544 Emergency Medicine
are not thought to produce psychiatric symptoms. Calcium-channel blockers
(e)and NSAIDs (d)have not shown to cause psychosis.
494.The answer is b.(Rosen, pp 1549-1583.)This is a typical manic episode
of which an elevated mood, grandiosity, flight of ideas, distractibility, and
psychomotor agitation are its cardinal features. Other medical conditions,
such as hyperthyroidism, antidepressant, or stimulant abuse may cause similar
symptoms and must be ruled out with laboratory testing. Certain frontal lobe
release syndromes that impair executive functioning must also be investigated
as a cause of this patient’s symptoms. These patients are usuallycombative, display
impaired judgment and impulsivity, and may need to be chemically or physically
restrained.
Hypothyroid disorder (a), benzodiazepines (c), anticonvulsants (d),
and barbiturates (e)may all cause depressive symptoms.
495.The answer is d.(Rosen, pp 1549-1583.)Given that this is an apparent
illness or health-related abnormality produced by a parent or caregiver upon
another, the by proxytitle is given. This is a psychiatric illness defined by the
Diagnostic and Statistical Manual of Mental Disorders(Fourth Edition) (DSM-IV)
as an apparent illness concocted by a caregiver upon a child who presents
for medical aid multiple times without ever being given a true diagnosis.
There is a failure by the perpetrator to acknowledge the true etiology and a
cessation of symptoms in the child once they are separated from the perpe-
trator. Simulated illness, without producing direct harm upon the child, is
commonly seen. As seen in this example, placing tincture in the child’s
urine to mimic blood. Sadly, produced illness in which the child is harmed
is most commonly seen (50% of cases). The most common presentations
include bleeding, seizures, vomiting, diarrhea, fever, and rash. Ninety-eight
percent of perpetrators are biologic mothers from all socioeconomic back-
grounds. Many have a background in health professions or have features of
Munchausen syndromein themselves. Most of these mothers have had an
abusive experience early in life and use the health-care system as a means
to satisfy personal nurturing demands. They are said to gain a sense of purpose
and meaning when their child is in the hospital, as well as an outlet for pity
and comfort. These children may display incidental characteristics that cannot
be linked to the presenting complaints. These children may also suffer from
learning difficulties or clinical depression caused by many hospitalizations
that are incurred upon them.
Malingering(a)is frequently found in connection with antisocial per-
sonalitydisorder. These patients are often vague about prior hospitalizations