Subjective

Chief Complaint: An 18-year old woman comes to the office due to concerns for hair
loss, feeling cold all the time, and worsening right leg pain. She also complains her
“stomach looks huge.”
Past Medical History: Acne Vulgaris
Medications: Topical retinoids
Allergies: N/A
Tobacco/Alcohol/Substances: N/A
Family history: Graves disease (mom), Sjogren syndrome (maternal grandma)
Social history: High school senior, runs 8 miles a day, diet consists exclusively of
fruits and veggies. Has been following this regimen for 10 months.
Review of Systems: anxiety, bloating, constipation, fatigue, irritability, irregular
menstruation
Objective – Vitals
Vitals
 Height: 5’ 6”
 Weight: 105 lb
 BMI: 17

 Temperature: 97.2° F
 BP: 90/60 mm Hg
 Pulse: 56/min
 Respirations: 16/min
Objective – Physical Exam

General: mildly anxious female in distress, thin habitus

Heart: regular, no murmurs, S3 or S4
Lungs: clear to auscultation bilaterally
Dermatological: dry skin, generalized thinning of hair
Gastrointestinal: distended abdomen, hypoactive bowel
sounds
Musculoskeletal: Tenderness of right lower tibia
Neurological: Alert & Oriented x 3
Objective – Labs
Complete Blood Count Endocrine
• TSH = 0.6 μU/mL
 Hemoglobin = 11.4 g/dL
• Thyroxine (T4) serum = 6.0 μg/dL
 Platelets = 260,000/mm^3 • Triiodothyronine (T3) serum = 132 ng/dL
 Leukocytes = 8,200 mm^3
Urine hCG = negative
Serum Chemistry
 Sodium = 132 mEq/L Liver Enzymes
• ALT = 50 U/L
 Potassium = 2.9 mEq/L
• AST = 15 U/L
 Chloride = 90 mEq/L • GGT = 8 U/L
 Blood Urea Nitrogen = 14 mg/dL • Total bilirubin = 0.1 mg/dL
 Creatinine = 0.6 mg/dL
Urine Drug Screen = negative
 Calcium = 8 mg/dL
 Glucose = 78 mg/dL
 Magnesium = 1.7 mg/dL
 Phosphorus = 2.0 mg/dL
Assessment: Differential
Anorexia Nervosa
Bulimia nervosa
Binge Eating Disorder
Avoidant-restrictive food intake disorder
OCD
Depression
Hyperthyroidism
Hypothyroidism
Neoplasm
Infection
Autoimmune
Anorexia
Nervosa
Prevalence
 Females > Boys (10:1)
 Peak age: 10-25 years of age

Etiology
Genetic Factors: Higher concordance of anorexia in identical twins than in fraternal twins
Psychiatric: associated with OCD, anxiety disorders, and mood disorders
Psychosocial factors: trauma, high-pressure careers and sports, unrealistic beauty
standards
Neurobiological: disorder of the endogenous reward system
 DSM-5 Diagnostic Criteria for Anorexia Nervosa
A. Restriction of energy intake relative to
requirements, leading to a significantly low
body weight in the context of age, sex,
developmental trajectory, and physical
health. Significantly low weight is defined
as a weight that is less than minimally
normal or, for children and adolescents,
less than that minimally expected.
B. Intense fear of gaining weight or of
becoming fat, or persistent behavior that
interferes with weight gain, even though at
a significantly low weight.
C. Disturbance in the way in which one's
body weight or shape is experienced,
undue influence of body weight or shape
on self-evaluation, or persistent lack of
recognition of the seriousness of the
current low body weight.
Types
Subtypes:
 Restricting type
 Binge-eating/purging type
Severity
 Mild: BMI  ≥ 17 kg/m2
 Moderate: BMI 16–16.99 kg/m2
 Severe: BMI 15–15.99 kg/m2
 Extreme: BMI < 15 kg/m2
 Initial Evaluation
Assessment:
 Obtain height and weight at each visit
 Measure height without shoes.
 Weigh patients wearing gowns.
 Ask the patient to void before weighing
Routine Laboratory Tests
 EKG
 CBC with diff
 TSH
 Na+, K, Cl, CO2, glucose, calcium, magnesium,
phosphorous, BUN, creatinine
 Urine drug screen
 Pregnancy test
Screening
Screening
1) Do you make yourself sick because you feel uncomfortably full? No

2) Do you worry you have lost control over how much you eat? Yes; that’s why she’s running 8 miles
a day and eating just fruits/veggies

3) Have you recently lost more than 14 lb in a three-month period? No

4) Do you believe yourself to be fat when others say you’re too thin? Yes; she feels fat

5) Would you say that food dominates your life? Yes; she’s been trying to have a healthy diet and
exercise regimen because of it
Clinical Presentation
 Plan/Treatment
 Psychotherapy (first-line)
 CBT, Psychodynamic psychotherapy
 Nutritional Support
 Medications: SSRIs, Antipsychotics
 Indications for Hospitalization
 BMI < 15 kg/m2
 Unstable vital signs (<96 degree F, <40
bpm, hypotension, arrhythmia,
hypoglycemia, marked dehydration)
 Treatment Complication → Refeeding
Syndrome
Prognosis

 50% fully recover

 30% partially recover
 20% remain chronically ill
 Highest mortality rate of any
mental health disorder
Sources

 https://www.upmc.com/services/behavioral-health/eating-disorders/for-pro
fessionals/assessment-guidelines
 https://www.aafp.org/afp/2015/0101/p46.html#sec-4
 https://next.amboss.com/us/article/GP0BTT#Zbe6ef6ee1ef700ad4a85bb34b6
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