Collapse / Syncope OSCE - Hypoglycemia

Diagnosis: Hypoglycemia

Case Overview

  • Age/Sex: 71-year-old female
  • Occupation: Retired school librarian
  • Setting: Brought to ED by ambulance after collapsing at home
  • Chief complaint: "I collapsed / blacked out"

Patient Script

Who I Am

I'm 71, I used to be a school librarian and I live alone in a ground-floor flat; my daughter checks in on me sometimes.

What Brings Me In

I woke up this morning feeling funny and then I just blacked out — I remember nothing for a little while and the neighbor called an ambulance.

My Story

This morning I felt very dizzy and sweaty while making tea, and then I collapsed at about 08:30. The neighbor says I was unconscious for a few minutes; when I came round I was confused and shaky and I couldn't really speak properly for a short time. Paramedics checked me and said my blood sugar was very low, so they gave me something in my arm and I felt a bit better. Since then I've been tired and a bit embarrassed.

Over the last few days I've felt a bit off — less appetite for the last 2 days and I had a mild diarrhoea episode yesterday that settled. I normally eat porridge for breakfast but I cut that short this morning because I was rushing. I take medicines every day, but I might have taken my evening tablets late last night because I was sleepy. I haven't had chest pain today, but I did have a mild ache in my left shoulder last week that went away.

My Medical Background

  • Past medical history: type 2 diabetes for ~15 years, chronic kidney disease (stage 3b), hypertension, ischemic heart disease, osteoarthritis
  • Medications: insulin (long-acting basal at night), gliclazide (sulfonylurea) twice daily, lisinopril, atorvastatin, aspirin, paracetamol PRN
  • Allergies: penicillin (rash)
  • Social: lives alone, daughter visits twice weekly, non-smoker, has a small glass of wine most evenings (one glass)
  • Family: daughter healthy; father had heart disease

What I Think & Worry About

  • I think I might have had a stroke or a mini-stroke because I couldn't speak properly when I came round.
  • I'm worried I'll keep fainting and won't be able to look after myself at home.
  • I hope it's nothing very serious like my heart — I had heart trouble before.

If You Ask Me About Other Symptoms...

  • Head: I had a mild headache after I came round but no severe ongoing headache; no vomiting.
  • Eyes: no double vision, vision returned to normal after I woke up.
  • Weakness / numbness: I felt weak for a while but it improved; I have diabetic neuropathy in my feet for years.
  • Chest: I had no chest pain today; last week I had a mild left shoulder ache that felt like muscle pain, not chest pain.
  • Breath: no shortness of breath today.
  • Fever / infection: I felt a bit cold and sweaty when I collapsed, no fever; had mild diarrhoea yesterday that settled.
  • Drugs / alcohol: I don't use recreational drugs; I had my usual single glass of wine last night.
  • Medication adherence: I try to take my tablets as prescribed but sometimes I forget or take them late.

Clinical Summary

Examination

  • General: alert but intermittently disoriented to exact time; appears pale and sweaty
  • GCS: 14 (Eye 4, Verbal 4, Motor 6) on arrival after paramedic treatment
  • Vital signs: HR 110 bpm (sinus), BP 100/60 mmHg, RR 18/min, SpO2 97% on room air, Temp 36.4°C
  • Capillary blood glucose on paramedic arrival: 1.9 mmol/L (34 mg/dL)
  • Capillary blood glucose after initial treatment (IV dextrose): 7.6 mmol/L
  • CVS: no added murmurs, no overt signs of heart failure
  • Resp: clear auscultation bilaterally
  • Neuro: briefly confused and slurred speech on arrival, no persistent focal neurological deficits, pupils equal and reactive; no lateralizing weakness on exam after correction of glucose
  • Other: warm, diaphoretic skin; no head injury signs

Investigations

  • Fingerstick glucose (pre-treatment): 1.9 mmol/L (hypoglycaemia)
  • Fingerstick glucose (post IV D50): 7.6 mmol/L (response to glucose)
  • Venous blood glucose: 2.1 mmol/L on ED venous sample (low) prior to dextrose
  • Serum electrolytes: Na 136 mmol/L, K 4.9 mmol/L, Cl 101 mmol/L
  • Creatinine: 190 µmol/L (baseline ~160), eGFR ~28 mL/min/1.73m2 (CKD stage 3b)
  • CBC: WCC 7.8 x10^9/L, Hb 12.2 g/dL
  • HbA1c: 7.2% (55 mmol/mol)
  • Serum insulin and C-peptide (sent): pending — to assess endogenous vs exogenous insulin effect
  • Blood ketones: 0.1 mmol/L (low)
  • ECG: sinus tachycardia, no acute ischemic changes
  • CXR: clear
  • Urinalysis: no significant infection markers

(Notes: paramedics documented immediate capillary glucose 1.9 mmol/L and administration of IV dextrose with rapid clinical improvement.)

