Physical examination only will differ from final diagnoses when the mimic (if one exists) is discovered.

EM2 ENDOCRINE EMERGENCIES

feeling sluggish, physically and mentally, having high blood pressure and high blood sugar levels are all symptoms of  Metabolic Syndrome. Hypertension is an important hallmark of metabolic syndrome.

Metabolic Syndrome  sets the stage for catastrophic health problems, such as heart disease, diabetes, etc.

glucose intolerance that is the hallmark of metabolic syndrome

and fibrinogen and thrombus formation increases. The increase in fibrinogen tends to increase coagulation.

Metabolic syndrome strongly linked to heart attack and stroke

a diet-caused hormonal logjam that interferes with your body's ability to efficiently burn off the sugar

hyperglycemia reflects the consequence of the metabolic derangement, not the cause. Signs and symptoms of diabetic ketoacidosis may mimic those of the flu.

Cerebral edema. A rare complication, cerebral edema is brain swelling caused by a buildup of fluid in the brain cells. It's not certain why treatment causes cerebral edema to develop, although it may be related to rapid fluid replacement.

Hypokalemia. This is an abnormally low level of the electrolyte potassium in the blood. Insulin and fluids facilitate the entry of potassium into the cells, which decreases the blood potassium levels. Low blood potassium levels can impair heart, muscle and nerve activities.

• Hyperglycemia. Hyperglycemia is an abnormally high level of glucose in the blood. People with diabetic ketoacidosis have hyperglycemia because there isn't enough insulin available to help your cells take up glucose. The hyperglycemia worsens as your body continues to break down fat into glucose and send the glucose into your bloodstream.
• Ketosis. When glucose is not available for your body to use as fuel, your body begins to break down fat to produce energy instead. This process, known as ketosis, releases byproducts known as ketones.
• Acidosis. Normally, blood is slightly basic, with a pH ranging from 7.35 to 7.45. Acidosis occurs when the blood pH drops below 7.35. An excess of ketones causes the blood to become acidic, which may be harmful to the organs in your body.
• Diabetic ketoacidosis (DKA) may  be triggered by a stressful event, such as an illness or another health problem. The condition may also arise as a result of insufficient insulin therapy. Diabetic ketoacidosis is most common in people with type 1 diabetes, but may also occur in those with type 2 diabetes. Occasionally, diabetic ketoacidosis is the first indication that a person has diabetes.
• The most common cause of DKA is an infection, such as pneumonia or a urinary tract infection. Other common causes include an  inadequately treated infection, or untreated hyperglycemia.

With appropriate medical care, diabetic ketoacidosis is usually successfully treated. Untreated DKA results in coma and eventual death.

Diabetic ketoacidosis

It comes down to the clinician's knowledge of metabolism and endocrinology

 excessive glucose-containing intravenous fluids may exacerbate ischemic cerebral injury.

The diagnosis of diabetes is established exclusively by the documentation of hyperglycemia (increased glucose concentrations in the plasma). Therefore, measurement of plasma glucose is the sole diagnostic criterion

Encephalopathies and other toxic-metabolic conditions

Hyperglycemia with hyperosmolar state may be associated with focal neurologic deficits simulating stroke but focal seizures are reported in this condition as well. Focal neurologic signs with hyperglycemia may include aphasia, homonymous hemianopia, hemisensory deficits, hemiparesis, unilateral hyperreflexia, and the presence of a Babinski sign. Other metabolic encephalopathies reported to cause stroke-like conditions include hyponatremia and hepatic encephalopathy.

Signs of Adrenal Crisis

• Hypotension
• Dehydration
• Hyponatremia

The main clinical manifestation of adrenal crisis is shock, but patients may also have nonspecific symptoms such as anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, confusion or coma.

Initial treatment: The aim of initial management in adrenal crises is to treat hypotension, i.e,. to correct the blood volume deficit, and to reverse the electrolyte abnormalities and cortisol deficiency. Large volumes of normal saline solution should be given intravenously. The glucocorticoid deficiency should be treated by immediate intravenous administration of dexamethasone sodium phosphate or hydrocortisone sodium succinate.

Adrenal crisis is characterized by dehydration, hypotension, and imbalances of sodium and potassium. Treatment usually consists of large volumes of intravenous salt solution and an injectable form of glucocorticoid.

Cool, dry skin suggests late sepsis.

Hyperosmolar Hyperglycemic Nonketotic Coma

Medical/Legal Pitfalls:  

• Failure to manage the airway with endotracheal intubation when necessary

• Failure to provide adequate fluid resuscitation (leading to shock)

• Cerebral edema (more common in children) secondary to overly rapid hydration (especially with hypotonic fluids) or failure to add glucose to fluids when the level falls to less than 250 mg/dL

• Hypoglycemia due to excessive insulin use without the initiation of glucose-containing fluids

• Failure to replete potassium in patients who have a total body potassium deficit but an initially normal serum potassium level (On the other hand, administration of IV potassium has been associated with significant morbidity and death, especially with iatrogenic errors.)

• Failure to treat empirically and early with broad-spectrum antibiotics when sepsis appears to be a possible precipitant.
• http://www.emedicine.com/emerg/ENDOCRINE_AND_METABOLIC.htm

Hyponatremia

Medical/Legal Pitfalls: 

• Failure to consider the possibility of sampling or analysis error, hyperglycemia, hyperproteinemia, or hyperlipidemia before making the diagnosis of hypovolemic hyponatremia

• Failure to recognize high-risk groups, including elderly patients, patients on diuretics, infants, postoperative patients, and patients with malignancy

• Failure to quickly recognize severe acute hyponatremia and to correct it promptly, allowing ongoing risk of brainstem herniation

• Correcting serum sodium level too rapidly in patients with chronic hyponatremia (in excess of 0.5 mEq/L/h or 12 mEq/L/d), thereby incurring the risk of CPM.

http://www.freewebs.com/medical_secrets/EndocrineCrisis.htm

Case in point: The Arlene Berry Case

http://www.geocities.com/target_injustice/Legacy.HTM

http://www.geocities.com/target_injustice/AlteredRecords.HTM