Diseases » Hypoglycemia » Diagnosis

Diagnosis of Hypoglycemia

Diagnostic Test list for Hypoglycemia:

The list of medical tests mentioned in various sources as used in the diagnosis of Hypoglycemia includes:

• Blood glucose test
• Successful response to sugar

Hypoglycemia Diagnosis: Book Excerpts

• Ask the Following Questions - HYPOGLYCEMIA
• Differential Diagnosis - Hypoglycemia
• Differential Diagnosis - Low Back Pain/Swelling
• Differential Diagnosis - Hypoglycemia
• Approach to the Diagnosis - HYPOGLYCEMIA
• Approach to the Diagnosis - LOW BACK PAIN
• History and physical examination - Low birth weight
• Diagnosis - Hypoglycemia
• History and physical examination - Low birth weight
• History - Low Back Pain
• Differential Overview - Low Back Pain
• Diagnosis - Hypoglycemia
• History and physical examination - Low birth weight
• Approach to the Diagnosis - LOW BACK PAIN
• Approach to the Diagnosis - HYPOGLYCEMIA

Tests and diagnosis discussion for Hypoglycemia:

To diagnose hypoglycemia in people who do not have diabetes, the doctor looks for the following three conditions:

• The patient complains of symptoms of hypoglycemia
• Blood glucose levels are measured while the person is experiencing those symptoms and found to be 45 mg/dL or less in a woman or 55 mg/dL or less in a man
• The symptoms are promptly relieved upon ingestion of sugar.

For many years, the oral glucose tolerance test (OGTT) was used to diagnose hypoglycemia. Experts now realize that the OGTT can actually trigger hypoglycemic symptoms in people with no signs of the disorder. For a more accurate diagnosis, experts now recommend that blood sugar be tested at the same time a person is experiencing hypoglycemic symptoms.

The doctor will also check the patient for health conditions such as diabetes, obtain a medication history, and assess the degree and severity of the patient's symptoms. Laboratory tests to measure insulin production and levels of C-peptide (a substance that the pancreas releases into the bloodstream in equal amounts to insulin) may be performed. (Source: excerpt from Hypoglycemia: NIDDK)

Diagnosis of Hypoglycemia: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Hypoglycemia:

• Facts on Gestational Diabetes
• Migraines more than just a headache
• New diagnostic technique for pre-diabetes
• More news »

Diagnostic Tests for Hypoglycemia: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Hypoglycemia.

HYPOGLYCEMIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the patient taking oral hypoglycemia drugs or insulin? If so, the dosage may be too high.
2. Is there a history of weight gain and/or episode of loss of consciousness? This would strongly suggest an insulinoma is the cause.
3. What is the plasma cortisol? If this is decreased, look for Addison's disease!
4. What is the plasma growth hormone? If this is decreased, look for Simmonds' disease.
5. What does a d- xylose absorption test show? If this is abnormal, look for malabsorption syndrome. If the diagnosis is still in doubt, the patient may have cirrhosis, glycogen storage disease, hypothyroidism, or functional hypoglycemia.

DIAGNOSTIC WORKUP

The finding of hypoglycemia on routine blood analysis requires nothing in an asymptomatic patient. If there is doubt, a repeat analysis should be done. If the patient is symptomatic, a 5-hr glucose tolerance test or hospitalization for repeated blood sugar during a 72-hr fast should be done. If these are negative, the patient most likely has functional hypoglycemia. Additional tests to order include a T ₄ , plasma, cortisol, plasma growth hormone assay, plasma proinsulin, C-peptide, plasma insulin, CT scan of the abdomen, and a tolbutamide tolerance test. Obtain an endocrinology consult.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Hypoglycemia: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Exogenous insulin administration is the most common cause of hypoglycemia
  –Most commonly occurs in patients with known diabetes mellitus
  –May occur with inadequate food ingestion or excessive exercise after an insulin injection
  –May occur with delayed absorption of food (e.g., diabetic gastroparesis)
  –Rarely, may occur as part of attention seeking behavior (i.e., factitious)

• Oral hypoglycemic medications (e.g., sulfonylurea)
  –This is especially common with severe liver disease, which prevents gluconeogenesis
• Other medications (e.g., salicylates, sulfonamides, tetracyclines, warfarin, MAO inhibitors, phenothiazines)
• Reactive hypoglycemia occurs 2–4 hours after meals, due to delayed and exaggerated insulin release (associated with a family history of type II diabetes)
• Hypothyroidism

• Malnutrition/fasting
• Insulinoma/islet cell hyperplasia
• Alcohol consumption

• Sepsis

• Renal failure

• Sarcomas
• Pituitary or adrenal insufficiency
• Congenital hormone or enzyme defects
• Severe hepatic dysfunction (e.g., hepatitis, hepatic toxins, hepatic necrosis)

