# Clinical Cases: Endocrine and Metabolic Emergencies

## Case 1: Diabetic Ketoacidosis - The New-Onset Diabetic

### Patient Demographics
- **Age:** 16 years
- **Sex:** Female
- **Occupation:** High school student

### Chief Complaint
"She's been vomiting all day and is breathing really fast."

### History of Present Illness
Parents bring their 16-year-old daughter for evaluation of progressive fatigue and malaise over 3 weeks, polydipsia and polyuria for 2 weeks, and today developed nausea, vomiting (x5 episodes), and abdominal pain. Parents note she has lost 15 pounds over the past month despite eating more than usual. She appears confused and is breathing rapidly.

### Initial Assessment

**ESI Level:** 2 - High-risk metabolic emergency

**First Impression:**
- Appearance: Lethargic, appears dehydrated
- Work of breathing: Deep, rapid respirations (Kussmaul breathing)
- Circulation: Dry mucous membranes, pale

**Vital Signs:**
- Heart rate: 124 bpm
- Blood pressure: 102/58 mmHg
- Respiratory rate: 28 breaths/min, deep
- SpO2: 99% on room air
- Temperature: 37.2C
- GCS: 13 (E3V4M6)
- Weight: 52 kg (usual 67 kg per parents)

**Point-of-Care Glucose:** 542 mg/dL

### Primary Survey

**Airway:** Patent
**Breathing:** Kussmaul respirations (deep, rapid) - respiratory compensation for metabolic acidosis
**Circulation:** Tachycardic, mild hypotension, delayed cap refill (4 seconds)
**Disability:** Lethargic, confused (only oriented to person)
**Exposure:** Dry skin and mucous membranes, fruity breath odor (acetone)

### Classic DKA Presentation

**The 3 P's of New Diabetes:**
- Polyuria - frequent urination (osmotic diuresis)
- Polydipsia - excessive thirst
- Polyphagia - increased appetite (with weight loss)

**DKA Triad:**
1. Hyperglycemia (>250 mg/dL)
2. Ketosis (ketonemia/ketonuria)
3. Acidosis (pH <7.3, HCO3 <18)

### Secondary Survey

**SAMPLE History:**
- Symptoms: Fatigue, polyuria, polydipsia, weight loss, nausea/vomiting, abdominal pain, confusion
- Allergies: None
- Medications: None
- PMH: Healthy, no known diabetes
- Last Meal: Attempted breakfast, vomited
- Events: Progressive symptoms over weeks, acute worsening today

**Physical Examination:**
- HEENT: Dry mucous membranes, sunken eyes, fruity breath
- Neck: Supple, no thyromegaly
- Cardiac: Tachycardic, no murmur
- Lungs: Clear, Kussmaul respirations
- Abdomen: Diffuse tenderness, no guarding (DKA gastroparesis)
- Skin: Dry, tenting
- Neuro: Lethargic, oriented x1, moving all extremities

### Diagnostic Testing

**Labs:**
- Glucose: 542 mg/dL
- Na: 128 mEq/L (factitious hyponatremia - calculate corrected)
- K: 5.4 mEq/L (elevated due to acidosis despite total body depletion)
- Cl: 98 mEq/L
- HCO3: 8 mEq/L
- BUN: 32
- Cr: 1.4 (prerenal AKI from dehydration)
- Anion gap: 128 - (98 + 8) = 22 (elevated)

**ABG:**
- pH: 7.14
- pCO2: 22 (appropriate respiratory compensation)
- HCO3: 7

**Additional Labs:**
- Beta-hydroxybutyrate: 6.8 mmol/L (elevated - confirms ketosis)
- Serum osmolality: 312 mOsm/kg
- HbA1c: 13.2% (confirms prolonged hyperglycemia)
- Urinalysis: Large ketones, large glucose

**Corrected Sodium Calculation:**
- Corrected Na = Measured Na + 1.6 x [(Glucose - 100)/100]
- Corrected Na = 128 + 1.6 x [(542-100)/100] = 128 + 7 = 135 mEq/L

### Diagnosis

**Diabetic Ketoacidosis (DKA)** - Severe (pH <7.1)
- New-onset Type 1 Diabetes Mellitus

### Management - DKA Protocol

**Hour 1:**
1. **IV Fluids:** NS 1L bolus (20 mL/kg)
2. **Insulin:** Regular insulin 0.1 units/kg/hour IV infusion (5.2 units/hour)
3. **Potassium:** Hold initially (K >5.2); recheck in 2 hours
4. **Monitoring:** Hourly glucose, q2-4h BMP, continuous cardiac monitoring

