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Comments ...

 +1  (nbme24#39)

This boy has achondroplasia, which is caused by an autosomal dominant mutation in Fibroblast Growth Factor Receptor 3. FGF signaling is needed for proper cartilage function, and without it, the long bones of the body will not grow because the growth plate (made of chondrocytes) does not function. However, bones that undergo membranous ossification, like the bones of the head, will grow normally. This results in the patient having short extremities with a normal size trunk and large head relative to the limbs.


 +1  (nbme24#16)

The patient seems to have an infection due to their elevated temperature and abnormal chest X-ray. However, their leukocyte count is low. In addition, the patient has hepatitis C, which is often associated with similar transmission routes to HIV, like intravenous drug use.

sajaqua1  Not only is their WBC count low, it is not uniform. If we assume a minimum normal WBC count of 5000 cells/mL^3, and a regular range of ~60% neutrophils, then normally a person should have ~3,000 neutrophils/mL^3. This patient has a total of 2000 cells/mL^3, with 1,800 neutrophils/mL^3. Their lymphocytes and macrophages have been whiped out. This is best accounted for by HIV.

 +0  (nbme24#46)

Vincristine is a chemotherapeutic drug that stabilizes microtubules and prevents them from disassembling. The cell in the picture is stuck in anaphase, with microtubules attached to its chromosomes, unable to pull them apart because it cannot disassemble its microtubules.

vshummy  So I get that by process of elimination cyclophosphamide, cyclosporine, doxorubicin, and 5-fluorouracil are not related to microtubules but vincristine in First Aid 2019 says it prevents microtubule formation, doesn’t stabilize it because the one that stabilizes microtubules is paclitaxel.
vshummy  Okay, I realize now- the picture is stuck in metaphase, not anaphase. Both paclitaxel and vincristine stop the cell in metaphase but by two different mechanisms. Vincristine prevents mitotic *spindle* formation while paclitaxel prevents mitotic spindle *breakdown*. Mitotic spindle is needed to pull the chromosomes apart before anaphase begins.

 +1  (nbme24#1)

Question is basically asking what are the substrates used the first step in heme synthesis. In that step, glycine and succinyl CoA are combined to make aminolevulinic acid.


 +1  (nbme24#32)

HMG CoA Reductase inhibitors prevent the liver from synthesizing its own cholesterol. In order to maintain its need for cholesterol, the liver has no choice by to increase its LDL receptor expression in order to take cholesterol from the blood.


 +5  (nbme24#28)

The "likelihood of missing an association" refers to Type II error. The risk of Type II error is represented by beta. This could be confused with power, which is 1 - beta.

usmleuser007  Just rereading this question without the stress, i got it quickly! Could't believe i missed something as simple as this.

 +4  (nbme24#25)

This man has pulsus paradoxus, a sign in which blood pressure decreases drastically during inspiration. Pulsus paradoxus is a classic sign of pericardial tamponade.

When fluid (often blood) has pooled around the heart, the heart struggles to expand and fill with blood. This becomes a bigger problem for the right ventricle during inspiration, because the right side of the heart receives increased venous return during inspiration. Because there is fluid preventing the right ventricle from expanding outward, the only other place it can expand to accommodate is by pushing on the septum, shrinking the size of the left ventricle. This causes decreased BP when the left ventricle contracts during that cardiac cycle.

sajaqua1  In addition to causing pulsus paradoxus, we see jugular venous distension, and muffled/distant heart sounds (hard to hear through the cardiac tamponade). https://radiopaedia.org/articles/beck-triad?lang=us

 +1  (nbme24#12)

The patient shows no sign of cortical activity, but has some brainstem function intact, which implies she is in a form of persistent vegetative state. She has a living will that designates mechanical ventilation should be discontinued if that situation arises, so we must follow it and make not attempt to resuscitate.

lfsuarez  Why would the second part of that be correct when there is not mention of a DNR?
ug123  DNI and DNR are different right? This patient had a DNI. Why would we assume it to be DNR too?
sherry  DNI and DNR are indeed different. But it is not the case here. The patient needs to be extubated means she did not sign a DNI or DNR in the first place. I assume her living will is more like terminate supporting treatment in a vegetative state. So there is no need to do resuscitation anyways. But I agree this is not a good question.
shayan  "The patient has signed the living will and is consistent with her directives" but the stem doesnt tell has what is in her living will about the extubation? we are extubating on the request of her husband? this is confusing !