Workup and Diagnosis

• History and physical examination
  –Medication, diet, and exercise history
  –Associated symptoms include tachycardia, diaphoresis, tremor, anxiety, hyperventilation, and hyperthermia
  –CNS symptoms may include dizziness, headache, confusion, convulsions, mental status changes, abnormal behavior, and coma

• Immediately measure serum glucose in any patient with altered mental status—missed diagnosis may result in irreversible neurologic damage or unnecessary procedures (e.g., intubation)
• Clinical symptoms of hypoglycemia usually begin to occur when the blood glucose level reaches 50 mg/dL; however, in diabetes, symptoms may begin at higher blood glucose levels or not at all
• Initial laboratory studies include serum or finger-stick glucose level, CBC, electrolytes, BUN/creatinine, magnesium, and urinalysis
• Consider LFTs, urinalysis, chest X-ray, TSH, cortisol, alcohol level and drug screen, head CT, blood cultures, and lumbar puncture if etiology is unclear
• Measure C-peptide and insulin before glucose infusion
  –Serum insulin is elevated by insulinomas (insulin:glucose ratio >0.3) and sulfonylurea or exogenous insulin administration
  –C-peptide is produced during endogenous insulin production; thus, decreased after exogenous insulin use; increased in insulinoma, sulfonylureas
• CT/MRI may be necessary to evaluate for insulinoma

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Low Back Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Lumbosacral muscle strain
  –Most common etiology of low back pain
  –Most common cause of disability in adults <45 years old
  –Aggravated by movement, better with rest
• Lumbar disc herniation
  –Especially of L4-L5 and L5-S1
  –Usually with unilateral radiation down the leg in a dermatomal pattern
  –Increased pain with sitting
  • Spinal stenosis
    –Back and bilateral buttock and thigh pain in older patients relieved by rest (pseudoclaudication)
    –Increased pain with standing
  • Sacral-iliac joint dysfunction
    –Especially in young, thin women or in pregnancy
    –Unilateral upper buttock pain, relieved with movement
  • Vertebral fracture
    –Often associated with trauma or osteoporosis
  • Spondylolisthesis
    –Especially in young athletes
  • Secondary gain (e.g., drug seeking, disability or liability issue)
  • Extraspinal causes (e.g., radiation from kidney stones)
  • Systemic causes (<1%)
    –Inflammation (e.g., ankylosing spondylitis): Morning stiffness, limited mobility
    –Infection: Osteomyelitis, abscess
    –Abdominal aortic aneurysm
    –Cancer (especially metastases from prostate, lung, colon, and breast or myeloma); constant, worsening pain, wakes up from sleep
    –Cauda equina syndrome
    –Paget's disease

  Workup and Diagnosis

  • History and physical are the most important diagnostic tools
    –Evaluate for range of motion, sensation, strength, straight leg raise test, reflexes, and neurovascular status
  • Imaging studies (e.g., X-ray, MRI, CT scan, myelogram, discogram) are indicated if “red flags” are present, if pain or limited function is refractory to treatment, or if trauma has occurred
  • Evaluate for “red flags” that may indicate serious conditions—if present, further workup is necessary (e.g., lumbosacral X-ray, CBC, ESR, calcium, electrolytes, alkaline phosphatase, bone scan, metastatic workup)
    –Red flags that suggest fracture: Major trauma, minor trauma, or strenuous lifting in an older or osteoporotic patient
    –Red flags that suggest tumor or infection: Age >50 or <20, history of cancer, constitutional symptoms (weight loss, fever), IV drug use, immunosuppression, pain worse at night
    –Red flags that suggest cauda equina syndrome: Saddle anesthesia, recent onset of incontinence, severe or progressive neurological deficit in leg
  • If red flags are absent, no imaging is necessary for 4–6 weeks; if pain persists, an MRI is the most useful study
  '>>'>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Hypoglycemia: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Normal neonates (in first 24 hours of life)
• Ketotic hypoglycemia
• Insulin excess
  –Exogenous insulin
  –Sulfonylurea ingestion
  –Infant of a diabetic mother
  –Perinatal stress-induced hyperinsulinism
  –Congenital hyperinsulinism
  –Beckwith-Wiedemann syndrome
• Hormone deficiency
  –Panhypopituitarism
  –Growth hormone deficiency
  –ACTH or cortisol deficiency
• Defects of glycogenolysis
  –Glycogen storage diseases
• Defects of gluconeogenesis
  –Glycogen storage disease type 1
  –Fructose-1,6-diphosphatase deficiency
  –Pyruvate carboxylase deficiency
  –PEPCK deficiency
• Fatty oxidation and ketogenesis defects
  –Medium-chain acyl-CoA dehydrogenase deficiency (most commonly)
  –Carnitine transport and metabolism
  –Electron transfer
  –HMG CoA synthase deficiency
  –HMG CoA lyase deficiency
• Liver disease
• Galactosemia
• Hereditary fructose intolerance
• Disorders of amino acid metabolism
  –Maple syrup urine disease
  –Methylmalonic acidemia
  –Tyrosinemia
• Dumping syndrome
  –Associated with Nissen fundoplication
• Reye syndrome
• Ethanol intoxication
  –Impaired gluconeogensis
• Salicylate intoxication
• Diarrhea and malnutrition
• Malaria
• Jamaican vomiting sickness
• Measurement error
  –Glucometer measurements are inaccurate in low range
  –Plasma glucose levels gradually fall if samples are not immediately tested

