A patient presents three days after suddenly stopping diazepam after having taken it for over two years. He feels generally unwell.
Which one of the following features would suggest a diagnosis other than benzodiazepine withdrawal syndrome?
Correct Answer A: Hypothermia is not a feature of benzodiazepine withdrawal syndrome.
Benzodiazepines:
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). They therefore are used for a variety of purposes:
Patients commonly develop a tolerance and dependence to benzodiazepines and care should therefore be exercised on prescribing these drugs. The Committee on Safety of Medicines advises that benzodiazepines are only prescribed for a short period of time (2-4 weeks).
The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given:
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include:
Psychic structure that relates desire to external environment is:
Correct Answer B:
In Sigmund Freud’s psychoanalytic theory of personality, personality is composed of three elements known as the id, the ego, and the superego, that work together to create complex human behaviors.
The ‘id’ is the only component of personality that is present from birth. This aspect of personality is entirely unconscious and includes of the instinctive and primitive behaviors.
The ‘ego’ operates based on the reality principle, which strives to satisfy the id's desires in realistic and socially appropriate ways.
The ‘superego’ is the aspect of personality that holds all of our internalized moral standards and ideals that we acquire from both parents and society, our sense of right and wrong.
A 48-year-old female nurse was recently admitted for evaluation of recurrent skin infections and sepsis. On review of her medical records, she has been treated for a non-healing abscess on her left forearm as well as her right calf. The medical staff has been particularly suspicious of her recurring infections and noted that she has missed many days of work as a result of needed hospitalizations. Nursing staff later uncovered a syringe that was concealed by the patient in her personal belongings. It was suspected that the patient has been injecting foreign material under the surface of her skin.
Which of the following statements is true about a patient with factitious disorder?
Correct Answer C:
Factitious disorder is characterized by intentional production or feigning of physical or psychological symptoms of a medical condition. Motivation for the behavior is to assume the sick role.
→ Symptoms that are not intentionally produced by a patient (choice A) to assume the sick role would be more characteristic of a somatoform disorder.
→ A patient with factitious disorder is more often demanding and disruptive with medical staff (choice B). These individuals will often dispute lab results and sign out against medical advice when confronted with a negative medical workup.
→ External incentives such as avoiding legal obligations, responsibilities, or just seeking a room for the night are absent in factitious disorder (choice E). Malingering would be the proper term for this behavior.
A 40 year old male is brought to the emergency department in a confused state.
His past medical history is unremarkable. He is not taking any medications. He is complaining of severe, weakness and lightheadedness that began an hour ago.
A STAT glucometer reveals a value of 2.5 mmol/L. The patient improved dramatically upon Dextrose 50% infusion. After careful history and physical exam, you ordered some lab tests that return abnormal for an elevated insulin levels and decreased C-Peptide.
Which of the following is the most likely diagnosis?
Our patient has classic symptoms of hypoglycemia (confusion, weakness, lightheadedness…), documented by lab test, then improved dramatically with glucose administration (Whipple’s triad).
This patient is likely injecting insulin surreptitiously for a primary gain (factitious disorder or Munchausen syndrome). The exogenous industrial insulin is purified and does not have the C-peptide as a component; thus in a person who is injecting insulin, expect low glucose, high insulin and low C-peptide.
Insulinoma would give high levels of both insulin and C-peptide (endogenous insulin).
Sulphonylurea drugs make the Beta cells of the pancreas secrete insulin thus the lab tests will be similar to insulinoma; a urine toxicology screen for sulphonylurea drugs will clench the diagnosis.
Glucagonoma presents with hyperglycemia and a characteristic rash (Necrolytic migratory erythema). Chronic pancreatitis may present with hyperglycemia and diabetes because of insulin deficiency.
Please remember that the C-peptide is an endogenous substance which is not present in pharmaceutical insulin and you will answer all the tricky questions around this issue correct.
A 25-year-old female comes to your clinic with the complaint of heat intolerance. The symptoms started three weeks ago. She also complains of weight loss, increased appetite and occasional palpitations. Her vital signs are significant for a pulse of 110/min and a BP of 150/60 mmHg.
On physical exam, her thyroid gland is normal in size. You order a thyroid workup which reveals low TSH, high T4, high T3, minimal uptake on radioactive iodine scan and undetectable thyroglobulin levels. Based on the described scenario, which of the following is the most likely diagnosis?
The patient is most likely ingesting thyroid medications surreptitiously. The symptoms and thyroid function tests point to hyperthyroidism however the low uptake scan with the low thyroglobulin level denotes an exogenous source of the thyroid hormones. Patients with factitious disorder (choice B) deliberately create or exaggerate symptoms of an illness in several ways. They may lie about or mimic symptoms, hurt themselves to bring on symptoms, or alter diagnostic tests (such as contaminating a urine sample). People with factitious disorders seek internal, primary (psychological) gain.
→ Subacute thyroiditis (choice A) may give thyrotoxic symptoms initially due to the inflamed follicles releasing thyroid hormones; however, the thyroglobulin levels would be very high.
→ Grave’s disease (choice C) would give a diffusely enlarged thyroid with a diffuse high uptake scan of the thyroid.
→ Hypothyroidism (choice D) is neither suggested clinically nor by lab tests.
→ Toxic multinodular goiter (choice E) would give a big nodular thyroid along with hot toxic nodules on the iodine uptake scan.
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