 +1  (nbme24#14)

Specificity is equal to the number of true negative tests over the number of true negatives plus false positives:

Spec = TN /(TN + FP)


 +3  (nbme24#50)

This patient shows signs of cirrhosis, which is likely associated with portal hypertension. Portal hypertension will cause increased pressure in all veins draining into the portal vein, and can cause bulging of these veins at areas where they meet those that drain to the vena cava. One area is the rectum and anus, where the superior rectal vein (from the portal system) meets up with the middle and inferior rectal veins (which drain to the caval system). Increased pressure in the superior rectal vein will cause hemorrhoids at this location.


 +2  (nbme24#14)

In SIADH, the excessive ADH causes the collecting duct of the kidney to reabsorb huge amounts of water that it should normally excrete. That means that the plasma will now have much more water relative to solute (low osmolality) and the urine will have much more salt relative to water (higher osmolality).


 +11  (nbme24#18)

The patient has loss of pain and temperature on the right side of his face. Sensation of the face is ipsilateral, so the issue must be on the patient's right side, which we can confirm by knowing that sensation of the body is contralateral, and he has lost left sided pain and temperature of the body.

Pain and temperature sensation of the body is part of the spinothalamic tract, which always runs laterally through the brainstem. This can be confirmed by remembering that sensation to the face also runs laterally through the brainstem. So, we can confirm this is a right sided lateral brainstem issue.

The loss of gag reflex and paralysis of the vocal cords imply impairment of cranial nerves IX and X, both of which localize to the medulla. Therefore, the answer is right dorsolateral medulla.

duat98  You're a good man.
charcot_bouchard  You must be handsome too

 +2  (nbme24#41)

Autonomy is the most important ethics principle that supersedes all others. However, it is applied only in situations in which a patient demonstrates decision-making capacity. In this situation, a patient with advanced disease unlikely to be cured is refusing treatment, which is his right under the principle of autonomy. However, his comments about "returning in 6 months after curing arthritis" are questionable, and warrant determining if he has decision making capacity. It is possible that he does, which is why any choices of forcing further treatment on him are incorrect.


 +1  (nbme24#47)

The most important ethical principle that supersedes all others is autonomy. From an ethical standpoint, this patient has the right to refuse further treatment as he is mentally competent, in this case in the form of having the respiratory removed. From a legal standpoint, the physician is allowed to discontinue treatment for a patient if that is what the patient wants. This is different from situations of physician assisted suicide, which is more complicated and has variable ethics and legality.

rhsteps  isnt this considered physician assisted suicide?
johnson  No - treatment is being withdrawn per the mentally competent patient's wishes. m-ice explained it well.
johnson  No - treatment is being withdrawn per the mentally competent patient's wishes. m-ice explained it well.
johnson  No - treatment is being withdrawn per the mentally competent patient's wishes. m-ice explained it well.

 +5  (nbme24#17)

All of the features described of this patient would be expected of a 68-year-old man. Shorter, less intense orgasms, as well as increased time needed between sex could be related to a slight drop in testosterone with age. However, he continues to grow hair well (feet and toes), implying that he hasn't dramatically lost testosterone production. His prostate is slightly enlarged, which could imply benign prostatic hyperplasia, but this should not directly impact his sexual function.


 +2  (nbme24#38)

A soft systolic murmur is common in many pregnant women due to a high volume of flow (increased cardiac output). The murmur tends to go away within a few weeks of delivery once the cardiac output is closer to baseline.


 +1  (nbme24#19)

The patient in this question has cluster headaches. These headaches can be differentiated from migraines and tension headaches, as they tend to come in episodes across several years, with absent periods in between. Cluster headaches are often described as excruciatingly painful (sometimes called "suicide headaches").


 +2  (nbme24#41)

Misoprostol is a prostaglandin analog (PGE2) that acts on the stomach to promote mucus protection of the stomach lining, but also acts in the uterus to encourage contraction, which makes it useful for abortion.


 +2  (nbme24#46)

This girl has malignant hyperthermia, a dangerous adverse effect of some anesthestic agents characterized by sudden high fever and rhabdomyolysis. The only drug among this list that can cause malignant hyperthermia is succinylcholine. The other drugs that cause malignant hyperthermia are the halonated gases (flurane, sevoflurane, etc.), but nitrous oxide does not cause it.