Workup and Diagnosis

• History
  –Classic symptoms associated with hypoglycemia that resolve with glucose ingestion
  –Symptoms of hypoglycemia: Anxiety, irritability, hunger, diaphoresis, tachycardia, shakiness, nausea/vomiting, weakness, headache, visual changes, poor speech, poor concentration, confusion, lethargy, somnolence, loss of consciousness, coma, hypothermia, seizure, personality changes
  –Fasting duration or frequency of feeding
  –Intercurrent illness, medications in the home
  –Birth history: Gestational diabetes, birth weight, stress
  –Developmental history: Delayed milestones

• Physical exam
  –Weight and height
  –Dysmorphism consistent with known genetic syndrome
  –Hyperpigmentation (in primary adrenal insufficiency)
  –Funduscopic exam (e.g., cataracts in galactosemia)
  –Midline defects (cleft palate, central incisor, microphallus) in hypopituitarism
  –Hepatomegaly (in glycogen storage and liver disease)
  –Neurologic exam for signs of CNS disease

• Critical labs during hypoglycemia: Electrolytes, HCO₃, insulin, C-peptide, cortisol, GH, free fatty acids, lactate, ammonia, β -hydroxybutyrate, acetoacetate, total and free carnitine, acyl carnitine profile, urine organic acids
  –Glycemic response to glucagon during hypoglycemia suggests hyperinsulinism or hypopituitarism

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

HYPOGLYCEMIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The clinical picture may fit one of the endocrine disorders mentioned above. If not, the laboratory can be of tremendous assistance. A glucose tolerance test will help diagnose functional hypoglycemia. Hospitalization for a 72-hour fast while taking frequent blood sugars will help diagnose an insulinoma.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

LOW BACK PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic exam should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive.

If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Low birth weight: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 382 and 383.) Follow with a routine neonatal examination.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hypoglycemia: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

A blood glucose monitor or glucose reagent strips provide quick screening methods for determining the blood glucose level. A reading less than 45 mg/dl indicates the need for a venous blood sample.

Confirming diagnosis  Laboratory testing confirms the diagnosis by showing decreased blood glucose levels. The following values indicate hypoglycemia:

❑ Full-term infants:

– less than 30 mg/dl before feeding

– less than 40 mg/dl after feeding

❑ Preterm infants:

– less than 20 mg/dl before feeding

– less than 30 mg/dl after feeding

❑ Children and adults:

– less than 40 mg/dl before meal

– less than 50 mg/dl after meal.

In addition, a 5-hour glucose tolerance test may be administered to provoke reactive hypoglycemia. Following a 12-hour fast, laboratory testing to detect plasma insulin and plasma glucose levels may identify fasting hypoglycemia. (See Diagnosing hypoglycemia.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Low birth weight: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 488 and 489.) Follow with a routine neonatal examination.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Low Back Pain: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 The history should include evaluation for “red flag” conditions.

A. Pain characteristics. Assess the nature of the pain, along with the onset and duration of the symptom. Is there any radiating pain, leg weakness, or paresthesia? Pseudoclaudication is suggestive of spinal stenosis. Pain radiating below the knee is more likely to be a true radiculopathy (1). Nerve root compression is highly unlikely without sciatic pain (1). Was the onset after a traumatic event? A seemingly insignificant episode (e.g., a minor fall) may be a “red flag” for fracture in an elderly patient. Are there alleviating or exacerbating factors? Does the pain limit the patient physically or socially? Is there a history of previous back problems or back surgery?

B. Review of systems. Look for associated symptoms that can indicate a “red flag” condition or an underlying medical cause. Gastrointestinal and genitourinary symptoms are particularly important, especially incontinence (Chapter 10.10).

 C. Psychosocial information. Has the patient initiated any new activities? If work-related, assess typical job tasks. Investigate whether the back pain could have any relationship, sexual, or mood implications. Sexual activity can be severely affected simply because of pain, but sexual dysfunction can also result from neurologic abnormalities associated with the cause of the back pain. Back pain is associated with depression and poor sleep patterns. Drug-seeking behavior may be exhibited along with a complaint of back pain. Addiction may have resulted from former or on-going treatment of the pain. Legal issues can complicate the diagnosis and treatment of back pain. Ask the patient whether litigation involving the back pain is under consideration.

