History and exam
Key diagnostic factors
common
presence of risk factors for hyperglycaemia
Key risk factors for hyperglycaemia include stress (e.g., severe illness such as myocardial infarction), infection, corticosteroid use, and poorly controlled diabetes mellitus.
presence of risk factors for hypoglycaemia
history of diabetes mellitus
In one study, hyperglycaemia was present in 38% of patients admitted to hospital (26% had a known history of diabetes and 12% had no history of diabetes before admission).[5]
severe intercurrent illness or infection (hyperglycaemia)
Key risk factors for hyperglycaemia include stress (e.g., severe illness such as myocardial infarction) and infection.
insulin use (hypoglycaemia)
A key risk factor for hypoglycaemia.
reduced level of consciousness/coma (hypoglycaemia and hyperglycaemia)
Can be a presenting feature of both severe hypoglycaemia and hyperglycaemia. Recognising this presentation is essential to institute immediate management.
sweating (hypoglycaemia)
May be a presenting feature of hypoglycaemia.
Recognising symptoms and signs of hypoglycaemia urgently is essential to institute immediate management.
tachycardia (hypoglycaemia)
May be a presenting feature of hypoglycaemia.
Recognising symptoms and signs of hypoglycaemia urgently is essential to institute immediate management.
unusual behaviour (hypoglycaemia)
May be a presenting feature of hypoglycaemia.
Recognising symptoms and signs of hypoglycaemia urgently is essential to institute immediate management.
Other diagnostic factors
common
history of recent corticosteroid use
May suggest transient hyperglycaemia.
signs of diabetic retinopathy
May suggest long-standing diabetes. Includes intraretinal haemorrhage, cotton wool spots, lipid exudates, venous beading, and intraretinal microvascular abnormalities.
signs of diabetic neuropathy
May suggest long-standing diabetes. Includes loss of vibratory sensation; altered proprioception; impaired pain, light touch, and temperature sensation; gastroparesis, constipation, orthostatic hypotension, or resting tachycardia.
uncommon
polyuria, polydipsia, or unintentional weight loss
Hyperglycaemia is usually asymptomatic, but severe or prolonged type 2 diabetes may produce symptoms.
May also suggest type 1 diabetes.
Risk factors
strong
severe illness (hyperglycaemia or hypoglycaemia)
Particularly severe illnesses such as myocardial infarction, sepsis, and pneumonia are strong risk factors for hyperglycaemia.[13] Sepsis can increase serum glucose levels through hormonal changes that increase hepatic glucose production and reduce peripheral glucose uptake. Patients at increased risk of hypoglycaemia include those with renal or hepatic impairment, heart failure, malignancy, infection, or sepsis.[1][3][11]
corticosteroid use (hyperglycaemia)
Corticosteroids oppose insulin action and stimulate hepatic gluconeogenesis. Higher body mass index and increased age increase the risk of corticosteroid-induced hyperglycaemia.[14]
poorly controlled diabetes mellitus (hyperglycaemia)
Patients with a known history of diabetes mellitus may present with hyperglycaemia.
insulin administration or insulin secretagogues (hypoglycaemia)
Insulin can induce hypoglycaemia, leading to neuroglycopenia. Insulin secretagogues (i.e., sulfonylureas, meglitinides) can also lead to hypoglycaemia. Physical activity in patients taking insulin or insulin secretagogues can lead to hypoglycaemia especially if the drug dose or carbohydrate consumption is not adjusted accordingly.[1] Hypoglycaemia is associated with adverse outcomes, especially in intensive care unit patients. Sedation or beta-blockers may mask symptoms of neuroglycopenia, and counter-regulatory responses may be impaired.
Compared with sliding scale insulin, basal-bolus insulin use is more frequently associated with hypoglycaemia.[15]
changes to corticosteroid or insulin regimen (hypoglycaemia or hyperglycaemia)
Iatrogenic factors that may lead to hypoglycaemia include sudden reduction in a corticosteroid dose, incorrect timing in relation to meals of short- or rapid-acting insulin, and reduction of intravenous dextrose (glucose) infusion or parenteral nutrition rate.[1]
poor nutritional intake (hypoglycaemia)
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