Hypoglycaemia

Question 1

What is the most common side effect of insulin therapy?

Answer 1

Hypoglycaemia

Question 2

Name three factors that can precipitate a hypoglycemic episode

Answer 2

(1) Irregular eating habits
(2) Unusual exertion
(3) Alcohol excess

Question 3

When are the times of greatest risk for hypoglycemia?

Answer 3

Before meals, during the night, and during or after exercise

Question 4

What is the glucose threshold for Level 1 hypoglycemia?

Answer 4

3.9 mmol/L (70 mg/dL) or less

Question 5

At what glucose level is hypoglycemia considered clinically serious (Level 2)?

Answer 5

<3.0 mmol/L (<54 mg/dL)

Question 6

What defines Level 3 (severe) hypoglycemia?

Answer 6

Severe cognitive impairment requiring external assistance for recovery.

Question 7

What are three autonomic symptoms of hypoglycemia?

Answer 7

Sweating, tremor, and palpitations

Question 8

What are three neuroglycopenic symptoms of hypoglycemia?

Answer 8

Confusion, cognitive impairment, and coma

Question 9

Why can beta-blockers make hypoglycemia harder to detect?

Answer 9

They mask adrenergic symptoms like tremor and palpitations but not sweating

Question 10

What tool can be used to assess hypoglycemia awareness?

Answer 10

The Gold score or Clarke score

Question 11

Why is delayed symptom recognition (<3.0 mmol/L) concerning?

Answer 11

It significantly increases the risk of severe hypoglycemia

Question 12

At what blood glucose level should hypoglycemia always be treated?

Answer 12

<4.0 mmol/L

Question 13

When should the DVLA be informed regarding hypoglycemia?

Answer 13

After one or more severe hypoglycemic episodes requiring hospital admission

Question 14

How much oral glucose should be given for mild hypoglycemia?

Answer 14

15-20g of fast-acting glucose
eg, full-sugar juice

Question 15

Why are chocolate bars or biscuits not recommended for treating hypoglycemia?

Answer 15

Their fat content slows glucose absorption

Question 16

How is severe hypoglycemia (confusion or coma) managed?

Answer 16

IM glucagon
(common outside healthcare settings) or IV glucose in the hospital

Question 17

What should be done after initial glucose administration?

Answer 17

Retest blood glucose after 15 minutes and repeat treatment if needed

Question 18

How many times per day is it recommended that people with poorly controlled type 1 diabetes check their finger-prick blood glucose levels (without showing improvements in control) before they would be considered suitable for the use of CGMS (continuous glucose monitoring

Answer 18

8-10 times per day

Question 19

What is the name given to the neurological features of hypoglycaemia
e.g. confusion, blurred vision, behaviour change, or seizures?

Answer 19

Neuroglycopenia

Question 20

What level of blood glucose do the DVLA recommend before driving a car?

Answer 20

Blood glucose of 5mmol/l or greater (‘5 to drive’)

Question 21

What level of blood glucose is generally taken to indicate hypoglycaemia?

Answer 21

A blood glucose level of 3.5 mmol/l or lower is generally regarded as the cut off for hypoglycaemia

Question 22

Who should be able to administer IM Glucagon to a person with symptomatic hypoglycaemia who is not able to treat themselves?

Answer 22

Close friends and relatives of people with insulin-treated type 1 diabetes should be trained to do this

Question 23

What is the first line treatment for management of hypoglycaemia in a fully conscious patient?

Answer 23

10-20g of fast acting oral carbohydrate

Question 24

A 40-year-old female is admitted to the hospital following a seizure. Her past medical history includes multiple non-fatal overdoses using her elderly mother’s insulin. Her capillary glucose returns at 3.4mmol/L (normal range 3.5-5.5 mmol/L)

What test would be the most useful in differentiating an endogenous from an exogenous cause of her hypoglycaemia?

Answer 24

Serum C-peptide

Question 25

A 63-year-old diabetic man is admitted to the hospital to have intravenous antibiotics for community-acquired pneumonia. On day 3 of admission, he becomes confused and drowsy after which he has a short seizure which spontaneously resolves. His capillary glucose is noted at 3.1mmol/L (normal 3.5-5.5 mmol/L) and he is unconscious What is the most appropriate immediate management of this patient?

Answer 25

Intravenous glucose

Question 26

A 28-year-old female with type 1 diabetes experiences confusion, fatigue and aggressive behaviour following a long cycle ride. Her husband checks her fingerprick blood glucose and finds that she has a level of 3.0 mmol/l (normal range 3.5-5.5 mmol/L). She is drowsy and not willing to eat or drink anything. She cannot manage to treat herself. What is the correct approach to treating her hypoglycaemia in this situation by her husband?

