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WorksheetsER endo emergencies
Total questions: 50
Worksheet time: 25mins
A 68-year-old diabetic male presents to the ED with confusion and diaphoresis. His glucose is 42 mg/dL. He is alert and oriented. What is the best initial management?
IV D50 bolus
Oral glucose followed by complex carbohydrate and protein
IM glucagon
Start insulin drip
Which patient is most likely to be admitted for observation after a hypoglycemic episode?
Patient with a glucose of 55 mg/dL corrected by juice, on short-acting insulin, with reliable caregiver
Patient who had a seizure from glucose of 48 mg/dL, on glipizide
Patient with reactive hypoglycemia after exercise, improved with snacks
Pregnant T1D patient with mild symptoms, now asymptomatic
A patient with T1DM and sepsis is found unresponsive. His glucose is 35 mg/dL. IV access is not yet available. What is the best next step?
Administer oral juice
Administer IM glucagon
Wait for IV access
Observe for 15 minutes
Why might IM glucagon fail to correct hypoglycemia in a chronic alcoholic patient?
Insulin resistance
Beta-blocker use
Depleted hepatic glycogen stores
Renal failure
A patient treated for hypoglycemia is at risk for rebound hypoglycemia. What prevents this complication best?
Administering glucagon
Administering complex carbohydrate and protein
Giving a second dose of D50
Starting an insulin drip
Which of the following is a common early symptom of hypoglycemia triggered by sympathetic activation?
Bradycardia
Urinary retention
Sweating and palpitations
Hypotension
In the prehospital setting, which action is most appropriate when stroke-like symptoms are noted?
Wait for labs before treatment
Administer aspirin
Check bedside glucose
Perform rapid CT scan
A hypoglycemic patient is given D10W. What is the approximate volume of D10W given in standard ED treatment?
500 mL bolus
50 mL bolus
250 mL bolus
1000 mL infusion
Which of the following increases risk for hypoglycemia in diabetic patients?
A. Hyperthyroidism
B. Acute renal failure
C. Glucocorticoid use
D. NSAID use
A diabetic patient becomes hypoglycemic while on vacation. Which scenario most likely contributed?
Took insulin, skipped lunch, went hiking
Ate double lunch, skipped insulin
Took oral steroids, ate snacks
Forgot nighttime insulin, ate a large dinner
A 12-year-old boy presents to the ED with abdominal pain, vomiting, and tachypnea. Vitals show HR 118, RR 32, and glucose 410 mg/dL. What is the most appropriate next step?
Administer subcutaneous insulin
Begin IV fluid resuscitation
Obtain HbA1C
Administer sodium bicarbonate immediately
Which of the following best describes the classic presentation of new-onset type 1 diabetes in the ED?
Fatigue, dry skin, elevated cholesterol
Polyuria, polydipsia, weight loss, tachypnea
Slow-healing wounds, hypertension, vision changes
Recurrent UTIs, obesity, numbness in toes
What is the primary mechanism leading to DKA?
Excessive dietary carbohydrate intake
Acute insulin overdose
Absolute or relative insulin deficiency
Increased insulin sensitivity
Which lab finding is most characteristic of DKA?
Respiratory alkalosis
Metabolic acidosis with elevated anion gap
Hypoglycemia
Elevated bicarbonate
Which of the following would indicate that a patient is likely in DKA?
Glucose 150 mg/dL, CO₂: 32, no ketones
Glucose 490 mg/dL, CO₂: 8, large serum ketones
Glucose 190 mg/dL, normal electrolytes, negative ketones
Glucose 250 mg/dL, pH 7.40, bicarbonate 24
What electrolyte abnormality is commonly seen after insulin therapy begins in DKA?
Hyperkalemia
Hypercalcemia
Hypokalemia
Hypernatremia
A patient presents with DKA. After initial fluid bolus, what is the next step in management?
Sodium bicarbonate drip
High-dose IV insulin bolus
Continuous insulin infusion and electrolyte monitoring
Immediate transition to subcutaneous insulin
What symptom of DKA is a result of prostaglandin release?
Weight loss
Polydipsia
Abdominal pain and nausea
Blurred vision
Which condition can result in euglycemic DKA despite near-normal glucose levels?
Chronic steroid use
Use of SGLT2 inhibitors
T2DM with insulin resistance
Excessive sugar intake
In DKA, which finding is most associated with severe disease and possible poor prognosis?
Serum glucose >250 mg/dL
Kussmaul respirations
Serum bicarbonate <10 mEq/L
Polyuria
A 45-year-old chronic alcoholic presents with abdominal pain, vomiting, and tachypnea. He hasn’t eaten in 3 days and has low or undetectable blood alcohol levels. Labs show a high anion gap metabolic acidosis. What is the most likely diagnosis?
Diabetic ketoacidosis
Lactic acidosis
Alcoholic ketoacidosis
Hyperosmolar hyperglycemic state
Which treatment is most appropriate in alcoholic ketoacidosis (AKA)?
IV insulin infusion
D5NS and thiamine
Normal saline and subcutaneous insulin
Glucagon and potassium
What key laboratory finding distinguishes alcoholic ketoacidosis from diabetic ketoacidosis?
Low anion gap
Negative or weakly positive serum ketones
Markedly elevated glucose levels
High TSH level
Why is insulin contraindicated in most patients with alcoholic ketoacidosis?
It worsens renal failure
It increases blood alcohol levels
Patients are not hyperglycemic and can become hypoglycemic
It increases lactic acid
Which of the following is a common complication of untreated AKA?
