CCRN - Review Endocrine and Metabolic Crises Questions and Answers 1 — Questions and Answers
Question 1: A 78-year-old male with a history of type 2 diabetes is brought to the ICU with altered mental status. His vital signs are: BP 90/60 mmHg, HR 125 bpm, RR 24, Temp 38.5°C. Laboratory results show: Glucose 1,150 mg/dL, Serum Osmolality 345 mOsm/kg, Arterial pH 7.36, Serum Bicarbonate 25 mEq/L, and small ketones in the urine. Which condition do these findings most strongly indicate?
- Diabetic Ketoacidosis (DKA)
- Hyperosmolar Hyperglycemic State (HHS) (Correct answer)
- Myxedema Coma
- Thyroid Storm
Correct answer: Hyperosmolar Hyperglycemic State (HHS)
The patient's presentation of profound hyperglycemia (>600 mg/dL), high serum osmolality (>320 mOsm/kg), and altered mental status without significant acidosis (pH > 7.30, Bicarb > 18) is characteristic of Hyperosmolar Hyperglycemic State (HHS). [10, 15] DKA would present with significant metabolic acidosis and large serum ketones. Myxedema coma and thyroid storm are not primarily characterized by extreme hyperglycemia.
Question 2: A patient with a history of Graves' disease is admitted to the ICU post-operatively and develops a fever of 40.5°C (105°F), heart rate of 165 bpm, agitation, and delirium. Which of the following medications is a priority to block the synthesis of new thyroid hormone?
- IV Levothyroxine
- IV Amiodarone
- Esmolol infusion
- Oral Propylthiouracil (PTU) (Correct answer)
Correct answer: Oral Propylthiouracil (PTU)
The patient is exhibiting signs of a thyroid storm, a life-threatening hypermetabolic state. The priority is to stop the production of new thyroid hormones. Propylthiouracil (PTU) or methimazole are thionamides that inhibit thyroid hormone synthesis. [5, 33, 37] Levothyroxine is a synthetic thyroid hormone and would worsen the condition. Esmolol (a beta-blocker) is crucial for controlling adrenergic symptoms like tachycardia but does not treat the underlying cause. [21] Amiodarone is an antiarrhythmic not indicated as a primary treatment.
Question 3: A critical care nurse is managing a patient with central Diabetes Insipidus (DI) following neurosurgery. Which set of laboratory and clinical findings is most characteristic of this condition?
- High serum sodium, low urine specific gravity, polyuria (Correct answer)
- Low serum sodium, high urine specific gravity, oliguria
- High serum potassium, low serum osmolality, hypertension
- Low serum sodium, low urine osmolality, fluid volume overload
Correct answer: High serum sodium, low urine specific gravity, polyuria
Diabetes Insipidus is caused by a deficiency of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine. This results in the excretion of large volumes of dilute urine (polyuria, low urine specific gravity <1.005, low urine osmolality). [7, 26] The massive free water loss leads to dehydration and concentrates the serum, causing hypernatremia (high serum sodium) and high serum osmolality. [1, 24]
Question 4: A patient with a known history of Addison's disease is admitted with profound hypotension that is refractory to fluid resuscitation and norepinephrine infusion. Labs reveal hyponatremia and hyperkalemia. Which medication is the priority to administer to treat the underlying cause of this patient's shock?
- Insulin and D50W
- Desmopressin (DDAVP)
- Hydrocortisone (Correct answer)
- Fludrocortisone
Correct answer: Hydrocortisone
This patient is in an adrenal (Addisonian) crisis, characterized by a deficiency of cortisol and aldosterone. The refractory shock is due to the lack of cortisol, which is necessary for the vascular system to respond to catecholamines. Immediate administration of IV hydrocortisone is the definitive, life-saving treatment. [3, 8, 18] While fludrocortisone replaces mineralocorticoids, hydrocortisone provides both essential glucocorticoid and some mineralocorticoid effects needed emergently. [32] Insulin/D50W treats hyperkalemia, and DDAVP is for diabetes insipidus.
Question 5: Which of the following findings is most consistent with a diagnosis of Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?
- Serum sodium 150 mEq/L, serum osmolality 315 mOsm/kg, polyuria
- Serum sodium 122 mEq/L, serum osmolality 260 mOsm/kg, urine specific gravity 1.030 (Correct answer)
- Serum sodium 138 mEq/L, urine specific gravity 1.002, intense thirst
- Serum sodium 125 mEq/L, decreased urine osmolality, signs of dehydration
Correct answer: Serum sodium 122 mEq/L, serum osmolality 260 mOsm/kg, urine specific gravity 1.030
SIADH is characterized by excessive ADH release, leading to renal water retention. This causes dilutional hyponatremia (low serum sodium), low serum osmolality, and the excretion of inappropriately concentrated urine (high urine specific gravity and high urine osmolality) in a euvolemic state. [9, 35] The other options describe dehydration/DI (A and C) or are contradictory (D).
Question 6: A 76-year-old female is found unresponsive. In the ICU, she has a temperature of 34.4°C (94°F), heart rate of 45 bpm, blood pressure of 82/50 mmHg, periorbital edema, and a Glasgow Coma Scale score of 7. These clinical findings are most suggestive of which endocrine emergency?
- Adrenal Crisis
- Thyroid Storm
- Myxedema Coma (Correct answer)
- Hyperosmolar Hyperglycemic State (HHS)
Correct answer: Myxedema Coma
Myxedema coma is a life-threatening complication of severe, longstanding hypothyroidism. Its hallmark features include altered mental status, profound hypothermia, and a precipitating event. [12, 29] Bradycardia, hypotension, hypoventilation, and non-pitting edema (myxedema) are also classic signs. [2, 4, 6] The other conditions are typically associated with tachycardia and/or normo/hyperthermia.
CCRN - Review Endocrine and Metabolic Crises Questions and Answers 1
A 78-year-old male with a history of type 2 diabetes is brought to the ICU with altered mental status.
His vital signs are: BP 90/60 mmHg, HR 125 bpm, RR 24, Temp 38.5°C.
Laboratory results show: Glucose 1,150 mg/dL, Serum Osmolality 345 mOsm/kg, Arterial pH 7.36, Serum Bicarbonate 25 mEq/L, and small ketones in the urine.
Which condition do these findings most strongly indicate?