Diagnose It Answer — April 13, 2026
ALL CLUES
44-year-old male with type 1 diabetes found by his roommate slumped in a chair, unresponsive to verbal stimuli. Roommate states he was 'acting strange and sweaty' for about 20 minutes before he stopped responding. Patient is now diaphoretic, pale, and moaning. EMS administered dextrose en route; he is beginning to rouse.
Type 1 diabetes diagnosed age 12. Uses an insulin pump set to deliver 1.2 units/hour basal. Roommate reports he gave himself a large correction bolus last night after a high reading, then skipped dinner. He had a longer-than-usual workout yesterday afternoon. History of three prior hypoglycemic episodes requiring outside assistance over the past 2 years.
BP 102/64 mmHg, HR 118 bpm (sinus tachycardia), RR 18 breaths/min, Temp 36.6°C, SpO2 98% on room air. Patient now opens eyes to voice but is confused and combative — oriented to name only. Skin pale, cool, and diaphoretic. Tremors visible in bilateral upper extremities.
Point-of-care glucose on EMS arrival: 28 mg/dL. Post-dextrose glucose on arrival to ED: 54 mg/dL. Patient remains confused. IV access confirmed; D50W 25g (one ampule) administered. Insulin pump paused by nursing staff. Patient beginning to follow simple commands 8 minutes after dextrose. Neuroglycopenic symptoms resolving — confusion clearing to full orientation within 15 minutes of treatment.
Repeat POC glucose post-treatment: 112 mg/dL. Serum glucose 108 mg/dL (confirms POC accuracy). BMP: otherwise unremarkable — Na 138, K 3.9, CO2 24. Beta-hydroxybutyrate 0.4 mmol/L (normal — not in DKA). Hemoglobin A1c: 8.9% (poorly controlled chronically). Insulin level drawn: elevated at 42 µIU/mL — consistent with recent insulin administration. EKG: sinus tachycardia, no ischemic changes.
Hypoglycemia in insulin-dependent diabetics is defined as a blood glucose below 70 mg/dL and becomes critically dangerous below 54 mg/dL, causing neuroglycopenia and seizure risk. The classic sympathoadrenergic symptoms — diaphoresis, tachycardia, tremor, pallor — are often the nurse's first warning before glucose testing. For the conscious patient, 15g of fast-acting carbohydrates followed by a 15-minute recheck (the 15/15 rule) is standard; for the unconscious patient, IV dextrose or IM glucagon is required. Always identify and address the underlying cause to prevent recurrence.
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