A 28-year-old woman is brought to the emergency department after passing out at work. The patient was diagnosed with type 2 diabetes a year and a half ago with a hemoglobin A1c of 8.2%. She was started on metformin at that time; however, within 2 months the medication was discontinued due to intolerable gastrointestinal side effects. The patient was then switched to glipizide, achieving good glycemic control within 3 months. However, approximately 6 months ago the patient began experiencing hypoglycemic episodes with associated dizziness and decreased level of consciousness. The glipizide dose was decreased, but she continued to report hypoglycemic episodes. The patient's primary care physician recommended that she switch to a different antidiabetic agent, but the patient preferred to continue glipizide. Over the previous 6 months, the patient has been seen in the emergency department on numerous occasions and has been hospitalized once. Her most recent hemoglobin A1c 2 weeks ago was 8.1%. Currently, the patient's only medication is glipizide, which she insists she is taking as prescribed.
Supine blood pressure is 122/83 mm Hg and pulse is 62/min. After 5 minutes of standing, blood pressure is 117/79 mm Hg and pulse is 71/min. The patient is currently drinking apple juice, chatting cheerfully with the nurse, and in no apparent distress. Physical examination is within normal limits.
Laboratory results drawn prior to any intervention are as follows:
Which of the following is the most likely explanation for this patient's symptoms?

Question

A 28-year-old woman is brought to the emergency department after passing out at work.  The patient was diagnosed with type 2 diabetes a year and a half ago with a hemoglobin A1c of 8.2%.  She was started on metformin at that time; however, within 2 months the medication was discontinued due to intolerable gastrointestinal side effects.  The patient was then switched to glipizide, achieving good glycemic control within 3 months.  However, approximately 6 months ago the patient began experiencing hypoglycemic episodes with associated dizziness and decreased level of consciousness.  The glipizide dose was decreased, but she continued to report hypoglycemic episodes.  The patient's primary care physician recommended that she switch to a different antidiabetic agent, but the patient preferred to continue glipizide.  Over the previous 6 months, the patient has been seen in the emergency department on numerous occasions and has been hospitalized once.  Her most recent hemoglobin A1c 2 weeks ago was 8.1%.  Currently, the patient's only medication is glipizide, which she insists she is taking as prescribed.
Supine blood pressure is 122/83 mm Hg and pulse is 62/min.  After 5 minutes of standing, blood pressure is 117/79 mm Hg and pulse is 71/min.  The patient is currently drinking apple juice, chatting cheerfully with the nurse, and in no apparent distress.  Physical examination is within normal limits.
Laboratory results drawn prior to any intervention are as follows:
 Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

This patient's history of repeated, unexplained hypoglycemic events in the context of a sustained hemoglobin A1c >8% despite treatment should raise suspicion of factitious disorder. Patients with factitious disorder deliberately falsify or manipulate their own medical condition to appear ill for purposes of assuming the sick role. This is in contrast to malingering, in which patients intentionally falsify their medical condition for external rewards (eg, to obtain disability pay or drugs) (Choice D). Additional clues that this patient is intentionally misusing her medication to manipulate her glucose levels include her frequent emergency department visits, atypical course of illness with inconsistent or poor response to standard treatments (eg, initially responds then destabilizes; unresponsiveness to glipizide dose reduction), resistance to changing her antidiabetic agent, and an upbeat, incongruent mood in the emergency department. Factitious disorder is a diagnosis of exclusion, and alternative explanations for a patient's symptoms must be explored and ruled out prior to a definitive diagnosis. This patient's history is consistent with factitious disorder with oral hypoglycemic agents. Management includes compassionate feedback about the clinical findings and psychotherapy referral if the patient is receptive. (Choice A) Although adrenal insufficiency may be associated with hypoglycemia, the patient's presentation, laboratory findings (normal sodium and potassium levels), and physician examination (no orthostatic hypotension, no hyperpigmentation to suggest primary adrenal insufficiency) make this diagnosis less likely and are more consistent with a diagnosis of factitious disorder. (Choice B) Brittle diabetes mellitus is rare in type 2 diabetics. The patient's presentation is better explained by factitious disorder. (Choice E) Somatic symptom disorder and factitious disorder can both manifest with excessive preoccupation with somatic symptoms and treatment seeking. However, in somatic symptom disorder, patients are not consciously falsifying their illness. Educational objective: Factitious disorder involves the intentional falsification of symptoms for the purpose of assuming the sick role. It should be suspected in patients with inconsistencies in their history, examination, and laboratory tests and poor response to standard treatments. __________ References: Factitious disorders and malingering: challenges for clinical assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/24612861) Spontaneous hypoglycemia: diagnostic evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/26951054)

A 28-Year-Old Woman Is Brought to the Emergency Department After