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NBME 24 Answers

nbme24/Block 3/Question#21 (22.8 difficulty score)
A 7-year-old girl is brought to the emergency ...
Factitious disorder imposed on anotherπŸ”

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submitted by jkan(23),
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ctepdpi-e si olw itwh enguxoose un.iisnl -tedpiep(c made sa a bpdcytoru fo niunils outocidpnr ni teh oreadyt beed)p svisi+t ihhg snlnu+olwii iecdt=ep-p oesgxoune iniulsn ue.sba nI a ;igdht&c-l icasiouftt by xoypr

sunshinesweetheart  ugh, I feel like a child could misuse their insulin by accident without proper supervision. Totally thought she had T1DM and not enough guidance on how to use the meds. annoying +3  
peqmd  I couldn't rule out if the child was trying to get swole and had a shady dealer. +3  
alwaysdivs94  Sorry, where doesn't it talk about insulin abuse in the question? I thought she was administered for an acute exacerbation of heart failure? +  

submitted by groovygrinch(25),
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roF othse hwo eewr ninoegrdw eikl ,me thye gvea teh eoryetd-atxyabrytBuh (a noekte body) elelsv in rerod ot eulr uto DKA iidce(tba tssaid)coeiko in a ptye 1 ticbaides nda which woldu hireseotw nto eb aihnilsetbsuidg sbead loyn on e-Cpdteip nda lsunnii lleesv

therealslimshady  Regardless of the ketones, DKA is not likely anyway, since you'd see hyperglycemia in it, but this patient has hypoglycemia +  

submitted by hyoid(40),
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Can nomoees leaxinp tish o––enI n'itdd lyarle ownk ahwt to aekm of het lab luves.a ylerCal hes was kingta oto mcuh liinsn,u utb owh nac you feierefidttan iiuacftots drireosd omfr a teyp 1 tbdciaie ohw akets oot cumh of htier nniislu ?oesd

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. +21  
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). +8