Diagnosis of Hypoglycemic attack

Hypoglycemic attack Diagnosis: Book Excerpts

• Ask the Following Questions - HYPOGLYCEMIA
• Differential Diagnosis - Hypoglycemia
• Differential Diagnosis - Hypoglycemia
• Approach to the Diagnosis - HYPOGLYCEMIA
• Diagnosis - Hypoglycemia
• Differential Overview - Hypo/Hyperpigmentation
• Diagnosis - Hypoglycemia
• Approach to the Diagnosis - HYPOGLYCEMIA

Diagnostic Tests for Hypoglycemic attack: Online Medical Books

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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

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

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

Hypo/Hyperpigmentation: Differential Overview
(Field Guide to Bedside Diagnosis)

Hyperpigmented Macules

❑ Nevus

❑ Seborrheic keratosis

❑ Post-inflammatory

❑ Solar purpura

❑ Solar lentigo

❑ Schamberg purpura

❑ Fixed drug eruption

❑ Melasma

❑ Atypical nevus

❑ Melanoma

❑ Cafe-au-lait

Generalized Hyperpigmentation

❑ Drugs

❑ Heavy metals

❑ Addison disease

❑ Ectopic ACTH syndrome

❑ Hemochromatosis

❑ Porphyria cutanea tarda

❑ Pellagra

❑ Whipple disease

❑ Primary biliary cirrhosis

❑ Metastatic melanoma

Hypopigmentation

❑ Tinea versicolor

❑ Vitiligo

❑ Halo nevus

❑ Postinflammatory

❑ Chemical

❑ Piebaldism

❑ Tuberous sclerosis

Diagnostic Approach

ABCDE criteria and their histopathological counterparts are: Asymmetry—If the lesion bisected in half is not identical to the other half, consistent with asymmetrical architecture at scanning magnification. Border—Border is uneven or ragged as opposed to smooth and straight; consistent with poor lateral circumscription (single cell extension along junction). Color—More than one shade of pigment is present; consistent with atypical melanocytes at various levels of the epidermis (brown/black) and thickening and fibrosis of the papillary dermis with loss of melanin from the epidermis (white-regression). Diameter—.6 mm; consistent with broad extension of melanocytes along
the junction. Evolving—Changed with respect to size, shape, symptoms (e.g., itching or tenderness), surface (e.g., bleeding) or shades of color. This will pick up 78% of nodular melanomas, which present at a more advanced stage but do not have the other signs.

» 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

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 Hypoglycemic attack

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