Question

Difficulty: HardSomatic Symptom and Eating Disorders

An attending physician is evaluating a 31-year-old female patient admitted to the telemetry unit for investigation of recurrent, severe hypoglycemic episodes. The patient, who works as a neonatal intensive care nurse at another facility, has had three syncopal events accompanied by diaphoresis over the past month. During the current admission, a fasting laboratory workup during a symptomatic episode (blood glucose of 38 mg/dL38 \text{ mg/dL}) reveals a serum insulin level of 72 \muU/mL72 \text{ \mu U/mL} (normal: <10 \muU/mL< 10 \text{ \mu U/mL}) and a C-peptide level of 0.1 ng/mL0.1 \text{ ng/mL} (normal: 0.5−2.0 ng/mL0.5 - 2.0 \text{ ng/mL}). A plasma sulfonylurea screen is negative. Later that evening, the nursing staff discovers several used insulin syringes and empty vials of short-acting insulin concealed inside the lining of the patient's cosmetic bag. The patient has no documented history of diabetes mellitus and is currently resting comfortably in her room.

Which of the following is the most appropriate next step in the management of this patient?

  1. Confront the patient regarding the hidden insulin in a supportive, nonjudgmental mannerAnswer
  2. B
    Breach confidentiality by immediately notifying her employer that she is unfit to practice
  3. C
    Diagnose schizophreniform disorder based on her one-month history of self-harming behavior
  4. D
    Bypass her documented healthcare proxy and ask her next-of-kin for consent to initiate treatment
  5. E
    Submit a punitive disciplinary report against the admitting nurse for failing to search the patient's belongings

Answer

Confront the patient regarding the hidden insulin in a supportive, nonjudgmental manner
The patient's laboratory results (high insulin, low C-peptide, negative sulfonylurea screen) confirm exogenous insulin administration. Combined with the discovery of concealed syringes and her background in healthcare, this strongly suggests Factitious Disorder (previously Munchausen syndrome). The primary goal in managing factitious disorder is to prevent further unnecessary and potentially dangerous medical interventions while offering psychiatric help. The most appropriate next step is a supportive, non-punitive confrontation, ideally led by the primary attending physician. Confronting the patient angrily or punitively typically leads to denial, hostility, and the patient leaving against medical advice, only to repeat the behavior at another hospital.

Step-by-Step Solution

1
Analyze the laboratory data to determine the cause of hypoglycemia.
High insulin with low C-peptide and a negative sulfonylurea screen indicates exogenous insulin administration.
Endogenous insulin production (like an insulinoma) would elevate both insulin and C-peptide. Exogenous insulin suppresses endogenous production, leading to low C-peptide.
2
Synthesize the lab findings with the discovery of concealed insulin and the patient's background.
The patient is consciously inducing her symptoms. Given her medical background and lack of obvious secondary gain, this points to Factitious Disorder.
Factitious disorder (Munchausen syndrome) involves the intentional production of symptoms to assume the sick role (primary gain).
3
Determine the optimal ethical and clinical management strategy.
The recommended management is a non-punitive, supportive confrontation.
A supportive approach reduces the risk of the patient eloping against medical advice and increases the chance she will accept psychiatric intervention.

Key Concept

Diagnosis and management of Factitious Disorder
Estimated Time:1m 30s
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