Hyperosmolar hyperglycemic state physical examination: Difference between revisions

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{{Hyperosmolar hyperglycemic state}}
{{Hyperosmolar hyperglycemic state}}


{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{HS}}


==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
Patients with the hyperosmolar hyperglycemic state may usually appear [[dehydrated]], [[lethargic]], [[disoriented]] and in [[shock]]. [[Physical examination]] of patients with the hyperosmolar hyperglycemic state is usually remarkable for [[hypothermia]], [[hypotension]], [[tachycardia]], [[tachypnea]], [[Nausea and vomiting|nausea]], [[vomiting]] and [[seizures]] or other [[Focal neurologic signs|focal neurological signs]].


OR
Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
OR
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
OR
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
==Physical Examination==
==Physical Examination==
*Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
*The presence of [finding(s)] on physical examination is diagnostic of [disease name].
*The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
Patient may look [[Dehydration|dehydrated]], ill-appearing, [[diaphoretic]], [[Disorientation|disoriented]] or [[Obtundation|obtunded]] due to severe [[hyperglycemia]] and [[hyperosmolality]].<ref name="urlHyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS) - Endotext - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK279052/ |title=Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS) - Endotext - NCBI Bookshelf |format= |work= |accessdate=}}</ref>


===Vital Signs===
===Vital Signs===
 
* [[Hypothermia]]<ref name="pmid102402">{{cite journal |vauthors=Gale EA, Tattersall RB |title=Hypothermia: a complication of diabetic ketoacidosis |journal=Br Med J |volume=2 |issue=6149 |pages=1387–9 |year=1978 |pmid=102402 |pmc=1608617 |doi= |url=}}</ref>
*High-grade / low-grade fever
* [[Hypotension]]<ref name="pmid17308209">{{cite journal |vauthors=Kearney T, Dang C |title=Diabetic and endocrine emergencies |journal=Postgrad Med J |volume=83 |issue=976 |pages=79–86 |year=2007 |pmid=17308209 |pmc=2805944 |doi=10.1136/pgmj.2006.049445 |url=}}</ref>
*[[Hypothermia]] / hyperthermia may be present
* [[Tachycardia]]<ref name="pmid17308209" />
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
* [[Tachypnea]]<ref name="pmid22127748">{{cite journal |vauthors=Rosenbloom AL |title=The management of diabetic ketoacidosis in children |journal=Diabetes Ther |volume=1 |issue=2 |pages=103–20 |year=2010 |pmid=22127748 |pmc=3138479 |doi=10.1007/s13300-010-0008-2 |url=}}</ref>
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
* Weak [[pulse]]<nowiki/>s due to [[dehydration]]
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
*[[Cyanosis]]  
* Poor skin [[turgor]] due to [[dehydration]]
*[[Jaundice]]
* [[Cutaneous]] infection (non-healing [[ulcer]])<ref name="pmid25653473">{{cite journal |vauthors=Duff M, Demidova O, Blackburn S, Shubrook J |title=Cutaneous manifestations of diabetes mellitus |journal=Clin Diabetes |volume=33 |issue=1 |pages=40–8 |year=2015 |pmid=25653473 |pmc=4299750 |doi=10.2337/diaclin.33.1.40 |url=}}</ref>
* [[Pallor]]
* [[Xerosis]]<ref name="pmid25653473" />
* Bruises
* [[Hair loss]]<ref name="pmid25653473" />
 
