19: A 30-year-old nursing student presents with confusion, sweating, hunger, and fatigue. Blood sugar is noted to be 40 mg/dL. The patient has no history of diabetes mellitus, although her sister is an insulin-dependent diabetic. The patient has had several similar episodes over the past year, all occurring just prior to reporting for work in the early morning. On this evaluation, the patient is found to have high insulin levels and a low C peptide level. The most likely diagnosis is: a. Reactive hypoglycemia b. Early diabetes mellitus c. Factitious hypoglycaemia d. Hepatoma e. Insulinoma
Medicine - 5 Answers
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1 :
I Think e. Low Peptide C. Low Blood Glucose.
2 :
A
3 :
I'm no doctor but... Have you checked to see if the patient is suffering form starvation or malnutriton syndrome? It's overlooked you know. http://healthresources.caremark.com/topic/topic100587123
4 :
I'm going with c. Endogenous insulin (from a. and e.) would have the c-peptide. The fact that there is no C-peptide means that the insulin comes from outside her body. c. is the only such choice. One hint is that her sister uses insulin; the patient would have access to insulin from her. Another hint is the timing: "just before work". That is consistent with factitious illness. Note that a. (reactive) would use pancreatic islet insulin, and so have c-peptide. Also, e. (insulinoma-produced) insulin has c-peptide: http://www.emedicine.com/med/topic2677.htm Choice b. would have low insulin levels, and choice d. (hepatoma) is irrelevant to glucose homeostasis.
5 :
Confusion, sweating, hunger, and fatigue are all classic symptoms of hypogycemia, and this is verified by blood sugar of 40mg/dL (normal is 70-120 mg/dL). High insulin levels would result in low blood sugar since effect of insulin is uptake of glucose from bloodstream by muscle and liver cells. Insulinomas (tumors of the islet cells in the pancreas that can produce uncontrolled amounts of insulin and C-peptide) can be eliminated since there are low C peptide levels. C peptide levels should mirror insulin levels, therefore if person has high insulin production they should have high C peptide levels (low C peptide = low insulin). Hepatomas are liver cancers, and this should be eliminated since sugar uptake is fine (liver cells can uptake glucose). The pancreas is the organ that secretes insulin and glucagon, so again another reason to eliminate. Factitious hypoglycaemia is the result of the patient inducing hypoglycemic conditions thru ingestion of insulin or other hypoglycemic agents. Thismeans that the student deliberately induced the hypoglycemic condition...need more psych eval to determine. Reactive hypoglycemia is a medical term describing recurrent episodes of symptomatic hypoglycemia occurring 2-4 hours after a high carbohydrate meal (http://en.wikipedia.org/wiki/Reactive_hypoglycemia). I would eliminate since I doubt student awoke 2-4 hrs before early-morning shift to eat. Early DM can be diagnosed by blood sugar and C peptide levels, which should show both levels high. This leaves us with factitious hypogycemia....student is ingesting/injecting insulin to induce hypoglycemia. She is busted since her C-peptide levels are low!