Diagnosis

  • Primary diagnosis: Severe hypoglycaemia (capillary glucose 1.9 mmol/L) with transient loss of consciousness, likely iatrogenic in a patient on insulin and sulfonylurea and with reduced renal clearance (CKD) and reduced oral intake.

    • Evidence: documented very low capillary/venous glucose, rapid clinical improvement after IV dextrose, low blood ketones suggesting hyperinsulinaemia, concurrent use of gliclazide and insulin, eGFR 28 mL/min.

  • Differential diagnoses and reasoning:

    • Acute cerebrovascular event (stroke/transient ischemic attack): considered because of transient language disturbance and collapse; less likely given resolution with glucose correction and absence of focal neurological signs on exam and no acute changes on exam/ECG.
    • Cardiac syncope (arrhythmia or ischemia): possible given IHD history, but ECG shows sinus tachycardia without ischemic changes and symptoms resolved with glucose correction; continue cardiac evaluation if indicated.
    • Seizure (primary or secondary): patient had transient loss of consciousness and post-event confusion; however, hypoglycaemia can provoke loss of consciousness and seizure-like activity — no prolonged post-ictal deficit and symptom resolution after glucose favors hypoglycaemia as cause.
    • Adrenal insufficiency or sepsis causing hypoglycaemia: less likely given lack of systemic infection signs and normal WCC/temperature; can be considered if recurrent unexplained episodes.

Management

  • Immediate/acute:

    • Confirm hypoglycaemia with capillary glucose; administer IV 50% dextrose bolus (e.g., 25 g D50 50 mL) then re-check capillary glucose after 10–15 minutes.
    • If no IV access: give IM glucagon 1 mg (and arrange IV access for follow-up).
    • Monitor airway, breathing, circulation; protect airway if reduced consciousness.

  • Ongoing inpatient steps:

    • Observe on monitored ward with hourly capillary glucose for initial 4–6 hours, then frequency as clinically indicated.
    • Hold gliclazide and review insulin regimen; discuss with diabetes team/diabetes nurse specialist to adjust doses given recent hypoglycaemia and CKD.
    • Investigations to determine cause: review medication administration (dose/timing), serum insulin/C-peptide/sulfonylurea screen results when available, review renal function and recent changes in renal status.
    • Assess for precipitating factors: reduced oral intake (missed breakfast), diarrhoea the day before, possible accidental extra dose of insulin or timing error, renal impairment reducing drug clearance.
    • Cardiac evaluation as indicated (troponin if chest pain or ECG changes, telemetry if arrhythmia suspected).
    • Consider social assessment and safe discharge planning: check ability to manage diabetes at home, involve daughter/GP, consider more frequent community support or change to medications with lower hypoglycaemia risk.

  • Secondary prevention and education:

    • Educate patient and carers about hypoglycaemia recognition and management.
    • Provide glucose rescue measures for home (oral glucose gel if safe) and provide instructions about when to seek help.
    • Arrange diabetes outpatient follow-up to consider stopping sulfonylurea (or reducing insulin), tailoring regimen for CKD, and arrange diabetes specialist review.

Key Learning Points

  • Elderly patients with diabetes are at high risk of severe hypoglycaemia from polypharmacy (sulfonylureas + insulin), reduced oral intake, and impaired renal clearance.

  • Always check a capillary blood glucose early in any patient presenting with collapse, confusion, or seizure-like activity — hypoglycaemia is rapidly reversible and can mimic stroke or seizure.

  • Immediate management is prompt glucose replacement (IV dextrose or IM glucagon if no IV access), followed by careful review of medications, monitoring, and multidisciplinary planning to prevent recurrence.

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