. A 58 y/o female with a 15 year history of type 2 diabetes is brought to the ER with a recent history of taking OTC medications for an upper respiratory tract infection and found to be lethargic and confused by her family. On physical exam the patient is lethargic with a BP of 80/60 mmHg and pulse of 120 bpm. Blood glucose level reveals >800mg/dl and arterial blood gas of pH 7.36. She is diagnosed with hyperosmolar hyperosmotic syndrome (HHS). Which statement below best describes the primary pathogenesis in HHS, leading to the presentation seen in the woman?

A. severe hyperglycemia induced by excessive use of OTC glucose laden medications

B. initial occurrence of severe hypoglycemia followed by a rebound hyperglycemia

C. severe hyperglycemia resulting from surges of growth hormones in an insulin dependent diabetic

D. severe states of hyperglycemia and persistent osmotic diuresis induced dehydration