**Fluid Management Protocol:**
- After initial bolus: NS at 250-500 mL/hour
- When glucose <200: Switch to D5 0.45% NS to prevent hypoglycemia while continuing insulin

**Insulin Goals:**
- Glucose decrease: 50-70 mg/dL per hour (avoid rapid correction)
- Continue insulin until anion gap closes, not based on glucose alone

### Serial Monitoring

| Time | Glucose | K | HCO3 | pH | Anion Gap |
|------|---------|---|------|-----|-----------|
| 0 hr | 542 | 5.4 | 8 | 7.14 | 22 |
| 2 hr | 412 | 4.8 | 10 | 7.22 | 18 |
| 4 hr | 298 | 4.2 | 12 | 7.28 | 16 |
| 6 hr | 198 | 3.8 | 14 | 7.32 | 14 |
| 12 hr | 156 | 4.0 | 18 | 7.38 | 10 |

**At 4 hours:**
- Glucose <300: Switched to D5 0.45% NS
- K <5: Started KCl 20 mEq/L in fluids

**At 12 hours:**
- Anion gap closed (<12)
- Patient eating
- Transitioned to subcutaneous insulin (overlap IV for 1-2 hours)

### Complications to Monitor

1. **Cerebral edema** (especially in children/new-onset)
   - Warning signs: Headache, altered mental status, bradycardia, HTN
   - This patient: Monitored closely, no signs developed

2. **Hypokalemia** (as acidosis corrects and insulin drives K intracellularly)
   - Aggressive K replacement as needed

3. **Hypoglycemia** (if insulin continued without dextrose)
   - Prevented by switching to dextrose-containing fluids

### Disposition
- ICU admission for first 12 hours
- Transfer to floor when anion gap closed
- Diabetes education initiated
- Endocrinology consultation
- Insulin regimen: Basal-bolus with carbohydrate counting
- Discharged day 4 with extensive education

### Teaching Points

1. **Don't stop insulin when glucose normalizes:** Continue until anion gap closes
2. **Potassium shifts:** Serum K may be high despite total body depletion; replace aggressively as it falls
3. **Cerebral edema risk:** Highest in children, new-onset diabetes, severe DKA; avoid overly rapid correction
4. **Fluid before insulin:** In severe dehydration, initial fluid bolus before insulin
5. **Search for precipitant:** Infection, medication non-compliance, new diagnosis (like this case)
6. **Corrected sodium:** Use formula to assess true sodium status
7. **Kussmaul respirations:** Deep, rapid breathing = respiratory compensation for metabolic acidosis

### Clinical Image
![Kussmaul Breathing Pattern](case_01_image.jpg)

**Image Description:** Illustration demonstrating Kussmaul respirations - the characteristic deep, labored breathing pattern seen in metabolic acidosis (such as DKA), representing respiratory compensation to blow off CO2 and raise pH.

**Attribution:** Image from Wikimedia Commons, Kussmaul breathing. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Kussmaul_breathing.svg

---

## Case 2: Thyroid Storm - The Agitated Hyperthyroid Patient

### Patient Demographics
- **Age:** 38 years
- **Sex:** Female
- **Occupation:** Marketing executive

### Chief Complaint
"She's acting crazy and won't stop sweating."

### History of Present Illness
Husband brings 38-year-old wife for evaluation of progressive agitation, tremor, and profuse sweating over the past 3 days. She has known Graves' disease diagnosed 6 months ago but stopped taking her methimazole 3 weeks ago "because she felt fine." Two days ago she developed an upper respiratory infection with fever. Today she became confused, extremely agitated, and her husband is worried she is "going to have a heart attack."

### Initial Assessment

**ESI Level:** 1 - Life-threatening endocrine emergency

**First Impression:**
- Appearance: Extremely agitated, restless, diaphoretic
- Work of breathing: Tachypneic
- Circulation: Flushed, visibly bounding pulses

**Vital Signs:**
- Heart rate: 168 bpm, irregularly irregular
- Blood pressure: 162/54 mmHg (widened pulse pressure)
- Respiratory rate: 28 breaths/min
- SpO2: 96% on room air
- **Temperature: 40.2C (104.4F)**
- GCS: 13 (E4V4M5 - confused, agitated)

### Thyroid Storm - Clinical Recognition

**Burch-Wartofsky Point Scale (>45 suggests thyroid storm):**

| Feature | Points | This Patient |
|---------|--------|--------------|
| **Temperature** | 40-40.5C = 25 | 25 |
| **Heart rate** | >140 = 25 | 25 |
| **Atrial fibrillation** | Present = 10 | 10 |
| **CHF** | Mild = 5 | 0 |
| **GI dysfunction** | Moderate = 10 | 10 (nausea/vomiting) |
| **CNS** | Moderate = 20 | 20 (agitation/confusion) |
| **Precipitant** | Present = 10 | 10 (infection, medication non-compliance) |

