Question: What is hypoglycemia? Explain the endogenous glucose regulation process to maintain euglyemia and the how failures in these responses lead to hypoglycemia

BACKGROUND

A man walked into a multi-specialty outpatient medical practice, proceeded to the reception counter and sat down.  He appeared to have difficulty understanding the receptionist.  He stated his name then his words became slurred, and he began to have repetitive gross upper body movements while seated.  The office manager was immediately notified, 911 was called and a Nurse Practitioner was asked to assess the patient in the waiting area.

Based on the patient’s self-reported name, he was confirmed to be J.R., a 44-year- old male who has a follow up appointment with the internist who is not yet onsite.  The most recent note was written by the internist documenting a visit approximately one month ago for a routine visit.

EXAMINATION

The patient is alert but confused.  No pallor, diaphoresis, vomiting or loss of consciousness.  No apparent respiratory distress.  The patient allowed the NP to check his glucose.  It was 35mg/dL at the time.

INTERVENTION

Patient was offered a box of apple juice using a straw (containing 21g of carbohydrate).  He was willing and able to drink the juice. Once finished drinking, the patient stood up and began pacing around the waiting area with steady gait, seemingly paranoid and agitated.  He refused to sit down.  After learning that the ambulance is on the way, the patient stormed out of the office.  A staff member was sent to follow the patient.  J.R. stopped at the end of the block and leaned on a parked truck.  Shortly after, the fire truck followed by ambulance arrived and was directed to the patient.

As per the EMS, Vital signs were 134/86, 92, 20, O2 Sat on room air was 98%, repeat glucose was 67mg/dL.  Patient was cooperative, calm with full return of cognitive function, speech fluent, no abnormal neuromuscular movements.  He was given a tube of dextrose gel (15 g of glucose) with 15-minute repeat glucose of 95mg/dL.

Once he became coherent, patient reported that he had taken his full dose of Lantus last night and Regular insulin in the morning with the intention of eating breakfast.  He was running late for his appointment thus left the house on an empty stomach without eating breakfast.

OUTCOME

Hypoglycemic response precipitated by excessive morning insulin due to a skipped meal.  Hypoglycemia symptoms may have been intensified secondary to chronic hyperglycemia over the last 2-3 months.  Cognitive, neuromuscular and speech deficits resolved completely following normalization of blood glucose.  Patient was released by EMS with instructions to proceed home with frequent glycemic monitoring for the rest of the day and follow up with his outpatient diabetes management provider.  He was accommodated by his internist the following day for an office visit.  Patient indicated, no adverse events.

Questions

1. What is hypoglycemia (1 point)?
2. Explain the endogenous glucose regulation process to maintain euglyemia and the how failures in these responses lead to hypoglycemia (1 point)
3. What are adrenergic symptoms and neuroglycopenic signs of hypoglycemia? (1 point)
4. Name three strategies to minimize the risk of hypoglycemia in patients with diabetes: type 1 or type 2 and provide a rationale (1.5 point)