Differentials

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

Patients are often younger and leaner; usually with type 1 diabetes.

Abdominal pain is uncommon in HHS but frequently seen (>50%) in patients in DKA.[1][8]

Patients with ketosis-prone type 2 diabetes are mainly African-American or Hispanic in origin.[44]

INVESTIGATIONS

Venous pH <7.3.

HCO3 <15 mEq/L; anion gap >12 mEq/L.

Presence of serum ketones or beta-hydroxybutyrate.

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

May be clinically indistinguishable from HHS and DKA although most patients do not have a history of diabetes.

Sometimes occurs in association with HHS and DKA.

INVESTIGATIONS

Venous pH <7.3.

HCO3 <15 mEq/L; anion gap >12 mEq/L.

Lactic acid >5 mmol/L.

Serum glucose and ketones are normal.

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

A history of chronic alcohol abuse is present.

Produced by starvation due to poor food intake.

Peripheral signs of chronic liver disease, such as spider nevi, leukonychia, palmar erythema, bruising, jaundice, scratch marks, and hepatomegaly, are present.

INVESTIGATIONS

Venous pH is variable and can be normal.

HCO3 <15 mEq/L; anion gap >12 mEq/L

Serum glucose is low or normal but serum ketones or beta-hydroxybutyrate is elevated.

Lactate levels are usually elevated but elevation is insufficient to account for acidosis.

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

History of ingestion of ethanol, methanol, ethylene glycol (constituent of automobile antifreeze), and/or propylene glycol (diluent in many intravenous medications, such as lorazepam) is present.

Paraldehyde ingestion is suggested by its characteristic strong odor in the breath.[1]

INVESTIGATIONS

Serum methanol levels will be elevated.[1]

Calcium oxalate and hippurate crystals in the urine suggest ethylene glycol ingestion.[1]

These organic toxins can produce an osmolar gap in addition to an anion gap due to their low molecular weight.[1]

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

A history of chronic acetaminophen ingestion or acetaminophen overdose is present.

Clinical signs include confusion, tinnitus, hyperventilation, and pulmonary edema.

INVESTIGATIONS

Urine and serum acetaminophen levels will be positive but not necessarily in the toxic range.

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

A history of chronic salicylate ingestion or salicylate overdose is present.

INVESTIGATIONS

Serum salicylate levels will be elevated.

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

Patient may have a history of prior seizure events.

May present with widespread motor manifestations.

INVESTIGATIONS

Blood chemistry may be normal.

Electroencephalogram will show epileptiform activity.

SIGNS / SYMPTOMS
INVESTIGATIONS
SIGNS / SYMPTOMS

In most cases, the symptoms of stroke appear rapidly, over seconds or minutes.

Patients may present with limb and/or facial weakness (typically affects face, leg, and arm equally); may show visual disturbance.

INVESTIGATIONS

Blood chemistries are normal.

Cranial CT or MRI demonstrates hemorrhage or attenuation.

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