Answer 26

IM Glucagon injection

Question 27

A 33-year-old female reports feeling generally unwell with fatigue, headaches, double vision and intermittent blackouts. She has been found on the latest occasion to have a random blood glucose of 2.2 mmol/L (normal range 3.5-5.5 mmol/L). She feels better when eating foods high in sugar. It is suspected that she has an insulinoma. What is the best test for establishing the diagnosis?

Answer 27

A 72 hour fast

Question 28

An 18-year-old female patient with known type 1 diabetes was admitted 4 days previously with DKA. She has been switched to her normal subcutaneous insulin and was due for discharge following diabetic team review. A nurse has taken her blood sugar (9:00 am) before breakfast and informs you that her blood glucose is 2.5, she has no symptoms. The patient is alert. What would be the next appropriate step?

Answer 28

Glucogel

Question 29

A 52-year-old man with Type 2 Diabetes on anti-hyperglycaemic drugs including Metformin has a hypoglycaemic event with a capillary blood glucose of 2.4 recorded on the ward. Which medication is most likely the cause?

Answer 29

Sulphonylureas = Gliclazide

Question 30

A 40-year-old male is on the general medical ward when he begins to feel tremulous. He has been admitted for hyperglycemia and was diagnosed with type 2 diabetes, for which he has started medication. A blood sugar is 3.3 mmol/L (3.5 - 5.5 mmol/L). On examination, he is alert, but sweaty, and feels nauseous. What is the next step in his management?

Answer 30

Oral Glucogel

Question 31

What is the management of patients with mild hypoglycaemia who are still conscious to restore normal glucose levels?

Answer 31

(1) Eat/drink 15-20g fast acting carbohydrate such as glucose tablets, a small can of Coca-Cola, sweets or fruit juice. (2) AVOID chocolate (3) Eat some slower acting carbohydrate afterwards (e.g. toast)

Question 32

What is the first line treatment in an alert patient with hypoglycaemia?

Answer 32

A sugary beverage or GlucoGel orally (aiming 15 - 20g simple carbohydrate), followed by a carbohydrate-rich meal

Question 33

What do you do for patients who are unconscious or unable to swallow in those with severe hypoglycaemia?

Answer 33

(1) Take an A-E approach and consider if airway protection is required (2) Administer 100ml of 20% glucose or 200ml of 10% glucose intravenously (3) In patients with no IV access, give 1mg of glucagon intramuscularly

Question 34

A 21-year-old woman presents to the emergency department. She has recently been diagnosed with type 1 diabetes mellitus and has accidentally given herself too much quick-acting insulin (40 units as opposed to her usual 4 units). She is panicked and cannot remember the name of the insulin that she takes. She is feeling lightheaded and generally weak. On examination, her GCS is 15, she is anxious but co-operative and sweating. Her blood glucose is 2.9 on a finger-prick test. What is the best next step in the management of this patient? and why?

Answer 34

Oral glucose = Oral glucose is a first-line treatment in patients who are co-operative and can swallow. This can take the form of dextrose tablets, glucose drinks or fruit juice with the aim of giving 15–20 g of a quick-acting carbohydrate

Question 35

With the Glasgow coma score, when is oral glucose used?

Answer 35

GCS 15 (Fully alert) ✅ Oral glucose can be safely given GCS 14-13 (Mild confusion, but following commands) ⚠️ Use caution—oral glucose may be considered if the patient can swallow safely GCS ≤12 (Drowsy, unresponsive, not protecting airway) ❌ Oral glucose is NOT safe. Use IV glucose or IM glucagon

Question 36

A 35-year-old woman with type 1 diabetes feels dizzy and shaky while shopping. She checks her blood glucose, which is 3.0 mmol/L. She is alert, oriented, and speaking normally. What is the most appropriate next step? A) IV 10% dextrose B) IM glucagon C) Oral glucose (e.g., glucose tablets or juice) D) IV 50% dextrose E) Observe without intervention

Answer 36

c - Oral glucose

Question 37

High insulin, Low C-peptide =

Answer 37

Exogenous insulin administration

Question 38

A 55-year-old man is brought to the emergency department by his colleagues due to confusion, unsteadiness, and slurred speech. On examination, he is disoriented, with a noticeable smell of alcohol on his breath. His vital signs include a blood pressure of 130/80 mmHg and a heart rate of 88 bpm. His colleagues are unsure about any of his past medical history. What is the best next immediate step?

Answer 38

Measure capillary blood glucose

Question 39

A 19-year-old man presents to the Emergency Department (ED) in the early hours of the morning looking very confused. The on-call doctor tries to take a history from the man however he has trouble speaking. He is unable to walk in a straight line and keeps bumping into other people in the ED. His girlfriend who has accompanied him informs the doctor that he recently contracted malaria for which he was taking quinine sulfate What is the most appropriate first-line investigation for this man and why is this the case?

Answer 39

Blood glucose measurement = Hypoglycaemia is commonly mistaken for being 'drunk', and so blood glucose measurement should always be part of the initial assessment