EM Boards Survival Guide: Endocrine/Metabolic 1

Author: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit)

Welcome back to the EM Boards Survival Guide! This emDocs series will provide you with regular tips and must-know items for EM boards and inservice. Each post will feature several key takeaways on a specific organ system. This week we cover endocrinology and metabolics.

Boards Must-Knows:

1) Adrenal insufficiency: Shock not responsive to IVF. Pts to consider in: chronic steroid use, history of TB or HIV, tan-appearing in winter, etc. (Note: often mistaken as gastroenteritis mimic). HyperK + hypoNa +/- hypoglycemia. Treat with hydrocortisone or dexamethasone.

2) Cushing’s syndrome: Too much cortisol. Know typical clinical presentation. HypoK + hyperglycemia.

3) Pheochromocytoma: Clinically it’s a rarity but the Boards love it. Think about it in your patient with uncontrolled hypertension on multiple agents with episodic signs/symptoms. Keep in mind the rule of 10s. Treat with alpha blocker, then beta blocker.

4) Metabolic acidosis: Anion gap (CAT-MUDPILES => KULT). No anion gap: think GI losses. Know how to calculate anion gap // osmolar gap // Winters’ formula (see https://www.mdcalc.com/and memorize formulas for exam only)

5) Metabolic alkalosis: #1 etiology is vomiting; treat with hydration.

6) Hyper/hypoparathyroidism: Hypercalcemia in young pt: think hyperparathyroidism. Hypo- scenario: s/p thyroidectomy, accidental removal of parathyroids (see hypocalcemia presentation below).

7) Hypocalcemia: ECG with prolonged QT, Trousseau’s, Chvostek’s; replace with calcium gluconate.

8) Hypercalcemia: ECG with shortened QT, stones/bones/groans; treat with fluid hydration to start. Older pt: need malignancy work-up.

9) DKA: Find and address trigger. Know classic lab findings and VBG. Start with IVF, replace K => insulin infusion.

10) HHS: Normal/slightly abnormal pH / fewer ketones but larger glucose than DKA. Address trigger. IVF and insulin (watch K). Higher mortality than DKA.

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