Anorexia Nervosa


Article Author:
Christine Moore


Article Editor:
Brooke Bokor


Editors In Chief:
Rodrigo Kuljis
Oleg Chernyshev
Aninda Acharya


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
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Saad Nazir
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James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/14/2019 12:49:05 PM

Introduction

Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image with the inability to recognize the seriousness of their significantly low body weight.[1][2][3]

Etiology

The success of many professions depends on a person's weight. Models and actors portray a level of thinness that is difficult to attain, and it enhanced by make-up and photographic alterations. Athletes in sports such as ballet, long-distance running, and martial arts are pressured to maintain lean body weights to outperform the competition. Media outlets promote diet secrets and weight loss tips in excess. Populations such as maturing females identify thin body types with increased self-esteem and link weight loss with self-control.[4][5]

Epidemiology

Anorexia nervosa is more common in females than males. Onset is late adolescence and early adulthood. Lifetime prevalence is 0.3% to 1% (European studies have demonstrated the prevalence of 2% to 4%), irrespective of culture, ethnicity, and race. Risk factors for eating disorders include childhood obesity, female sex, mood disorders, personality traits (impulsivity and perfectionism), sexual abuse, or weight-related concerns from family or peer environments.[6][7][8]

Pathophysiology

Studies demonstrate biologic factors play a role in the development of anorexia nervosa in addition to environmental factors. Genetic correlations exist between educational attainment, neuroticism, and schizophrenia. Patients with anorexia nervosa have altered brain function and structure there are deficits in neurotransmitters dopamine (eating behavior and reward) and serotonin (impulse control and neuroticism), differential activation of the corticolimbic system (appetite and fear), and diminished activity among the frontostriatal circuits (habitual behaviors). Patients have co-morbid psychiatric disorders such as major depressive disorder and generalized anxiety disorder.

History and Physical

Patients will report symptoms such as amenorrhea, cold intolerance, constipation, extremity edema, fatigue, and irritability. They may describe restrictive behaviors related to food like calorie counting or portion control, and purging methods, for example, self-induced vomiting or use of diuretics or laxatives. Many exercise compulsively for extended periods of time. Patients with anorexia nervosa develop multiple complications related to prolonged starvation and purging behaviors.

Evaluation

Work-up includes a thorough medical history (comprehensive review of systems, family and social history, medications including nonprescribed, past medical and psychiatric history, prior abuse) and physical exam (looking for complications above). Basic labs include coagulation panel, complete blood count, complete metabolic profile, 25-hydroxyvitamin D, testosterone (males), thyroid-stimulating hormone, and urine testing (beta-hCG [females] and drugs, either illicit or prescription). An electrocardiogram is recommended to assess for life-threatening arrhythmias. Additional studies may be necessary if BMI less than 14 kg/m, for example, echocardiogram in patients with hemodynamic compromise (dyspnea, murmurs, syncope) or computed tomography of the abdomen to rule out superior mesenteric artery syndrome or amenorrhea more than 9 months (dual-energy x-ray absorptiometry).[9][8]

Complications of anorexia nervosa are listed:

  • Cardiovascular: bradycardia, dilated cardiomyopathy, electrolyte-induced arrhythmias, hypotension, mitral valve prolapse, pericardial effusion
  • Constitutional: arrested growth, hypothermia, low body mass index (BMI), muscle wasting
  • Dermatologic: carotenoderma, lanugo, xerosis
  • Endocrine: hypothalamic hypogonadism, osteoporosis
  • Gastrointestinal: constipation (laxative abuse), gastroparesis
  • Hematologic: cytopenias (inc. normocytic anemia), bone marrow hypoplasia/aplasia
  • Neurologic: brain atrophy, peripheral neuropathy (mineral and vitamin deficiencies)
  • Obstetric: antenatal and postnatal complications
  • Psychiatric: depression, impaired concentration, insomnia, irritability
  • Renal and electrolytes: hypokalemic metabolic acidosis or alkalosis (laxative or diuretic abuse, resp.), prerenal renal failure, refeeding syndrome.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides the diagnostic criteria for anorexia nervosa (A-C). It classifies the disease by type, status, and severity.

