Endocrine, Metabolic & Acute Emergencies

A 19-year-old with type 1 diabetes is drowsy with vomiting. Capillary glucose is 24 mmol/L, blood ketones 5.2 mmol/L and venous pH 7.18. What is the diagnosis and the first treatment?

• AHyperosmolar hyperglycaemic state; intravenous 0.45% sodium chloride and a variable-rate insulin infusion
• BHypoglycaemia; intravenous 10% glucose bolus followed by a glucose infusion and hourly capillary checks
• CDiabetic ketoacidosis; a stat dose of subcutaneous rapid-acting insulin followed by hourly glucose checks
• DDiabetic ketoacidosis; intravenous 0.9% sodium chloride then fixed-rate intravenous insulin✓

Answer: Glucose above 11 mmol/L (or known diabetes), ketones of 3 mmol/L or more and a pH below 7.3 or bicarbonate below 15 define DKA. Treatment starts with intravenous fluid resuscitation, followed by a fixed-rate intravenous insulin infusion of 0.1 units/kg/hour with potassium replacement.

A 40-year-old woman has tiredness, weight gain and cold intolerance. Her TSH is 18 mU/L and free T4 is low. What is the most appropriate treatment?

• ACarbimazole
• BRadioactive iodine
• CPropranolol
• DLevothyroxine✓

Answer: A raised TSH with a low free T4 is primary hypothyroidism, treated with levothyroxine replacement and titrated against TSH. Carbimazole and radioactive iodine treat hyperthyroidism.

A 34-year-old man with Addison's disease is admitted with vomiting, hypotension and a sodium of 124 mmol/L after a bout of gastroenteritis. What is the immediate treatment?

• AIntravenous hypertonic saline
• BOral fludrocortisone and encourage oral fluids
• CIntravenous dexamethasone alone
• DIntravenous hydrocortisone and intravenous fluids✓

Answer: This is an adrenal (Addisonian) crisis: hydrocortisone 100 mg intravenously (or intramuscularly) is given immediately along with fluid resuscitation, without waiting for results. Oral treatment is inadequate in a vomiting, hypotensive patient.

A 70-year-old man with small-cell lung cancer has a sodium of 121 mmol/L. He is euvolaemic, his serum osmolality is low and his urine osmolality is inappropriately high. What is the most appropriate initial management?

• AFluid restriction✓
• BOral salt tablets and furosemide
• CRapid intravenous 0.9% sodium chloride
• DDesmopressin

Answer: Euvolaemic hyponatraemia with low serum and high urine osmolality is the syndrome of inappropriate antidiuretic hormone secretion, commonly caused by small-cell lung cancer. First-line management is fluid restriction; desmopressin would worsen it, and sodium must not be corrected too quickly.

A 25-year-old develops stridor, lip swelling and hypotension minutes after a peanut. What is the immediate treatment?

• AIntravenous hydrocortisone
• BNebulised salbutamol
• CIntramuscular adrenaline 0.5 mg (500 micrograms)✓
• DIntravenous chlorphenamine

Answer: Anaphylaxis is treated with intramuscular adrenaline 500 micrograms (0.5 mL of 1 in 1,000) into the anterolateral thigh, repeated after five minutes if needed, with high-flow oxygen and fluids. Antihistamines and steroids are not first-line treatments in current Resuscitation Council UK guidance.

A 62-year-old woman with a urinary tract infection has a temperature of 39°C, heart rate 124, respiratory rate 26 and a lactate of 4 mmol/L. Which set of actions should be completed within the first hour?

• ABlood cultures, urine culture and a chest X-ray, then wait for the culture results before choosing an antibiotic, so that treatment is targeted
• BA CT scan of the abdomen and pelvis to find the source of infection before any antibiotic is given, so that drainage of any collection is not delayed
• COral antibiotics for the urinary infection, encourage oral fluids and paracetamol for the fever, and arrange a review of the observations in 24 hours
• DOxygen if needed, blood cultures, intravenous antibiotics, intravenous fluids, lactate measurement and urine output monitoring✓

Answer: These features indicate sepsis with a raised lactate. The 'sepsis six' — giving oxygen, taking blood cultures, giving intravenous antibiotics, giving intravenous fluids, measuring lactate and monitoring urine output — should be completed within one hour, without waiting for culture results.

A 52-year-old man with a BMI of 33 is newly diagnosed with type 2 diabetes. Lifestyle changes alone have not controlled his HbA1c. What is the first-line drug?

• AInsulin
• BMetformin✓
• CSitagliptin
• DGliclazide

Answer: Metformin is the first-line drug for type 2 diabetes because it does not cause weight gain or hypoglycaemia and has cardiovascular benefit. Sulfonylureas and DPP-4 inhibitors are later additions, and insulin is reserved for when oral agents fail.

A 66-year-old woman with breast cancer is confused and dehydrated with a corrected calcium of 3.4 mmol/L. What is the first step in treatment?

• ACalcitonin nasal spray
• BIntravenous 0.9% sodium chloride rehydration✓
• CIntravenous zoledronic acid immediately, before any fluids are given
• DOral calcium restriction

Answer: Severe hypercalcaemia is treated first with intravenous fluid rehydration, which restores volume and increases renal calcium excretion. An intravenous bisphosphonate such as zoledronic acid follows after rehydration, since it takes two to four days to work.

A 30-year-old woman has weight loss, heat intolerance, palpitations and a smooth goitre. TSH is suppressed and free T4 raised. What is the most likely diagnosis?

• AA toxic multinodular goitre
• BHypothyroidism
• CGraves' disease✓
• DHashimoto's thyroiditis

Answer: A young woman with hyperthyroid symptoms and a diffuse smooth goitre most likely has Graves' disease, an autoimmune condition confirmed by TSH-receptor antibodies. Multinodular goitre affects older people with a nodular gland.

A 60-year-old woman with type 2 diabetes is found drowsy with a blood glucose of 38 mmol/L, serum osmolality of 340 mOsm/kg and no ketones. What is the diagnosis?

• ALactic acidosis caused by her metformin
• BHyperosmolar hyperglycaemic state✓
• CHypoglycaemia from her evening insulin dose
• DDiabetic ketoacidosis with mild dehydration

Answer: Very high glucose with hyperosmolality and no significant ketosis in type 2 diabetes is HHS; it develops over days, carries a higher mortality than DKA, and is treated with careful fluid replacement before insulin.

A 50-year-old man has a serum potassium of 2.8 mmol/L after several days of vomiting. Which ECG change is most characteristic?

• AFlattened T waves and prominent U waves✓
• BA shortened QT interval with a prolonged PR interval
• CST elevation in the inferior leads with reciprocal changes
• DTall, peaked T waves with a widened QRS complex

Answer: Hypokalaemia flattens T waves and produces U waves, with a prolonged QT; tall peaked T waves are the sign of hyperkalaemia.

A 25-year-old woman with type 1 diabetes has a blood glucose of 2.9 mmol/L and is unconscious. What is the treatment?

• AOral glucose gel rubbed into the inside of the cheek, where it is absorbed through the lining
• BIntramuscular glucagon or intravenous glucose, since she cannot swallow safely✓
• CWait for her to regain consciousness naturally and then give biscuits and a sugary drink
• DA sugary drink through a straw, held to her lips by the nurse

Answer: An unconscious patient must not be given anything by mouth. Glucagon 1 mg intramuscularly or intravenous glucose is used, followed by carbohydrate once she can swallow.