 +2  (nbme24#12)

HMG CoA reductase inhibitors block the ability of the body to produce its own cholesterol. The liver, unable to make its own cholesterol and still needing to do its job of making lipoproteins, needs to get it from somewhere. So, the liver increases expression of LDL receptors to take more LDL out of the blood for repackaging.


 +3  (nbme24#29)

The jaw pain and headaches in an older woman are worrisome for Temporal Arteritis. This is a vasculitis, which could be best identified by determining the erythrocyte sedimentation rate.


 +3  (nbme24#19)

The patient needs medical attention immediately, which eliminates obtaining a court order, or transferring her. A nurse does not have the same training and qualifications as a physician, so it would be inappropriate to ask them to examine the patient. Asking the hospital chaplain again could be inappropriate, and would take more time. Therefore, the best option among those given is to ask the patient if she will allow with her husband present.

sympathetikey  Garbage question.
masonkingcobra  So two men is better than one apparently
zoggybiscuits  GarBAGE! ?
bigjimbo  gárbágé
fulminant_life  this question is garbage. She doesnt want to be examined by a male how would the presence of her husband make any difference in that respect?
dr.xx  I guess this is a garbage question because what hospital, even small and rural, does not have a female physician on staff. NBME take notice -- this is the 2010s not 1970s. https://images.app.goo.gl/xBL4cK31ta7nG4L39
medpsychosis  The question here focuses on a specific issue which is the patient's religious conservative beliefs vs. urgency of the situation. A physician is required to respect the patient's autonomy while also balancing between beneficence and non-maleficence. The answer choice where the physician asks the patient if it would be ok to perform the exam with the husband present is an attempt to respect the conservative religious belief of the patient (not being exposed or alone with another man in the absence of her husband) while also allowing the physician to provide necessary medical treatment that could be life saving for her and or the child. Again, this allows for the patient to practice autonomy as she has the right to say no.
sahusema  I showed this question to my parents and they said "this is the kind of stuff you study all day?" smh
sherry  I totally agree this is a garbage question. I personally think there is more garbage question on new NBME forms than the previous ones...they can argue in any way. I feel like they were just trying to make people struggle on bad options when everybody knows what they were trying to ask.

 +4  (nbme24#1)

This girl has chronic granulomatous disease, in which the immune system cannot properly form reactive oxygen species needed to kill phagocytosed organisms. This is especially bad when dealing with catalase positive organisms (like Staph), because these organisms already use catalase to break down reactive oxygen species. The most common cause of this condition is a mutation in NADPH oxidase, responsible for the generation of the superoxide radical.

et-tu-bromocriptine  To add on: If neutrophils don't have access to NADPH oxidase, they can still use the bacteria's own hydrogen peroxidase to create ROS and kill the bacteria; however, catalase + organisms will not have this hydrogen peroxidase available (because catalase converts hydrogen peroxidase to O2 and water). So then the neutrophils are screwed and have no way of creating ROS.

 +3  (nbme24#41)

Tetrodotoxin, found in puffer fish, inhibits sodium channels. This prevents depolarization of cardiac muscle and neurons, which leads to death if consumed in high enough quantity. The symptoms are vague (nausea, diarrhea, paresthesia), so questions will need to give some form of history about eating at a Japanese restaurant or eating pufferfish to give you a big hint. There is unfortunately not treatment.


 +0  (nbme24#50)

Case series is a study in which the researchers present the history and treatment of a small group of similar patients, without describing any sorting into groups or randomization.


 +1  (nbme24#40)

This boy has meningitis caused by Strep pneumoniae, the most common cause of infectious meningitis in general. The vaccine for Strep pneumo is a polysaccharide protein conjugate vaccine. The other major bacteria with a vaccine like this is H. influenzae.


 +2  (nbme24#18)

Competitive inhibitors increase the Km of the substrate. The Km represents how easily a substrate can bind the active site, with a lower Km representing easy binding, and a higher Km meaning more difficult. If you add a competitive inhibitor, like ethanol in this case, it makes it more difficult for the methanol to bind the active site, because it must compete with the ethanol.


 +0  (nbme24#28)

Dysmetria is the lack of coordination of intended movements. Normally these movements are coordinated by the cerebellum. This is located specifically on the man's right side, not both sides, so only one lobe will be injured.


