Typical exam stem
An older patient with type 2 diabetes presents with severe dehydration, confusion and very high glucose but minimal ketones. How would you manage the case?
Active exam mode
Plan the case before reading, then mark sections, reveal pearls and self-rate the viva.
1. Sixty-second answer plan
1:00Before reading the notes, say or write your assessment, investigations and management structure.
2. Section checklist
Mark each section only after you can explain its main decision points without reading.
3. Exam-pearl flashcards
Try to predict the pearl before revealing it.
4. Viva drill
Answer aloud before rating yourself. Anything marked “review” stays visible in your progress.
How does HHS differ from DKA?
Progress is saved on this device. Use “Reset session” when you want a fresh attempt.
Distinguish HHS from DKA
HHS is dominated by marked hyperglycaemia, hyperosmolality and severe dehydration, usually with little or no significant ketoacidosis. Patients are often older and may have substantial comorbidity. Neurological dysfunction becomes more likely as effective osmolality rises.
Mixed DKA/HHS presentations occur, so assess ketones and acid-base status rather than forcing the patient into a single label.
Assessment priorities
- Assess airway, breathing, circulation and mental state.
- Measure glucose, electrolytes, renal function, ketones and venous blood gas.
- Calculate or monitor serum osmolality using the local protocol.
- Search for infection, myocardial infarction, stroke, medication-related causes or reduced access to fluids.
- Assess thrombosis risk because severe dehydration and hyperosmolality increase risk.
Treatment logic
Fluid replacement is central and is usually more gradual than in DKA because rapid shifts in osmolality can be harmful. Insulin is introduced according to the biochemical response and local protocol, particularly when glucose does not fall adequately with fluid or when significant ketosis coexists. Monitor sodium, potassium, glucose, osmolality, renal function and fluid balance closely.
The patient may require high-dependency care when there is marked hyperosmolality, severe electrolyte disturbance, haemodynamic instability, altered consciousness or major comorbidity.
Guideline source for further reading
This page is an original exam-revision summary. For clinical decisions, use current local protocols and the primary guidance below.