**Total Score: 100** (thyroid storm very likely)

### Primary Survey

**Airway:** Patent, speaking (rapid, pressured speech)
**Breathing:** Tachypneic, clear lungs
**Circulation:** Tachycardic (atrial fibrillation with RVR), hyperdynamic
**Disability:** Agitated, confused, moving all extremities
**Exposure:** Profuse diaphoresis, tremor, no goiter visible (check for proptosis)

### Physical Examination

**Thyroid-Specific Findings:**
- Eyes: Lid lag, proptosis (Graves' ophthalmopathy)
- Neck: Diffusely enlarged thyroid gland, bruit over thyroid
- Cardiac: Irregular, tachycardic, hyperdynamic precordium
- Skin: Warm, moist, pretibial myxedema present
- Neuro: Fine tremor, hyperreflexia, agitation
- Extremities: Proximal muscle weakness

### Secondary Survey

**SAMPLE History:**
- Symptoms: Agitation, sweating, tremor, palpitations, confusion
- Allergies: None
- Medications: Methimazole (stopped 3 weeks ago)
- PMH: Graves' disease, anxiety
- Last Meal: Yesterday (poor appetite)
- Events: URI symptoms x2 days, progressive symptoms

**Precipitants of Thyroid Storm:**
- Infection (this patient - URI)
- Medication non-compliance (this patient - stopped methimazole)
- Surgery, trauma, iodine load, pregnancy

### Diagnostic Testing

**Labs:**
- TSH: <0.01 mIU/L (suppressed)
- Free T4: 8.2 ng/dL (markedly elevated; normal 0.8-1.8)
- Free T3: 18.4 pg/mL (elevated; normal 2.3-4.2)
- CBC: WBC 12.8 (infection)
- BMP: K 3.2, glucose 142
- LFTs: AST 88, ALT 76 (mild elevation)
- Cortisol: Ordered (check for adrenal insufficiency)

**ECG:** Atrial fibrillation with RVR, rate 168

**Chest X-ray:** Mild cardiomegaly, no infiltrates

### Diagnosis

**Thyroid Storm** secondary to:
1. Medication non-compliance (methimazole)
2. Precipitated by upper respiratory infection

### Management - Multi-Pronged Approach

**1. Block Hormone Synthesis (Thionamide):**
- **Propylthiouracil (PTU) 200mg PO/NG q4h** (preferred over methimazole in storm - also blocks peripheral T4→T3 conversion)

**2. Block Hormone Release (Iodine - give AFTER thionamide):**
- **SSKI 5 drops PO q6h** OR **Lugol's solution** (started 1 hour after PTU)
- Must give thionamide first or iodine will increase hormone synthesis

**3. Block Peripheral Effects (Beta-blocker):**
- **Propranolol 60-80mg PO q4-6h** OR **Esmolol drip**
- Controls heart rate and blocks peripheral T4→T3 conversion

**4. Block Peripheral Conversion (Corticosteroid):**
- **Hydrocortisone 100mg IV q8h**
- Blocks T4→T3 conversion
- Prevents relative adrenal insufficiency

**5. Supportive Care:**
- Aggressive cooling (external cooling, acetaminophen)
- IV fluids (high output state)
- Glucose supplementation
- Treat underlying precipitant (antibiotics if bacterial infection)

**6. Rate Control (Atrial Fibrillation):**
- Beta-blocker (propranolol)
- Consider digoxin if hypotensive (thyroid storm patients may need higher doses)

### Treatment Summary

| Medication | Dose | Mechanism |
|------------|------|-----------|
| PTU | 200mg q4h | Block synthesis |
| SSKI | 5 drops q6h | Block release |
| Propranolol | 60mg q4h | Block peripheral effects |
| Hydrocortisone | 100mg q8h | Block conversion, adrenal support |
| Acetaminophen | 1g q6h | Fever (avoid aspirin - displaces T4 from binding proteins) |

### Clinical Course

**At 6 hours:**
- Temperature: 38.8C (cooling measures)
- HR: 118 (beta-blocker effect)
- Less agitated, following commands

**At 24 hours:**
- Temperature: 37.4C
- HR: 92, converted to sinus rhythm
- Alert, oriented, cooperative

**At 48 hours:**
- Stable, free T4 trending down
- Transitioned to oral medications
- Thyroid levels: Free T4 4.2 ng/dL (improving)