* [[Acanthosis nigricans]] in [[Diabetes mellitus type 2|type 2 diabetics]]<ref name="urlChapter 151. Diabetes Mellitus and Other Endocrine Diseases | Fitzpatricks Dermatology in General Medicine, 8e | AccessMedicine | McGraw-Hill Medical">{{cite web |url=http://accessmedicine.mhmedical.com/content.aspx?bookid=392&sectionid=41138874 |title=Chapter 151. Diabetes Mellitus and Other Endocrine Diseases &#124; Fitzpatrick's Dermatology in General Medicine, 8e &#124; AccessMedicine &#124; McGraw-Hill Medical |format= |work= |accessdate=}}</ref>  
<gallery widths=150px>
* [[Diabetic dermopathy]] (small <1 cm, well-demarcated, atrophic depressions, [[Macule|macules]], or [[Papule|papules]] on the pretibial region) in type 2 diabetics<ref name="urlChapter 66. Dermal Hypertrophies and Benign Fibroblastic/Myofibroblastic Tumors | Fitzpatricks Dermatology in General Medicine, 8e | AccessMedicine | McGraw-Hill Medical">{{cite web |url=http://accessmedicine.mhmedical.com/content.aspx?bookid=392&sectionid=41138766 |title=Chapter 66. Dermal Hypertrophies and Benign Fibroblastic/Myofibroblastic Tumors &#124; Fitzpatrick's Dermatology in General Medicine, 8e &#124; AccessMedicine &#124; McGraw-Hill Medical |format= |work= |accessdate=}}</ref>
 
* Eruptive [[xanthomas]] in [[Diabetes mellitus type 2|type 2 diabetics]]<ref name="pmid10815049">{{cite journal |vauthors=Paron NG, Lambert PW |title=Cutaneous manifestations of diabetes mellitus |journal=Prim. Care |volume=27 |issue=2 |pages=371–83 |year=2000 |pmid=10815049 |doi= |url=}}</ref><ref name="pmid25653473" />
UploadedImage-01.jpg | Description {{dermref}}
* [[Necrobiosis lipoidica]] (irregular, painless ovoid plaques with a yellow atrophic center and a red to purple periphery)<ref name="pmid25653473" />
UploadedImage-02.jpg | Description {{dermref}}
* [[Vitiligo]]<ref name="pmid25653473" />
 
* [[Diabetic]] bullae<ref name="pmid12170881">{{cite journal |vauthors=Ferringer T, Miller F |title=Cutaneous manifestations of diabetes mellitus |journal=Dermatol Clin |volume=20 |issue=3 |pages=483–92 |year=2002 |pmid=12170881 |doi= |url=}}</ref><ref name="pmid25653473" />
</gallery>


===HEENT===
===HEENT===
* Abnormalities of the head/hair may include ___
* [[Extraocular muscle|Extra-ocular]] movements may be abnormal due to the involvement of [[Oculomotor nerve palsy|third]], [[Fourth (trochlear) nerve palsy|fourth]], [[Sixth nerve palsy|sixth]], and [[Facial nerve palsy|seventh]] [[cranial nerves]] affecting [[ocular]] movements.<ref name="pmid21760834">{{cite journal |vauthors=Skarbez K, Priestley Y, Hoepf M, Koevary SB |title=Comprehensive Review of the Effects of Diabetes on Ocular Health |journal=Expert Rev Ophthalmol |volume=5 |issue=4 |pages=557–577 |year=2010 |pmid=21760834 |pmc=3134329 |doi=10.1586/eop.10.44 |url=}}</ref>
* Evidence of trauma
* [[Ophthalmology|Ophthalmoscopic]] exam may be abnormal with findings of [[diabetic retinopathy]].
* Icteric sclera
* Hearing acuity may be reduced.
* [[Nystagmus]]
*Sunken eyes due to [[dehydration]].
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
*[[Jugular venous distension]]
* Not significant
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
===Lungs===
* Asymmetric chest expansion / Decreased chest expansion
*[[Rales/Crackles|Rales/crackles]] due to [[pulmonary edema]] (in case of treatmnet complication) or [[pneumonia]] (in cases where infection is a precipitating cause)<ref name="pmid26240698">{{cite journal |vauthors=Konstantinov NK, Rohrscheib M, Agaba EI, Dorin RI, Murata GH, Tzamaloukas AH |title=Respiratory failure in diabetic ketoacidosis |journal=World J Diabetes |volume=6 |issue=8 |pages=1009–23 |year=2015 |pmid=26240698 |pmc=4515441 |doi=10.4239/wjd.v6.i8.1009 |url=}}</ref>
*Lungs are hypo/hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds / Distant breath sounds
*Expiratory/inspiratory wheezing with normal / delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
===Heart===
*Chest tenderness upon palpation
* [[Heart sounds|S1]] normal
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
* [[Heart sounds|S2]] normal
*[[Heave]] / [[thrill]]
* [[The U Wave|U wave]] ([[hypokalemia]])<ref name="pmid25430801">{{cite journal |vauthors=Davis SM, Maddux AB, Alonso GT, Okada CR, Mourani PM, Maahs DM |title=Profound hypokalemia associated with severe diabetic ketoacidosis |journal=Pediatr Diabetes |volume=17 |issue=1 |pages=61–5 |year=2016 |pmid=25430801 |pmc=4896141 |doi=10.1111/pedi.12246 |url=}}</ref>
*[[Friction rub]]
* [[Cardiac arrhythmia]] ([[Atrial fibrillation]] and [[Ventricular arrhythmias|ventricular arrhythmia]])<ref name="pmid26862372">{{cite journal |vauthors=Koektuerk B, Aksoy M, Horlitz M, Bozdag-Turan I, Turan RG |title=Role of diabetes in heart rhythm disorders |journal=World J Diabetes |volume=7 |issue=3 |pages=45–9 |year=2016 |pmid=26862372 |pmc=4733448 |doi=10.4239/wjd.v7.i3.45 |url=}}</ref>
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope


===Abdomen===
===Abdomen===
*[[Abdominal distention]]  
* [[Nausea]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
* [[Vomiting]]
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
===Back===
*Point tenderness over __ vertebrae (e.g. L3-L4)
* Not significant
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump


===Genitourinary===
===Genitourinary===
*A pelvic/adnexal mass may be palpated
* [[Polyuria]]<ref name="pmid17308209">{{cite journal |vauthors=Kearney T, Dang C |title=Diabetic and endocrine emergencies |journal=Postgrad Med J |volume=83 |issue=976 |pages=79–86 |year=2007 |pmid=17308209 |pmc=2805944 |doi=10.1136/pgmj.2006.049445 |url=}}</ref>
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
===Neuromuscular===
*Patient is usually oriented to persons, place, and time
* [[Irritability]]
* Altered mental status
* [[Restlessness]]
* Glasgow coma scale is ___ / 15
* [[Stupor]]
* Clonus may be present
* [[Muscle twitching|Muscular twitching]]
* Hyperreflexia / hyporeflexia / areflexia
* [[Hyperreflexia]]
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* [[Lethargy]]
* Muscle rigidity
* [[Spasticity]]
* Proximal/distal muscle weakness unilaterally/bilaterally
* [[Seizures]]<ref name="pmid23590576">{{cite journal |vauthors=Yun C, Xuefeng W |title=Association between seizures and diabetes mellitus: a comprehensive review of literature |journal=Curr Diabetes Rev |volume=9 |issue=4 |pages=350–4 |year=2013 |pmid=23590576 |doi= |url=}}</ref>
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
* [[Coma]]
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Extremities===
*[[Clubbing]]  
* [[Muscle cramps|Muscle cramping]]<ref name="pmid17549168">{{cite journal |vauthors=Wyatt LH, Ferrance RJ |title=The musculoskeletal effects of diabetes mellitus |journal=J Can Chiropr Assoc |volume=50 |issue=1 |pages=43–50 |year=2006 |pmid=17549168 |pmc=1839979 |doi= |url=}}</ref>
*[[Cyanosis]]  
* Cold [[extremities]]<ref name="pmid17308209">{{cite journal |vauthors=Kearney T, Dang C |title=Diabetic and endocrine emergencies |journal=Postgrad Med J |volume=83 |issue=976 |pages=79–86 |year=2007 |pmid=17308209 |pmc=2805944 |doi=10.1136/pgmj.2006.049445 |url=}}</ref>
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==
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[[Category:Medicine]]
[[Category:Endocrinology]]
[[Category:Up-To-Date]]
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[[Category:Emergency medicine]]

Latest revision as of 18:09, 23 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Husnain Shaukat, M.D [2]

Overview

Patients with the hyperosmolar hyperglycemic state may usually appear dehydrated, lethargic, disoriented and in shock. Physical examination of patients with the hyperosmolar hyperglycemic state is usually remarkable for hypothermia, hypotension, tachycardia, tachypnea, nausea, vomiting and seizures or other focal neurological signs.

