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nbme24/Block 3/Question#21 (21.4 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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-cptpeedi si wol wiht ousoegnex lisi.unn etdcepi-p( mead as a cydprbuot fo nnlisiu podtcriuon ni eth eyeddo tpebr)a +siivst hihg liiwousnn+l e-etpdi=pc usxegnoeo linunsi aesu.b nI a &ligd-ch;t utcsaofiit by yxrop

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(22),

For those who were wondering like me, they gave the Beta-hydroxybutyrate (a ketone body) levels in order to rule out DKA (diabetic ketoacidosis) in a type 1 diabetics and which would otherwise not be distinguishable based only on C-peptide and insulin levels

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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nCa nseooem ipnelax shti nI–o–e 'tndid lleray nowk thwa ot aekm fo the alb ulvesa. raCeyll seh was aikngt oto mhcu n,lsniiu ubt ohw can uoy nteafidritefe taisutcoif dersdroi mrof a ptey 1 cdatibei how kstae too muhc of erith lnnusii ods?e

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. +19  
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