quite large. When I saw the patient he was in quite a lot of pain from his wound, but insisted it was a good time to talk. I did a diet education on carbohydrate counting which he said he had heard of but wasn't using. I tried to emphasize that counting carbs would leave him lots of choices and prevent him from ending up with such high blood sugar again. Of course I forgot to mention the one thing I had written down ahead of time: that eating better will help his wound heal and get him out of here, but luckily my RD was there to back me up. As with many of the diet educations reported, I don't know that I did any good. Pts this week overall were pretty challenging because they all had multiple things going on. I worry about this patient's future kidney function which seems to be going downhill, but we didn't even address that because that blood sugar in the 600s was our first priority.