A confused 74-year-old female has left-sided weakness and a blood glucose of 52 mg/dL. You should:

• A. perform a stroke assessment.
• B. activate a stroke alert.
• C. administer oxygen.
• D. administer oral glucose.

Answer: (D)

When a patient presents with confusion and weakness and you find a critically low blood sugar, the immediate priority is to correct that metabolic problem, because hypoglycemia is a reversible cause of neurologic symptoms that can mimic a stroke. A glucose of 52 mg/dL is dangerously low and can impair brain function quickly. If the patient can swallow safely, administer oral glucose right away to raise the blood sugar and see if neurologic signs resolve as the glucose level normalizes. Recheck the glucose after a few minutes and reassess mental status and any focal deficits.

If the patient cannot protect the airway or swallow safely, or if there is no reliable way to give oral glucose, give an appropriate parenteral option (such as IV dextrose or glucagon). Oxygen is only helpful if there is a true oxygen deficit; it does not treat hypoglycemia. A stroke alert or full stroke workup is important if deficits persist after correcting the glucose, but the first step must be to restore normal glucose to determine whether the symptoms were due to hypoglycemia rather than a stroke.