Seizures due to hyperglycemia
Hypoglycemia and electrolyte imbalances
Pulmonary embolism
Diabetic nephropathy
Which vitamin deficiency must be corrected in patients with chronic alcohol use and suspected AKA?
Vitamin C
Vitamin D
Thiamine (Vitamin B1)
Folic acid
A 76-year-old nursing home resident presents with lethargy and confusion. Blood glucose is 720 mg/dL, serum osmolality is 320 mOsm/kg, and serum ketones are negative. What is the most likely diagnosis?
Diabetic ketoacidosis
Myxedema coma
Hyperosmolar hyperglycemic state
Sepsis
What is the first priority in the management of hyperosmolar hyperglycemic state (HHS)?
IV insulin drip
Administration of bicarbonate
Rapid correction of hypernatremia
Aggressive IV fluid replacement with normal saline
Which patient is most at risk for developing HHS?
A T1DM patient using an insulin pump
An elderly patient with undiagnosed T2DM and UTI
A middle-aged alcoholic with pancreatitis
A child with known T1DM noncompliant with insulin
Which of the following is a key clinical feature of HHS, but not typically seen in DKA?
Kussmaul respirations
Severe dehydration and profound mental status changes
Abdominal pain and vomiting
Serum glucose >250 mg/dL
A postpartum woman presents with fever, altered mental status, tachycardia, and lid lag. TSH is undetectable and free T4 is very high. What is the most likely diagnosis?
Thyrotoxicosis
Thyroid storm
Sepsis
Myxedema coma
Which of the following symptoms is most specific for myxedema coma?
Heat intolerance, palpitations, diarrhea
Facial swelling, hypothermia, bradycardia
Tremor, insomnia, anxiety
Seizure, hyperreflexia, exophthalmos
What is the initial pharmacologic treatment of choice in thyroid storm?
IV levothyroxine
Radioactive iodine
Propranolol
Methimazole only
What is the primary trigger for thyroid storm in many patients?
Metformin overdose
High iodine diet
Stressful event like infection, surgery, or postpartum state
Prolonged fasting
A 74-year-old female presents with confusion, hypotension, hypoventilation, and bradycardia. TSH is elevated, and free T4 is undetectable. What is the next best step in management?
Start oral levothyroxine and observe
IV levothyroxine and IV hydrocortisone
Oral methimazole
Wait for thyroid panel before starting therapy
Why are glucocorticoids given in myxedema coma?
To stimulate thyroid hormone production
To reduce insulin resistance
To prevent adrenal crisis and reduce peripheral conversion of T4 to T3
To treat hyperkalemia
What complication should be closely monitored in patients with myxedema coma and hypothermia?
Hypertension crisis
Bradyarrhythmia and QT prolongation
Seizures
Hyperthermia
What distinguishes thyroid storm from uncomplicated thyrotoxicosis?
Elevated TSH
Hypothermia and lethargy
CNS dysfunction, high fever, and decompensated cardiovascular system
Absence of goiter
What scoring system helps confirm the diagnosis of thyroid storm?
Glasgow Coma Scale
Burch-Wartofsky Point Scale
MELD Score
Wells Criteria
Which of the following medications should be given one hour after PTU in thyroid storm to block hormone release?
Iodine (SSKI or Lugol’s solution)
Methimazole
Hydrocortisone
Lithium
A 58-year-old male on chronic prednisone abruptly discontinues his medication and presents with hypotension, fatigue, and nausea. What is the most likely diagnosis?
Sepsis
Addison’s disease
Adrenal crisis due to secondary adrenal insufficiency
Hypovolemic shock
Which of the following is a classic lab finding in primary adrenal insufficiency but not typically seen in secondary?
Hyperglycemia
Hyperkalemia
Elevated cortisol
Elevated sodium
What is the most appropriate initial treatment for adrenal crisis in the ED?
IV insulin and fluid restriction
Oral hydrocortisone and observation
IV fluids and IV hydrocortisone 100 mg bolus
Vasopressors only
Which of the following symptoms is most suggestive of an acute adrenal crisis?
Fever, bradycardia, hypothermia
Hypotension unresponsive to fluids and pressors
Headache and photophobia
Polyuria and hypernatremia
A patient with adrenal insufficiency is undergoing surgery. What pre-procedure management is essential?
IV dextrose
Antibiotic prophylaxis
Stress-dose steroids
Withholding all medications
A patient presents with weakness, nausea, craving for salt, and hyperpigmentation of the skin. Labs show hyponatremia and hyperkalemia. What is the most likely diagnosis?
Syndrome of inappropriate antidiuretic hormone (SIADH)
Primary adrenal insufficiency (Addison’s disease)
Secondary adrenal insufficiency
Diabetes insipidus
What diagnostic lab values are most consistent with adrenal insufficiency?
Cortisol >20 mcg/dL, low ACTH
Cortisol <10 mcg/dL, hyperkalemia, hyponatremia
Normal electrolytes, elevated glucose
Elevated cortisol and aldosterone
What should be done before administering steroids if adrenal insufficiency is suspected, but the patient is stable?
Order thyroid function tests
Obtain a cortisol and ACTH level
Start levothyroxine
Give potassium replacement
What fluid is preferred in the management of adrenal crisis?
D5½NS
Lactated Ringer’s
D5NS or NS
3% hypertonic saline
Which of the following patients is most at risk for developing adrenal crisis?
T2DM patient on metformin
Patient with long-term steroid use undergoing major surgery
Patient with hyperaldosteronism
Elderly female with hypothyroidism
