A 75 year old woman with a history of residual left hemiparesis due to a stroke, is transferred to the Emergency Room of the hospital. Recently, the patient has had intense polyuria and complained of profound thirst, the result of consuming of large quantities of juices. During the previous week she had experienced a decrease in her level of consciousness, with gradual clouding of sensorium, slowly deteriorating until she fell into a coma.
Physical examination revealed signs of dehydration, with blood pressure of 110/80 mmHg and pulse rate of 110 per min. The patient was deeply comatose, with bilateral positive Babinski sign, unresponsive even to painful stimuli and with decreased deep tendon reflexes. Initial impression was that she was suffering from a very severe stroke, probably in the medulla.
A stat-computed tomography of the brain showed an ischaemic area of the right hemisphere, compatible with the history of left hemiparesis, but no signs of haemorrhage of recent thromboembolic lesion. The patient had a temperature of 36 °C (96.8 °F) (37.2 °C [98.9 °F] rectally). Laboratory results were: Na+ 138 mmol/L; K+ 3.6 mmol/L; Cl~ 105.0 mmol/L; HCO3 30 mmol/L; urea 92 mg/dl (15.3 mmol/L); creatinine 2.2 mg/dl (194.5 imol/L). Blood glucose was 1,235 mg/dl (68.5 mmol/L)!! Urinalysis showed 4+ glucose and 1 + ketones.
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