 +7  (nbme24#20)

This woman has Paroxysmal Nocturnal Hemoglobinuria. This most often presents in a young adult who has episodes of dark urine in the middle of the night or when waking up in the morning. It's caused by complement activity directly against the patient's own RBCs. Certain glycolipids are needed on the RBC surface to prevent attack from complement, the most notable of which are CD55 and CD59. Patients with PNH have a somatic mutation in which they lost function of a PIGA enzyme needed for proper presentation and attachment of CD55/CD59 on the RBC surface. Therefore the answer is a defect in a cell membrane anchor protein. Without this, complement attacks RBCs.

usmleuser007  I knew the disorder and its pathophysiology. But sometimes the answer choices are so wordy or colorful that you still get it wrong....

 +4  (nbme24#12)

This woman has a lot of signs that point toward an intestinal parasitic infection: recent travel to Papua New Guinea, cough and alveolar infiltrates, high eosinophil count, and a stool sample that has a worm in it. Most likely the patient has a Strongyloides infection, as this is the intestinal parasite that shows larva on stool sample. Basically all intestinal parasites can be treated with Bendazole drugs, such as Thiabendazole. Praziquantel would be more appropriate for a worm or liver fluke infection.

fulminant_life  just to add to the explanation above," cutaneous larva currens" is a specific finding for strongyloides. Also the picture they used is the exact same one on wikipedia lol
yb_26  they really should add Wikipedia in the list of top-rated review resources with A+ level of recommendation in FA2020)))

 +6  (nbme24#47)

The patient states that she does not want a hormonal form of birth control. So, the question is really asking which of the non-hormonal options is most effective. The tricky part here, I think, is that the question makes you want to not pick IUD, because many IUDs are hormonally based. However, a non-hormonal IUD, like a copper IUD, is still more effective than the other options listed.


 +4  (nbme24#32)

This girl has Mono caused by Epstein-Barr Virus. The symptoms are relatively vague, but lymphadenopathy like this would be common for Mono. The CBC shows elevated lymphocytes, implying this is not a bacterial illness, so viral is likely. Combined with the lymphadenopathy, this makes us worry about Mono. The Mono-Spot test for EBV is what the question is referring to when describing the sheep erythrocytes agglutinating. From there, this question requires that you know that in EBV infection, EBV infects B cells, but does not cause them to become abnormal. Instead, CD8 cells, which are actively trying to kill the B cells, become abnormal.

medskool123  NBME does trick now and then.. when they zig you zag. then when you think they are going to zag, they zig just to destroy yourself confidence.
kylemax  The abnormal T-cells are known as Downey type II cells (Sketchy)
haliburton  I was recognized EBV, then knew EBV infects Bc, and the atypical lymphocytes are Tc. Then I said CD8 are MHC1 for virii, and bingo bango, boom.
trichotillomaniac  congrats you played yourself

 +4  (nbme24#17)

All HOX genes are transcription factors that help regulate body layout and different expression of genes for each body segment.


 +3  (nbme24#10)

This question only concerns women in the 50-54 age group. The group has a mean of 246 and standard deviation of 50. Therefore, all those with values greater than 296 are all those above one standard deviation. 2/3 of all values on a normal distribution are within one standard deviation in either direction. Therefore, 1/3 are outside of this in either direction, meaning 1/3 of women have a value less than 196 or greater than 296. If we split that in half to only choose those greater than 296, we get 1/6 women, which is about 16%.

guillo12  Sorry, but there is not other way that I can understand this?
fulminant_life  @guillo12 basically 67% fall within 1 sd. That means that 33% are +/- >1sd. So taking only those with above 296, you only look at those >1sd above the mean which is 16.5% . The other 16.5% are those >1sd below the mean.
guillo12  Thank you!!! @fulminant_life

 +1  (nbme24#6)

This patient has a gallstone lodged in the common bile duct. Therefore, the markers most likely to be elevated is something from the biliary tract, the best of which is alkaline phosphatase. There could potentially be elevations in AST and ALT, but this is not the MOST likely answer. Unconjugated bilirubin is not a good answer, because the liver can still conjugate all bilirubin, it just has issues now excreting that conjugated form. So the woman's CONJUGATED bilirubin is more likely to be elevated.


 +9  (nbme24#38)

They explicitly state that the patient has been taking excess of his levothyroxine medication. Levothyroxine is the exogenous form of T4. Therefore, free T4 must be elevated. T4 is converted to T3 at most peripheral tissues, so T3 will also be elevated. Because the body has more thyroid hormone than needed, less TSH will be made, and the thyroid will be less active, taking up LESS iodine.


