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Target exams

Red flags

• Whipple triad — symptoms consistent with hypoglycaemia, low plasma glucose measured at the time, and relief with glucose — must be documented before any invasive workup of hypoglycaemia begins; without it the diagnosis is not established
• Neuroglycopenic symptoms — confusion, focal neurological deficit, seizure, coma — at a plasma glucose < 3.0 mmol/L are a medical emergency demanding immediate IV dextrose and a critical sample before treatment where possible
• Hypoglycaemia in a patient not on insulin or sulfonylurea therapy demands an inpatient supervised 72-hour fast with paired insulin, C-peptide, proinsulin, beta-hydroxybutyrate and sulfonylurea screen — never accept 'glucose just dropped' without a critical sample
• Recurrent severe hypoglycaemia in type 1 diabetes signals hypoglycaemia-associated autonomic failure — the counter-regulatory and symptomatic responses are both blunted, and the patient loses the warning that should trigger treatment
• Non-islet cell tumour hypoglycaemia — recurrent fasting hypoglycaemia with low insulin and C-peptide in a patient with a known or occult tumour — is driven by tumour secretion of incompletely processed 'big IGF-2'; management differs from insulinoma