### Disposition
- ICU admission for first 48 hours
- Step-down for 24 hours
- Endocrinology consultation
- Discharged day 4 on methimazole with close follow-up
- Educated extensively on medication compliance
- Discussed definitive treatment options (radioactive iodine, surgery)

### Teaching Points

1. **Thyroid storm is clinical diagnosis:** Don't wait for labs; treat based on Burch-Wartofsky score
2. **Multi-drug approach essential:** Target synthesis, release, peripheral conversion, and effects
3. **Order matters:** Give thionamide BEFORE iodine
4. **Avoid aspirin:** Displaces thyroid hormone from binding proteins, increasing free hormone
5. **Beta-blockers do double duty:** Control symptoms AND block peripheral T4→T3 conversion (propranolol)
6. **Steroids for everyone:** Blocks conversion and prevents adrenal crisis
7. **Identify precipitant:** Infection, non-compliance, surgery - treat underlying cause
8. **Atrial fibrillation common:** Usually converts with treatment of underlying storm

### Clinical Image
![Graves' Disease - Exophthalmos](case_02_image.jpg)

**Image Description:** Photograph demonstrating bilateral exophthalmos (proptosis) in a patient with Graves' disease, showing characteristic lid retraction and scleral show above and below the iris.

**Attribution:** Image from Wikimedia Commons, Graves' disease exophthalmos. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Proptosis_and_lid_retraction_from_Graves%27_Disease.jpg

---

## Case 3: Hyperosmolar Hyperglycemic State (HHS)

### Patient Demographics
- **Age:** 72 years
- **Sex:** Male
- **Occupation:** Retired

### Chief Complaint
"Found confused at home."

### History of Present Illness
EMS brings a 72-year-old male found by his daughter lying in bed, confused and minimally responsive. She last spoke to him 3 days ago and he seemed "a little tired." The patient lives alone and has poorly controlled type 2 diabetes. The home was hot (air conditioning was broken), and daughter noticed many empty soda bottles around.

### Initial Assessment

**ESI Level:** 1 - Altered mental status, critically ill

**First Impression:**
- Appearance: Obtunded, appears severely dehydrated
- Work of breathing: Normal rate and depth
- Circulation: Dry skin, poor turgor

**Vital Signs:**
- Heart rate: 116 bpm
- Blood pressure: 88/52 mmHg
- Respiratory rate: 18 breaths/min
- SpO2: 95% on room air
- Temperature: 38.4C
- GCS: 9 (E2V3M4)

**Point-of-Care Glucose:** "HIGH" (>600 mg/dL - above meter range)

### HHS vs. DKA Comparison

| Feature | DKA | HHS | This Patient |
|---------|-----|-----|--------------|
| Glucose | Usually 250-600 | Usually >600 | >600 |
| pH | <7.3 | >7.3 | 7.34 |
| Ketones | Significantly elevated | Absent/mild | Trace |
| Osmolality | Variable | >320 | 358 |
| Mental status | Variable | Often significantly altered | Obtunded |
| Dehydration | Moderate (3-6L) | Severe (8-12L) | Severe |

### Primary Survey

**Airway:** Patent, not protecting well (GCS 9)
**Breathing:** Normal rate (no Kussmaul - not acidotic)
**Circulation:** Tachycardic, hypotensive, severely dehydrated
**Disability:** Obtunded, GCS 9, no focal deficits, glucose critical
**Exposure:** Dry skin, tenting, concentrated urine

### Resuscitation

**Immediate Interventions:**
1. IV access x2 (difficult - dehydrated)
2. Aggressive fluid resuscitation: NS bolus
3. Continuous cardiac monitoring
4. Labs, including osmolality
5. Urinary catheter (monitor output)

### Secondary Survey

**SAMPLE History (from daughter):**
- Symptoms: Progressive lethargy, confusion
- Allergies: Sulfa
- Medications: Metformin, glipizide (unsure if taking)
- PMH: Type 2 diabetes (poorly controlled), hypertension, CKD
- Last Meal: Unknown
- Events: Found at home after 3 days

**Risk Factors:**
- Elderly with T2DM
- Limited access to water (debilitated, alone)
- Heat exposure (broken AC)
- Possible infection precipitant

**Physical Examination:**
- HEENT: Extremely dry mucous membranes, sunken eyes
- Neck: No thyromegaly, no JVD
- Cardiac: Tachycardic, no murmur
- Lungs: Clear (no crackles - severely dehydrated)
- Abdomen: Soft, non-tender
- Skin: Very poor turgor, concentrated urine
- Neuro: Obtunded, moving all extremities, no focal signs

