I n this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italics) is integrated throughout the discussion.Clinical Information. A 76-year-old woman with hypertension and polymyalgia rheumatica presents with episodic diaphoresis and anxiety for 3 months.Anxiety is a commonly encountered symptom in the ambulatory setting; however, when it presents suddenly in an elderly patient who has no recent stressors, it may be secondary to a new underlying medical condition. There are numerous entities that can lead to anxiety. At this point, I would take a detailed history of the symptoms and circumstances surrounding the episodes.Diagnostic Reasoning. The clinician quickly recognizes that without recent major life stressors, the new presentation of anxiety in an elderly person does not fit the more common illness script of generalized anxiety disorder. Illness scripts are the key risk factors, clinical presentations, and pathophysiology that summarize a specific clinical problem. 1 For instance, a clinician's illness script for an acute myocardial infarction might include the acute onset of angina and shortness of breath in a patient with risk factors for coronary artery disease. As a clinician gains knowledge and experience with a particular diagnosis, they refine and expand their illness script for that diagnosis. 2 Once the clinician realizes that he doesn't have one illness script that exactly fits our patient's presentation, he consciously stops to gather more information instead of making an early differential diagnosis.Clinical Information. Three months before presentation, she felt very anxious and noticed palpitations while fasting for a routine laboratory evaluation. She was also diaphoretic, had slurred speech, and eventually lost consciousness. Emergency Medical Service personnel found her blood glucose to be 45 mg/dl, and after intravenous administration of dextrose, her symptoms resolved.Hypoglycemia is an intriguing diagnosis and can certainly cause episodes of anxiety and diaphoresis associated with the adrenergic surge that attempts to raise the blood sugar. The first step in the diagnosis of hypoglycemia is determining whether the patient fulfills Whipple's triad: symptoms of hypoglycemia, documented hypoglycemia, and resolution of symptoms with the administration of glucose. Our patient has all three components. If her other episodes of anxiety and diaphoresis have been similar to the one above, I believe hypoglycemia likely explains her anxiety. Now we must determine the etiology of her hypoglycemia.We should first determine whether her symptoms occur in the fasting or post-prandial state, as the differential diagnosis varies depending on the circumstances of the hypoglycemia. We should obtain more information regarding recent weight changes or history of diabetes, as early diabetes can present with hypoglycemia. Alcohol abuse or malnutrition can deplete...