Nonketotic hyperosmolar hyperglycemic state is typically characterized by which of the following?

• A. Significant ketosis and metabolic acidosis
• B. Hyperglycemia with ketosis
• C. Hyperosmolarity with minimal or no ketosis and altered mental status
• D. Hypoglycemia and dehydration

Answer: (C)

The key idea is that this condition produces very high blood sugar with marked high serum osmolality and severe dehydration, but only minimal or no ketone production and little or no metabolic acidosis. That lack of ketosis differentiates it from diabetic ketoacidosis, even though both can have extreme hyperglycemia. Enough insulin is present to suppress lipolysis and ketogenesis, so you don’t see the significant ketosis or acidosis seen in DKA, but enough hyperglycemia and water loss to raise osmolality well above normal. The high osmolality pulls water out of brain cells, leading to neurologic symptoms that range from confusion to coma, i.e., altered mental status. This scenario is most common in older adults with type 2 diabetes and is often precipitated by dehydration, infection, or poor intake.

Therefore, describing hyperosmolarity with minimal or no ketosis and altered mental status is the best match. The other descriptions fit different patterns (for example, significant ketosis with acidosis points to DKA; hypoglycemia contradicts the hyperglycemic state).