Physical examination

Evaluation should be both general and specific. It is prudent to leave the potentially most painful parts of the examination to the end.

 A. General. Examination includes auscultation of the heart and assessment of peripheral pulses and blood pressure. Abdominal examination should focus on possible causes of back pain (Table 12.5). Assess gait.

 B. Neurologic. The lower extremity examination includes motor strength, deep tendon reflexes, sensation, proprioception, and certain functional maneuvers (Table 12.6). Romberg and Babinski reflexes should also be assessed. Rectal examination should assess sphincter tone, which can be compromised in sacral root dysfunction. In the primary care setting, most clinically significant disc herniations will be detected by the following limited examination: dorsiflexion of the great toe and ankle, Achilles reflex, light touch sensation of the medial (L ₄), dorsal (L₅), and lateral (S₁) aspect of the foot, and the straight leg raise (SLR) test (1).

 C. Musculoskeletal. Assess range of motion of the spine and lower extremities. Perform the SLR test passively with the patient supine. Note the angle of leg elevation precipitating pain. A positive test for sciatica is buttock pain radiating to the posterior thigh, and perhaps to the lower leg and foot. Sciatica, with pain and resistance on internal rotation of the hip, can indicate piriformis muscle spasm or strain. The SLR test is usually negative in spinal stenosis (2). Percussion of the spine and upper pelvis helps to identify areas of localized tenderness, as in fracture, metastatic disease, and some rheumatologic conditions. Palpate standard trigger points looking for fibromyalgia. Check for paraspinal muscle spasm. Measure thigh and calf circumferences to look for muscular atrophy.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Low Back Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Musculoligamentous strain

❑ Lumbar disc herniation

❑ Osteoarthritis

❑ Compression fracture

❑ Pyelonephritis

❑ Secondary gain

❑ Scoliosis

❑ Spondylolisthesis

❑ Metastatic cancer

❑ Spinal stenosis

❑ Transverse process fracture

❑ Pancreatic cancer

❑ Ankylosing spondylitis

❑ Sacroiliitis

❑ Aortic dissection

❑ Cauda equina syndrome

❑ Vertebral osteomyelitis

❑ Epidural abscess

Diagnostic Approach

Radicular pain has such a high sensitivity for nerve root compression that its absence makes important disc herniation unlikely. Not all radicular pain is due to a herniated disc however. Other causes include spinal stenosis, ligamentous hypertrophy, deep lumbar muscle spasm, and deep trochanteric bursitis.

Back pain at rest or unassociated with posture/movement should increase the suspicion of tumor, fracture, infection, or referred visceral pain. Spinal tenderness is a sensitive but not specific indicator. Clues to metastatic cancer include a history of cancer, unexplained weight loss, and signs of cord compression, such as motor weakness of the legs, urinary or fecal incontinence, and absent anal reflex. Recent bacterial infection, injection drug use, or immune suppression (from steroids, chemotherapy, or HIV) should raise suspicion for infection. Fever occurs in osteomyelitis (50%), epidural abscess (83%), and tuberculosis (27%).

A red flag for fracture in a young adult is major trauma, such as a fall from a height or a motor vehicle accident. In older adults, minor trauma or strenuous lifting can cause a compression fracture.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Hypoglycemia: Diagnosis
(Handbook of Diseases)

Reagent or glucose reagent strips provide quick screening methods for determining blood glucose level. A color change that corresponds to less than 45 mg/dl indicates the need for a venous blood sample.

Laboratory testing confirms the diagnosis by showing decreased blood glucose values. The following values indicate hypoglycemia:

❑ full-term neonates — less than 30 mg/dl before a feeding; less than 40 mg/dl after a feeding

❑ preterm neonates— less than 20 mg/dl before a feeding; less than 30 mg/dl after a feeding

❑ children and adults — less than 40 mg/dl before a meal; less than 50 mg/dl after a meal.

In addition, a 5-hour glucose tolerance test may be administered to provoke reactive hypoglycemia. After a 12-hour fast, laboratory testing to detect plasma insulin and plasma glucose levels may identify fasting hypoglycemia.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Low birth weight: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

As soon as possible, evaluate the neonate's neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age.) Follow with a routine neonatal examination.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

LOW BACK PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic examination should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive. If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow-up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

HYPOGLYCEMIA: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The clinical picture may fit one of the endocrine disorders mentioned above. If not, the laboratory can be of tremendous assistance. A glucose tolerance test will help diagnose functional hypoglycemia. Hospitalization for a 72-hour fast while taking frequent blood sugar tests will help to diagnose an insulinoma.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Hypoglycemia

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