Consultation note
Time in:
MR#:
Patient Name:
Date of Birth:

Dr. ___________ has asked for consultation on this patient regarding regarding _______________.

Thank you for inviting us to see this patient.

Chief complaint: ___ year old male/female presents today for evaluation and treatment of hypoglycemia.
Type:
Diagnosed:
Treated with:
Blood Glucose checks:
Blood Glucose average at home:
Hba1c:
For Diabetes is seen by:
Retinopathy:              
Neuropathy:
Nephropathy:
Dyslipidemia:
Nocturia/Polyuria/Polydypsia:
Hypoglycemia/Symptoms:

Adrenergic (homeostatic) symptoms (secondary to stimulation of epinephrine, norepinephrine, cortisol, glucagon + GH) - sweating, tachycardia, palpitations, tremulousness, tremor, anxiety, hunger

Neuroglycopenic symptoms - seizures (focal or generalized), fatigue, headache, syncope, behavior changes (bizarre behavior), visual disturbances (blurred vision), hunger, numbness or tingling of mouth and lips, syncope, inability to concentrate, confusion, incoherent speech, stupor, coma, death

In hospitalized patients without diabetes > 65 years old, risks of hypoglycemic episodes include albumin < 3 g/dL, liver disease, renal disease, malignancy, congestive heart failure and sepsis, based on retrospective case-control study (J Am Geriatr Soc 1998 Aug;46(8):978)

My key findings of the ROS, Past Hx, Family Hx, and social Hx are:
ROS: Review of 12 systems was negative with exception of those things mentioned above in the HPI and weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Patient denies weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Past Medical History:

Past Surgical History:

Family History:

Social History:
Diet:
Exercise:
Smoking:
Recreational Drug use :
Education:
Occupation:
Lives with ____ where ____

Home Meds:

Allergies:

My key findings of this patient's Physical Exam are:
VITALS:
Pulse:
Blood Pressure:
Respirations:
Temperature:
Weight:
Height:
BMI:

GENERAL: sitting up/reclined in bed, awake, alert, and oriented
HEAD: normocephalic, atraumatic, no temporal wasting, negative chvostek sign
NOSE, MOUTH: lips and mucous membranes are moist, normal color of buccal mucosa
EYES: EOMI, PERLA, no proptosis
NECK: supple, thyroid normal in size, thyroid small, thyroid low set, no thyromegaly or masses
RESPIRATORY: clear to ascultation bilaterally
CARDIOVASULAR: S1S2, no murmurs/rubs/gallops
GI: soft, non-tender, + bowel sounds
LYMPHATIC: no cervicoclavicular adenopathy appreciated
MUSCULOSKELETAL: moving all extremities
EXTREMITIES: no edema present
NEUROLOGIC: monofilament sensed in all areas of the foot, vibratory sensation intact, fine/crude touch intact, pulses palpable, DTRs 2+, CN grossly intact
DERMATOLOGY: no xanthomas appreciated, no skin ulcers, no calluses, no onchyomycosis/dermatophyosis, no striae,
PSYCHIATRY: patient answers questions appropriately, appropriate affectcoherent thoughts without flight of ideas

Labs:
Glycemic Panel:
C-Peptide:
Insulin:
Pro-Insulin:
Beta Hydroxy-butyrate:

Assessment:

In patients with diabetes

•  medication overdose, eating at wrong time, skipping or not finishing meals, more exercise than usual
•  trimethoprim-sulfamethoxazole increases risk of hypoglycemia with glyburide; case-control study comparing 909 glyburide recipients hospitalized for hypoglycemia with controls taking glyburide and not hospitalized for hypoglycemia, hospitalized cases more likely to have taken trimethoprim-sulfamethoxazole in prior week with odds ratio 6.6 (95% CI 4.5-9.7)
•  possibly ACE in hypertensive patients with diabetes receiving insulin or oral agents; results corroborated in another case-control study which adjusted for multiple variables but potential confounding factors still exist

Reactive hypoglycemia (post-prandial hypoglycemia)
•  no symptoms in fasting state, rarely loss of consciousness
•  drop 3-4 hours after meal (especially after meal rich in carbohydrates) with return to normal within 5-6 hours, as opposed to fasting hypoglycemia which doesn't return to normal
•  etiologies
•  idiopathic reactive hypoglycemia
•  after subtotal gastrectomy - rapid absorption of carbohydrate then insulin surge
•  congenital enzyme deficiencies, e.g. hereditary fructose intolerance

Fasting hypoglycemia - symptoms without food intake (night, early am)

•  factitious hypoglycemia
•  report of 2 cases of Munchausen Syndrome by proxy with factitious hypoglycemia leading to partial pancreatectomy can be found in Pediatrics 2005 Jul;116(1):e145 full-text
•  insulinoma
•  noninsulinoma pacreatogenous hypoglycemic syndrome (case presentation and discussion can be found in Mayo Clin Proc 2006 Nov;81(11):1495   EBSCO host Full Text )
•  non-islet cell neoplasms
•  tumors of mesodermal origin in peritoneal or retroperitoneal cavity with nonsuppressible insulin-like activity (NSILA)
•  retroperitoneal fibrosarcomas, hamangiopericytomas, carcinomas of gut, adrenal, breast, prostate
•  should see low plasma insulin levels
•  case report of non-islet cell tumor hypoglycemia due to metastatic pancreatic carcinoma can be found in PLoS Med 2006 Aug;3(8):e331   EBSCO host Full Text full-text
•  hormonal deficiency - glucagon, catecholamines, cortisol (adrenal insufficiency), GH (pituitary insufficiency)
•  liver disease (hepatic necrosis), renal disease (uremia), alcohol-induced hypoglycemia
•  glycogen storage diseases (types I, III, IV), hereditary fructose intolerance, fructose 1,6-diphosphatase deficiency, galactosemia
•  deficient gluconeogenesis enzymes
•  pregnancy (lack of precursors)
•  #1 at age 1-4 is ketotic hypoglycemia of childhood (carbohydrate deprivation)
•  starvation
•  nesidioblastosis (age < 2, case reports in adults, functional hyperinsulinism)

