Medical, Gastrointestinal, and Genitourinary Emergencies
Metabolic and endocrine crises
Candidates must recognize the presentations of diabetic ketoacidosis, hyperosmolar hyperglycemic state, hypoglycemia, thyroid storm, myxedema coma, and adrenal crisis. DKA management priorities are fluids, insulin after confirming potassium is not critically low, and potassium replacement; total body potassium is depleted even when serum potassium looks normal or high. Hypoglycemia is treated immediately with glucose and then a meal or dextrose infusion, and the cause is investigated.
Gastrointestinal emergencies
Upper gastrointestinal bleeding presents with hematemesis or melena; lower with hematochezia. Resuscitate before endoscopy, and remember that a patient on anticoagulants or with cirrhosis decompensates quickly. Acute abdomen: pain out of proportion with a soft abdomen suggests mesenteric ischemia; painless bleeding in an older adult suggests malignancy. Pancreatitis, cholecystitis, appendicitis, and bowel obstruction have characteristic histories and locations. Bowel obstruction presents with vomiting, distention, and absent or high-pitched bowel sounds.
Genitourinary emergencies
Testicular torsion is a surgical emergency with sudden severe pain, high-riding testis, and absent cremasteric reflex; do not wait for ultrasound if suspicion is high. Renal colic causes flank pain with hematuria. Urinary retention requires decompression. Sepsis from a urinary source in an older adult may present as confusion without fever.
Traps in questions
- Do not start insulin in DKA before checking potassium; severe hypokalemia must be corrected first.
- A normal serum potassium in DKA does not mean total body potassium is normal.
- Absent fever does not exclude sepsis in older adults.
- "Wait for imaging" is wrong for a high-suspicion torsion.
Rule of thumb
In any endocrine crisis, the first question is what will kill the patient in the next hour - usually hypoperfusion, hypoglycemia, or an arrhythmia from potassium. Worked example: a patient with DKA, potassium 3.0, and glucose 30 mmol/L receives fluids and potassium before insulin.