Physical Examination

Appearance of the Patient

Patient may look dehydrated, ill-appearing, diaphoretic, disoriented or obtunded due to severe hyperglycemia and hyperosmolality.[1]

Vital Signs

Skin

HEENT

Neck

  • Not significant

Lungs

Heart

Abdomen

Back

  • Not significant

Genitourinary

Neuromuscular

Extremities

References

  1. ↑ "Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS) - Endotext - NCBI Bookshelf".
  2. ↑ Gale EA, Tattersall RB (1978). "Hypothermia: a complication of diabetic ketoacidosis". Br Med J. 2 (6149): 1387–9. PMC 1608617. PMID 102402.
  3. ↑ 3.0 3.1 3.2 3.3 Kearney T, Dang C (2007). "Diabetic and endocrine emergencies". Postgrad Med J. 83 (976): 79–86. doi:10.1136/pgmj.2006.049445. PMC 2805944. PMID 17308209.
  4. ↑ Rosenbloom AL (2010). "The management of diabetic ketoacidosis in children". Diabetes Ther. 1 (2): 103–20. doi:10.1007/s13300-010-0008-2. PMC 3138479. PMID 22127748.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Duff M, Demidova O, Blackburn S, Shubrook J (2015). "Cutaneous manifestations of diabetes mellitus". Clin Diabetes. 33 (1): 40–8. doi:10.2337/diaclin.33.1.40. PMC 4299750. PMID 25653473.
  6. ↑ "Chapter 151. Diabetes Mellitus and Other Endocrine Diseases | Fitzpatrick's Dermatology in General Medicine, 8e | AccessMedicine | McGraw-Hill Medical".
  7. ↑ "Chapter 66. Dermal Hypertrophies and Benign Fibroblastic/Myofibroblastic Tumors | Fitzpatrick's Dermatology in General Medicine, 8e | AccessMedicine | McGraw-Hill Medical".
  8. ↑ Paron NG, Lambert PW (2000). "Cutaneous manifestations of diabetes mellitus". Prim. Care. 27 (2): 371–83. PMID 10815049.
  9. ↑ Ferringer T, Miller F (2002). "Cutaneous manifestations of diabetes mellitus". Dermatol Clin. 20 (3): 483–92. PMID 12170881.
  10. ↑ Skarbez K, Priestley Y, Hoepf M, Koevary SB (2010). "Comprehensive Review of the Effects of Diabetes on Ocular Health". Expert Rev Ophthalmol. 5 (4): 557–577. doi:10.1586/eop.10.44. PMC 3134329. PMID 21760834.
  11. ↑ Konstantinov NK, Rohrscheib M, Agaba EI, Dorin RI, Murata GH, Tzamaloukas AH (2015). "Respiratory failure in diabetic ketoacidosis". World J Diabetes. 6 (8): 1009–23. doi:10.4239/wjd.v6.i8.1009. PMC 4515441. PMID 26240698.
  12. ↑ Davis SM, Maddux AB, Alonso GT, Okada CR, Mourani PM, Maahs DM (2016). "Profound hypokalemia associated with severe diabetic ketoacidosis". Pediatr Diabetes. 17 (1): 61–5. doi:10.1111/pedi.12246. PMC 4896141. PMID 25430801.
  13. ↑ Koektuerk B, Aksoy M, Horlitz M, Bozdag-Turan I, Turan RG (2016). "Role of diabetes in heart rhythm disorders". World J Diabetes. 7 (3): 45–9. doi:10.4239/wjd.v7.i3.45. PMC 4733448. PMID 26862372.
  14. ↑ Yun C, Xuefeng W (2013). "Association between seizures and diabetes mellitus: a comprehensive review of literature". Curr Diabetes Rev. 9 (4): 350–4. PMID 23590576.
  15. ↑ Wyatt LH, Ferrance RJ (2006). "The musculoskeletal effects of diabetes mellitus". J Can Chiropr Assoc. 50 (1): 43–50. PMC 1839979. PMID 17549168.

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