Case

     A 59 year-old man was brought to the emergency room due to loss of consciousness
at a Muslim church. He was diagnosed to have Diabetes mellitus type 2 since 9 years
prior to admission and had been maintained on Glibenclamide tablet as his daily
medication. History revealed that he had been fasting for 3 straight days during the
Ramadan period but still religiously took his daily maintenance medication every
morning. According to the informant who witnessed the event, the patient initially
experienced palpitations, tremors and cold sweats for about 1 hour prior to admission.
After another 30 minutes, he complained of headache associated with dizziness,
confusion and slurring of speech, then he eventually collapsed on the ground, thus was
brought to the nearby hospital for admission.  
 
Pertinent findings upon admission:
Blood pressure: 140/100 mmHg (normal: 120/80 mmHg)
Cardiac rate: 105 bpm (elevated: 60–100 beats per minute)
Respiratory rate: 23 cpm (12 to 16 breaths per minute)
Temperature: 36.8 0C
Weight: 80 kgs (BMI=32.26, obese = 30 and above)
Height: 5’2”
 
He was brought in stretcher- borne, unconscious, not in cardiopulmonary distress
Anicteric sclerae, pale conjunctivae
Dynamic precordium, tachycardic with regular & rhythm
Symmetrical chest expansion with clear breath sounds
Abdomen is flabby, soft with normoactive bowel sounds, (-) tenderness
Pale extremities with full peripheral pulses
 
Diagnostic procedure done at the ER:
Random capillary blood sugar:  30 mgs/ dl (below normal)
 80–140mg/dl (4.4–7.8 mmol/l), between 140-200mg/dl (7.8–11.1 mmol/l) is
considered pre-diabetes, and ≥ 200 mg/dl is considered diabetes
 
Guide Questions:
1. What caused the patient’s loss of consciousness? Correlate the patient’s
manifestations with the biochemical processes which occur in his body during
this condition.
 The patient shows symptoms of hypoglycemia, a severe type. Hypoglycemia
occurs when the level of glucose in your blood drops below 70 mg/dL.
 Since the patient is diagnosed with DM Type 2, the cause is diabetic
hypoglycemia. This occurs when someone with diabetes doesn’t have enough
glucose in the blood. DM Type 2 produces inadequate amounts of insulin to meet
the demands of the body. Insulin helps the body turn glucose into energy.
Glucose is the main source of fuel for the body and brain so if it is not enough,
the body cannot function well.
 Hypoglycemia also triggers the release of body hormones, such as epinephrine
and norepinephrine. The brain depends on these hormones to raise blood sugar
levels. The release of these hormones causes additional symptoms of tremor,
sweating, rapid heartbeat, anxiety and hunger. Considering that the brain
depends on blood sugar as its primary source of energy, hypoglycemia interferes
with brain’s ability to function properly which can cause dizziness, headache,
blurred vision, difficulty concentrating, and other neurological symptoms.
 If the blood sugar level stays low for too long, this will cause seizure or diabetic
coma.
2. What other medical conditions and events might have contributed to the
patient’s signs and symptoms?
 Fasting causes low blood sugar. It happens when the body turns to ketones for
fuel instead of glucose. The cells have to adapt on ketones for energy not
glucose. It can come along with keto flu which includes lightheadedness and
headaches. This will have an impact on the brain first since it is dependent on
glucose.
 Glibenclamide works by increasing the amount of insulin. Too much insulin or
oral medication can lower the blood sugar leading to hypoglycemia because too
much glucose will go into the cells leaving less in the bloodstream since the
patient i

3. What is “ Whipple’s Triad?” Explain its biochemical effects.

 Technique used to diagnose a symptomatic hypoglycemia. It consists of
symptoms of hypoglycemia, plasma glucose concentration <55 mg/dL, and
resolution of those symptoms after the plasma glucose concentration is raised.
Its biochemical effects was explained in the first question.
  Hypoglycemic patients has less than 70mg/dL of blood sugar, and symptoms will
only show when blood sugar level is 55mg/dL and below.
4. Based on the biochemical processes which caused the patient’s condition,
what is/ are the ideal management of patients with the same medical illness?
 If the patient cannot eat, glucagon injection or intravenous glucose must be
administered.
 Call for emergency if the patient is unconscious. Once the patient is awake, a
complex carbohydrate food source should be given to the patient to achieve
sustained euglycemia. More frequent blood glucose monitoring should occur
 For conscious patient able take oral medications, readily absorbable
carbohydrates sources such as fruit juice should be given.

 Always bring with you glucose source like gel, candy, or tablets.

https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-
problems/low-blood-glucose-hypoglycemia
https://www.mayoclinic.org/diseases-conditions/diabetic-hypoglycemia/symptoms-
causes/syc-20371525#:~:text=Overview,you%20don't%20have%20enough.
https://intermittentdieter.com/can-you-get-hypoglycemia-when-fasting/
https://www.healthline.com/health/diabetes/insulin-overdose#od-symptoms