 +2  (nbme24#27)

Avoidant personality disorder is characterized by a desire for social relationships, but a fear of being rejected or feeling inadequate for others. This is different from Schizoid, because Schizoid individuals do not desire relationships with others, and want to remain alone. The trickiest differentiation might be between Avoidant and Schizotypal, but Schizotypal individuals tend to remain isolated because of odd thinking, or "magical beliefs".





Subcomments ...

Can anybody explain this one? I put repeated tests because I assumed an 83-year-old woman is an unusual demographic for syphilis.

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +2  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +2  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +1  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +4  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +2  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +4  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +1  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) https://www.uofmhealth.org/health-library/hw5839 +1  


submitted by iguzman2(0),

Aren't M1 receptors found in the brain and are responsible for motion sickness?

m-ice  M1 receptors are for sure the major muscarinic receptor type found in the CNS, but M3 receptors are the muscarinic subtype involved in vomiting controlled by the CNS. This is definitely a random fact, but I think they also wanted you to eliminate all other options. Targeting the sympathetic system (options A and B) won't make a difference. NMDA receptors are a major receptor throughout the CNS, but they're not a target of antihistamines, and neither are serotonin receptors. We know that antihistamines target histamine and muscarinic receptors, but the H2 histamine receptor is responsible for gastrin secretion in the stomach, so the answer must be antagonism of M3 receptors. +  
dorsal_vein  ^ First generation antihistamines definitely antagonize serotonin receptors within the CNS, which can cause weight gain and increase appetite. However, this plays little role in motion sickness. +  


submitted by neonem(226),

I think the reason you need to inject gonadotropins in this case is because you need FSH and LH to produce sperm. FSH stimulates the sertoli cells, which line the seminiferous tubules and help the spermatogonia produce spermatocytes. Testosterone is a product of Leydig cells when they're stimulated by LH, so injecting testosterone would bypass that step but it wouldn't really help with spermatogenesis. However, injecting GnRH also doesn't doesn't really help because you need that pulsatile GnRH at night to make LH and FSH whereas long-acting GnRH analogs actually decrease LH and FSH production.

m-ice  Adding on to the answer above. I was stuck between the gonadotropin injections and clomiphene. But, clomiphene acts to increase activity of GnRH which then exerts its effects on the pituitary. The man in this question had his pituitary removed because of an adenoma. So, he needs the FSH and LH directly. +7  
mousie  agree! Removal of the pituitary would case a deficit in Gonadotropins (LH, FSH) and therefore nothing to simulate the testes to make sperm... replacing the T with a patch would not stimulate the testes to make sperm and if his axis was intact (although its not) this would further down regulate the production of sperm. I eliminated Clomiphene because if he dosent have T to induce negative influence on the hypothalamus he will have increased GnRH and further increasing it with Clomiphene would not correct the deficit in Gonadotropins. +2  
neonem  Oh duh... that makes much more sense. Thanks! P.s. I thought clomiphene was more of a fertility drug for women, since it blocks negative feedback of estrogen on the hypothalamus/pituitary. But in men the system is under feedback due to testosterone, not estrogen. +4  


Can anybody explain this one? I put repeated tests because I assumed an 83-year-old woman is an unusual demographic for syphilis.

m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +2  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +2  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +1  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +4  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +2  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +4  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +1  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) https://www.uofmhealth.org/health-library/hw5839 +1  


submitted by hyoid(7),

Can someone explain this one––I didn't really know what to make of the lab values. Clearly she was taking too much insulin, but how can you differentiate factitious disorder from a type 1 diabetic who takes too much of their insulin dose?

m-ice  I think the trick here is that they don't mention that the daughter has a history of Type 1 DM, so she has no reason to be taking insulin at all. She's definitely receiving insulin, but we don't have any history implying she's a type 1 diabetic. That, combined with the fact that there have been multiple episodes like this one, favors that the mother is giving the daughter insulin when she doesn't need it. +3  
sajaqua1  C-peptide is produce by endogenous insulin, but is not part of exogenous insulin. She has elevated insulin, with low C-peptide, so she is receiving too much exogenous insulin. A history of recurrent episodes this year implies a behavioral issue; Factitious disorder imposed on another (also called Munchausen syndrome by proxy). +4