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|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=Endocrine
|SubCategory=Endocrine
|Prompt=A 7-year-old boy is brought to the pediatrics clinic for fever of 39 °C (102.2 °F), cough, and wheezing for the past week. Over the last 24 hours, the child has developed nausea, vomiting, and watery diarrhea.  The child's past medical history is significant for neurofibromatosis, asthma, and seizure disorder.  He is currently taking daily albuterol and valproic acid. His mother explains that she was diagnosed with insulin-dependent diabetes mellitus at his age and fears he may have developed it too.  On physical examination, you note a lethargic and ill-appearing boy.  His heart rate is 96/min, blood pressure is 124/84 mm Hg, temperature is 36.8°C (98.2°F), and respiratory rate is 28/min. You decide to admit the child for evaluation and monitoring. Over the next two days, the patient has recurrent episodes of hypoglycemia, with fingerstick glucose levels as low as 33 mg/dL. Both episodes occur at night, with the mother alerting the nurses each time. Further investigation reveals a serum insulin level of 2344 µU/mL (5–25 µU/mL) and a C-peptide level of 0.9 ng/mL (0.8–4.0 ng/mL). Which of the following is a possible explanation of the boy’s hypoglycemia?
|Prompt=A 7-year-old boy is brought to the pediatrics clinic for fever of 39 °C (102.2 °F), cough, and wheezing for the past week. Over the last 24 hours, the child has developed nausea, vomiting, and watery diarrhea.  The child's past medical history is significant for neurofibromatosis, asthma, and seizure disorder.  He is currently taking daily albuterol and valproic acid. His mother explains that she was diagnosed with insulin-dependent diabetes mellitus at his age and fears he may have developed it too.  On physical examination, you note a lethargic and ill-appearing boy.  His heart rate is 96/min, blood pressure is 124/84 mm Hg, temperature is 36.8°C (98.2°F), and respiratory rate is 28/min. You decide to admit the child for evaluation and monitoring. Over the next two days, the patient has recurrent episodes of hypoglycemia, with fingerstick glucose levels as low as 33 mg/dL. Both episodes occur at night, with the mother alerting the nurses each time. Further investigation reveals a serum insulin level of 2344 µU/mL (5–25 µU/mL) and a C-peptide level of 0.7 ng/mL (0.8–4.0 ng/mL). What is the most likely diagnosis in this patient?
|Explanation=[[Munchausen syndrome by proxy]] is a behavioral pattern in which a caregiver deliberately exaggerates, fabricates, and/or induces physical, psychological, behavioral, and/or mental health problems in those who are in their care. In this vignette, the child was been injected insulin as demonstrated by the markedly elevated plasma insulin level despite a normal serum C-peptide level, and the mother was most likely responsible. 
|AnswerA=Insulinoma
 
|AnswerB=Sulfonylurea intake
Munchausen syndrome by proxy should be suspected in the following scenarios:
|AnswerC=Exogenous insulin administration
* Persistent or recurrent illness that cannot be explained
|AnswerD=Type 1 diabetes mellitus
* Discrepancies between clinical findings and history
|AnswerE=Adrenal insufficiency
* Symptoms that occur only when the mother (or suspected perpetrator) is present
|RightAnswer=C
* Symptoms or treatment course that is not clinically consistent
* A working diagnosis that is less plausible than Munchausen syndrome by proxy
* A mother who welcomes even painful medical tests for her child, is constantly at the bedside, and has previous medical experience, yet seems less concerned than the medical staff about the health of her child
* Family history of sudden or unexplained infant death
|AnswerA=Malingering
|AnswerB=Munchausen’s syndrome by proxy
|AnswerBExp=This happens when illness in a child is caused by a caregiver.
|AnswerC=Insulinoma
|AnswerE=Type 1 Diabetes Mellitus
|RightAnswer=B
|WBRKeyword=Munchausen syndrome by proxy, malingering, insulinoma, insulin, hypoglycemia, diabetes, c-peptide
|Approved=No
|Approved=No
}}
}}

Revision as of 14:58, 15 September 2014
Author [[PageAuthor::Ayokunle Olubaniyi, M.B,B.S [1]]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Behavioral Science/Psychiatry
Sub Category SubCategory::Endocrine
Prompt [[Prompt::A 7-year-old boy is brought to the pediatrics clinic for fever of 39 °C (102.2 °F), cough, and wheezing for the past week. Over the last 24 hours, the child has developed nausea, vomiting, and watery diarrhea. The child's past medical history is significant for neurofibromatosis, asthma, and seizure disorder. He is currently taking daily albuterol and valproic acid. His mother explains that she was diagnosed with insulin-dependent diabetes mellitus at his age and fears he may have developed it too. On physical examination, you note a lethargic and ill-appearing boy. His heart rate is 96/min, blood pressure is 124/84 mm Hg, temperature is 36.8°C (98.2°F), and respiratory rate is 28/min. You decide to admit the child for evaluation and monitoring. Over the next two days, the patient has recurrent episodes of hypoglycemia, with fingerstick glucose levels as low as 33 mg/dL. Both episodes occur at night, with the mother alerting the nurses each time. Further investigation reveals a serum insulin level of 2344 µU/mL (5–25 µU/mL) and a C-peptide level of 0.7 ng/mL (0.8–4.0 ng/mL). What is the most likely diagnosis in this patient?]]
Answer A AnswerA::Insulinoma
Answer A Explanation AnswerAExp::
Answer B AnswerB::Sulfonylurea intake
Answer B Explanation AnswerBExp::
Answer C AnswerC::Exogenous insulin administration
Answer C Explanation AnswerCExp::
Answer D AnswerD::Type 1 diabetes mellitus
Answer D Explanation AnswerDExp::
Answer E AnswerE::Adrenal insufficiency
Answer E Explanation AnswerEExp::
Right Answer RightAnswer::C
Explanation [[Explanation::

Educational Objective:
References: ]]

Approved Approved::No
Keyword
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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