A patient with confusing symptoms
A 48 year old woman presented to her general practitioner with a 16 month history of her mouth and fingers going numb and tingly. She also complained of feeling vacant and mentally detached. She reported numerous episodes of wandering, confusion, repeating words inappropriately, looking vacant, and not responding. All these events were witnessed by her children, but she had no recollection of them. All her symptoms were improved on eating.
She was otherwise well, with no clinical features of Addison's disease, no past medical history of note, and was on no regular medication other than oestrogen implants.
Home capillary glucose readings were 3.2 mmol/l, 2.7 mmol/l, 2.7 mmol/l, and 1.2 mmol/l (reference range 4-8 mmol/l).
She was admitted for an overnight fast and was found to be completely unrousable by nursing staff in the morning.
Secondly, high insulin and low c peptide—this is hypoglycaemia most likely to be from exogenous