### Diagnostic Testing

**Labs:**
- Glucose: 1,142 mg/dL
- Na: 152 mEq/L (severe hypernatremia)
- K: 4.8 mEq/L
- Cl: 112 mEq/L
- HCO3: 22 mEq/L (near-normal)
- BUN: 86
- Cr: 3.2 (baseline 1.4)
- **Serum osmolality: 358 mOsm/kg** (severely elevated)
- ABG: pH 7.34, pCO2 36, HCO3 20 (no significant acidosis)
- Beta-hydroxybutyrate: 0.8 mmol/L (mildly elevated, not ketotic)

**Corrected Sodium:**
- Corrected Na = 152 + 1.6 x [(1142-100)/100] = 152 + 17 = 169 mEq/L (severe!)

**Effective Osmolality:**
- 2(Na) + Glucose/18 = 2(152) + 1142/18 = 304 + 63 = 367 mOsm/kg

**Additional Labs:**
- WBC: 18.4 (likely hemoconcentration vs. infection)
- UA: Pyuria, bacteria (UTI - likely precipitant)

### Diagnosis

**Hyperosmolar Hyperglycemic State (HHS)** with:
- Severe dehydration (estimated 10-12L deficit)
- Precipitated by urinary tract infection
- Concurrent AKI

### Management - HHS Protocol

**Fluid Resuscitation (AGGRESSIVE):**
- Hour 1: NS 1.5L bolus
- Then: NS 500-1000 mL/hour until hemodynamically stable
- Calculate fluid deficit: Estimated 10L over 24-48 hours

**Fluid Type Decision:**
- Start with NS (volume resuscitation)
- After initial resuscitation: Assess corrected sodium
- If corrected Na high (>145): Switch to 0.45% NS
- When glucose <300: Add dextrose

**Insulin:**
- May not need initially if glucose falling with fluids
- If starting: Lower dose than DKA (0.025-0.05 units/kg/hour)
- Fluid replacement causes glucose to drop significantly
- Goal: Glucose decrease 50-70 mg/dL/hour (avoid rapid changes)

**Potassium:**
- Monitor closely (will fall with treatment)
- Replace when K <5.2 and UOP adequate

**Osmolality Correction:**
- Target decrease: 3-8 mOsm/kg/hour
- Too rapid correction risks cerebral edema

### Serial Monitoring

| Time | Glucose | Na (corrected) | Osmolality | Mental Status |
|------|---------|----------------|------------|---------------|
| 0 hr | 1142 | 169 | 367 | Obtunded (GCS 9) |
| 4 hr | 724 | 158 | 332 | Lethargic (GCS 11) |
| 8 hr | 482 | 150 | 308 | Follows commands (GCS 13) |
| 12 hr | 286 | 145 | 294 | Alert (GCS 14) |
| 24 hr | 184 | 142 | 286 | Baseline (GCS 15) |

**Fluid Balance:**
- Total fluids in first 24 hours: 9L
- Urine output recovered after 6 hours

### Additional Management

**Infection Treatment:**
- Blood cultures obtained
- Started ceftriaxone for presumed UTI/urosepsis

**AKI Management:**
- Fluids, avoid nephrotoxins
- Creatinine peaked at 3.4, then improved

### Disposition
- ICU admission
- Continuous monitoring
- Creatinine improving (1.8 at day 3)
- Transitioned to subcutaneous insulin
- Diabetes education
- Discharged day 5 to rehab
- Follow-up with endocrinology and primary care

### Teaching Points

1. **HHS = profound dehydration:** Average fluid deficit 8-12L; aggressive replacement essential
2. **Less acidosis than DKA:** Enough insulin to prevent ketosis but not hyperglycemia
3. **Mental status correlates with osmolality:** Confusion/coma with osmolality >320
4. **Fluids before insulin:** Volume replacement may significantly lower glucose
5. **Corrected sodium critical:** Assess true sodium status; guide fluid choice
6. **Mortality higher than DKA:** 10-20% vs. <5%; often due to precipitating illness
7. **Look for precipitant:** Infection, MI, stroke common triggers
8. **Slow and steady correction:** Avoid rapid osmolality shifts; risk of cerebral edema

### Clinical Image
![Serum Osmolality Calculation](case_03_image.jpg)

**Image Description:** Diagram illustrating the calculation of serum osmolality and the relationship between glucose, sodium, and osmolality in hyperosmolar states such as HHS.

**Attribution:** Image from Wikimedia Commons, Serum osmolality. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Serum_osmolality_formula.svg