Time of admission: Attending physician: Admitting diagnosis: On Admission on Emergency department, Mrs. Possingham was suffering from Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), also called Hyperosmolar nonketotic Coma (HONK), as a consequences Diabetes type 2. She was experiencing increasing confusion and irritability, increased thirst and needing to void frequently (Figure 1). Her husband stated that her Blood Glucose Level (BGL) was 20 mmol/L but no ketones were found when she tested her urine 2 hrs previously. Figure 1: Symptoms for diabetes Type 2(c)History of Present IllnessAccording to Cassandra’s her diabetes was diagnosed 3 years ago and is managed with Avandamet 4mg/500mg BD after food.
Cassandra also had a week off work whilst experiencing a serious bout of food poisoning 2 week ago. Cassandra works as an accountant and has business lunches/dinners several days a week, which makes it difficult for her to avoid excessive intake of food an alcohol. Her BMI is presently 26. She also smokes 10 cigarettes per day and has 2-3 glasses of red wine with the evening meal. She does not enjoy exercise but usually 4 times a week takes the family dog around the block for the dog’s exercise.
She has three children the eldest currently doing year 12 and she does most of the housework and cooking herself. Mr Possingham states that he feels his wife has been extremely stressed over the last month as her firm has moved to new premises. She has also been complaining of cramps and restless legs at night. Mrs Possingham explained that she has small area near her left ankle that she injured during the move of her business from one building to another she is concerned that it is very slow to heal. (d) Admission ExaminationT38.8 Pulse 132; BP 164/70; RR 24; SaO2 96% room air; BGL 38mmol/L; Urine: 15mL/hr, dark amber, pH of 5; Glucose +++.
Neurovascular obs: peripheral pulses decreased (L) leg which is shiny and hairless to mid calf and a relatively painless 1.5cm round oozing wound on left lateral mallelous was noted – Area around the mallelous red and hot to touch. The R leg pulses palpable, CWMS good, skin not shiny and plenty of hair. Calf on this leg also looks swollen in comparison to the other leg. From the above information, we can conclude that Mrs. Possingham was suffering from Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), also called Hyperosmolar nonketotic Coma (HONK), resulting to Type 2 Diabetes mellitus.
According to Venkatraman & Singhi (2006), Hyperglycemic Nonketotic Syndrome (HHNS) is a complication resulting from uncontrolled type 2 diabetes mellitus. HHNS in most cases is characterized by increased serum osmolality and dehydration without accumulation of ketone bodies, and severe hyperglycemia. Extended osmotic diuresis results to dehydration and hence a term referred to hypertonic dehydration.
The rationale for Type 2 diabetes is seen from literature whereby, suggested risk factors for type 2 diabetes is in accord with Mrs. Possingham’s background. According to American Diabetes Association (2004), Type 2 diabetes is associated with the following risk factors (Figure 2). Overweight (Body Mass Index ≥25 kg/m2), Age 45 years and older, Physical inactivity, History of Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG), Presence of coronary artery disease and/or hypertension (blood pressure ≥140/90 mm Hg), SaO2 96% and Presence of other vascular complications. Furthermore, the medical history and Laboratory test results confirmed this scenario.
For instance, on Admission on Emergency department Mrs. Possingham was suffering Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) as a consequences Diabetes type 2. Her level Glucose indicated +++, BGL 38 mmol/L, SaO2 96 %, pH of 5 and Urine: 15 mL/hr. According to Cassandra’s her diabetes was diagnosed 3 years ago and is managed with Avandamet 4mg/500mg BD after food. According to Cassandra’s her diabetes was diagnosed 3 years ago and is managed with Avandamet 4mg/500mg BD after food.