A Weightlifter With Palpitations, Tremors, and Confusion

Ricardo Correa, MD; Sri Harsha Tella, MD


January 11, 2021

Physical Examination and Workup

On physical examination, the patient had a blood pressure of 110/70 mm Hg, a heart rate of 65 beats/min, a respiratory rate of 16 breaths/min, and weight of 154.3 lb (70 kg) with a body mass index of 22 kg/m2. He had a well-built, muscular body and was calm and cooperative. His neck examination revealed a normal-sized thyroid, with no palpable nodules or lymph nodes. Heart and lung examination findings were unremarkable. His abdomen was soft, nontender, and nondistended, with no central adiposity. Neurologic examination findings were unremarkable. Genital examination revealed 25 mL of volume in both testes, with no masses and normal development of the penis.

Coincidentally, the patient experienced the typical episode of palpitations, tremors, fatigue, and confusion during his clinic visit. His blood glucose level was 88 mg/dL. He was offered a can of orange juice and a bag of crackers, which made his symptoms disappear. A fasting test was ordered, and he was given a glucometer to log his glucose level along with the time and day when he has episodes.

His significant fasting laboratory data included a white blood cell count of 7000 cells/µL, a hemoglobin level of 16.8 g/dL, a hematocrit of 49.5%, and a platelet count of 200,000 cells/µL. Blood chemistry revealed a blood glucose level of 75 mg/dL, normal electrolyte levels, normal liver function test results, and creatinine level of 1 mg/dL. His lipid panel revealed a total cholesterol level of 250 mg/dL, a triglyceride level of 150 mg/dL, a low-density lipoprotein cholesterol level of 180 mg/dL, and a high-density lipoprotein cholesterol level of 45 mg/dL.

His thyroid-stimulating hormone level was 1.4 mIU/L, his free thyroxine level was 1 µg/dL, his 8 AM cortisol level was 12 µg/dL, his insulinlike growth factor 1 level was 190 ng/mL, and his urine metanephrine levels were within the reference range. His 8 AM total testosterone level was 700 ng/dL, his follicle-stimulating hormone level was 4.3 IU/L, and his luteinizing hormone level was 3.6 IU/L. A review of his blood glucose logs over a couple of weeks revealed a blood glucose range of 77-130 mg/dL, including fasting and postmeal readings. He reported having six to 10 episodes of palpitations, tremor, fatigue, and confusion per day and checked his fingerstick glucose level at least four or five times per day.


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