Induced hypoglycemia is most common form of hypoglycemia

•  insulin
•  health care workers
•  family members of patients with diabetes
•  patients with diabetes who increase exercise or decrease food intake
•  increased subcutaneous absorption
•  intramuscular injection
•  FDA alerted clinicians of potential for life-threatening falsely elevated glucose readings in patients receiving parenteral maltose or galactose, or oral xylose, and tested using glucose dehydrogenase pyrroloquinolinequinone (GDH-PQQ) based glucose monitoring systems; which may result in inappropriate insulin administration ( FDA MedWatch 2005 Nov 10 )
•  sulfonylureas - wrong dose, mistaken for other medication
•  salicylates
•  alcohol - presents 6-24 hours after drinking, does not respond to glucagon (depleted glycogen stores); presents with hypothermia, coma, tachypnea, nonspecific liver function test abnormalities
•  trimethoprim-sulfamethoxazole associated with hypoglycemia in elderly patient (case report in J Am Board Fam Pract 2000 May-Jun;13(3):211), commentary can be found in J Am Board Fam Pract 2000 Sep-Oct;13(5):386
•  fluoroquinolones may induce hypoglycemia
•  12-month incidence of hypoglycemia was 1.1% after levofloxacin and 2.1% after gatifloxacin in cohort of 7,287 hospitalized patients who received gatifloxacin or levofloxacin therapy ( Pharmacotherapy 2005 Oct;25(10):1296 )
•  quinolone may cause hypoglycemia in first 3 days and hyperglycemia after 3 days, increased risk in patients with diabetes or renal failure (Prescriber's Letter 2006 Jan;13(1):4)
•  gatifloxacin (Tequin) labeling updated with warnings of risks for hypoglycemia and hyperglycemia, and CONTRAINDICATION for use in patients with diabetes ( FDA MedWatch 2006 Feb 16 )
•  gatifloxacin associated with hypoglycemia and hyperglycemia in 2 case-control studies Click for Details
gastric bypass surgery followed by hyperinsulinemic hypoglycemia with nesidioblastosis in 6 cases ( N Engl J Med 2005 Jul 21;353(3):249 ), editorial can be found in N Engl J Med 2005 Jul 21;353(3):300, commentary can be found in N Engl J Med 2005 Nov 17;353(20):2194 , commentary can be found in N Engl J Med 2005 Dec 29;353(26):2822

Rule out:
if fasting hypoglycemia without explained cause, rule out nonhypoglycemia (parents often concerned about hypoglycemia as cause for hyperactivity, inattentiveness, headache or low energy; oral glucose tolerance testing is not helpful in children with hypoglycemia)
factitious disorder (case report can be found in J Am Board Fam Pract 1999 Mar-Apr;12(2):133, case report can be found in Am Fam Physician 2002 Dec 1;66(11):online)

Diagnostic Plans:
3 diagnostic criteria (Whipple's triad)
*symptoms
*glucose < 50 during symptoms
*relief of symptoms after carbohydrate ingestion (or administration of glucose)

72-hour fast with plasma glucose and insulin during symptoms or at least every 6 hours, do not treat hypoglycemia until labs are drawn
Details for 72-hour fast protocol:
Perform in hospital setting
Patient requirements: must refrain from all caloric intake for duration of test, may imbibe calorie-free, caffeine-free liquids and continue usual level of physical activity
Conclude test when patient develops symptoms or 72 hours after last meal; at conclusion of test, obtain samples for:
Glucose, Insulin, Beta-hydroxybutyrate, C-peptide, Proinsulin, Sulfonylureas, Insulin-like growth factor II
Glucose after glucagon stimulation - give 1 mg glucagon intravenously; obtain additional samples for glucose 10, 20, and 30 minutes after infusion
Insulin level, Insulin Ab, Sulfonylurea level, C-peptide
in insulinoma - increased insulin and C-peptide
in exogenous insulin - much increased insulin, insulin Ab
in sulfonylurea - increased insulin and C-peptide, sulfonylurea
Blood tests:
Fingerstick glucose determinations not accurate in severely hypotensive patients (Ann Intern Med 1991 Jun 15;114(12):1020 EBSCOhost Full Text in ACP J Club 1992 Jan-Feb;116(1):16)
Urine studies: urine sulfonylurea level

Therapeutic Plans:
Eat food with sugar (if blood sugar < 70)
Carry diabetic identification
Glucagon injection
Glucagon Emergency Kit
Octreotide prevents rebound hypoglycaemia of sulfonylurea overdose

Patient Education:
Return to Clinic:
We have discussed our diagnostic and treatment plans with the patients and family/friends that were present. All questions have been answered to the patient's satisfaction.

Thank you for inviting to see this consult!

Written by ___ _____________________ Time out_______

1