Of note, amenorrhea has been removed from the DSM-5 criteria. Patients who meet the new criteria and continue to menstruate have similar outcomes as those who do not.

Other eating disorders have similar features to anorexia nervosa. Avoidant or restrictive food intake disorder involves food restriction with failure to meet the nutritional need. While patients are often underweight, this disturbance does not meet diagnostic criteria for anorexia nervosa. Individuals with binge eating disorder eat excessive amounts of calories in a short period with a lack of self-control but do not display compensatory behaviors such as purging or restriction. Patients with bulimia nervosa will binge and purge without a corresponding low BMI. Pica refers to chronic ingestion of nonfood substances and may be a manifestation of underlying medical or psychiatric condition. For example, patients with anorexia nervosa may eat toilet paper when they are hungry. Rumination disorder occurs when patients repeatedly regurgitate food for one month when no other medical condition can be identified and does not occur solely during the course of another eating disorder. Other specified feeding or eating disorder refers to conditions with symptoms that impair functioning but do not meet criteria for a specific eating disorder, for example, patients who meet criteria for anorexia nervosa but have BMI more than 18.5 kg/m are classified as “atypical anorexia nervosa.”

Major depressive disorder can cause anorexia and weight loss. However, patients are not obsessed with body habitus. Patients with obsessive-compulsive disorder may have food rituals but maintain a normal weight. Patients who abuse stimulants such as cocaine and methamphetamine experience weight loss through increased metabolism and concentrated efforts to obtain illicit substances rather than consume calories.

Medical conditions can cause weight loss. Examples are celiac disease, hyperthyroidism, inflammatory bowel disease, malignancy, poorly controlled diabetes mellitus, primary adrenal insufficiency, and tuberculosis. The diagnosis will come from the history and physical examination. Order labs as dictated by the clinical picture.

Treatment / Management

Treatment for anorexia nervosa is centered on nutrition rehabilitation and psychotherapy. Patients who need inpatient treatment have the following characteristics:

  • Existing psychiatric disorders requiring hospitalization
  • High risk for suicide (intent with highly lethal plan or failed attempt)
  • Lack of support system (severe family conflict or homelessness)
  • Limited access (lives too far away to participate in a daily treatment program)
  • Medically unstable (bradycardia, dehydration, hypoglycemia or poorly controlled diabetes, hypokalemia or other electrolyte imbalances indicative of refeeding syndrome, hypothermia, hypotension, organ compromise requiring acute treatment)
  • Poorly motivated to recover (uncooperative, preoccupied with intrusive thoughts)
  • Purging behaviors that are persistent, severe, and occur multiple times a day
  • Severe anorexia nervosa (less than 70% of ideal body weight or acute weight loss with food refusal)
  • Supervised feeding and/or specialized feeding (nasogastric tube) required
  • Unable to stop compulsively exercising (not a sole indication for hospitalization).

Outpatient treatment includes intensive therapy (2 to 3 hours per weekday) and partial hospitalization (6 hours per day). Pediatric patients benefit from family-based psychotherapy to explore underlying dynamics and restructure the home environment.

Refeeding syndrome can occur following prolonged starvation. As the body utilizes glucose to produce molecules of adenosine triphosphate (ATP), it depletes the remaining stores of phosphorus. Also, glucose entry into cells is mediated by insulin and occurs rapidly following long periods without food. Both cause electrolyte abnormalities such as hypophosphatemia and hypokalemia, triggering cardiac and respiratory compromise. Patients should be followed carefully for signs of refeeding syndrome and electrolytes closely monitored.

Pharmacotherapy is not used initially. For acutely ill patients who do not respond to initial treatment, olanzapine is a first-line medication. Other antipsychotics have not demonstrated similar effects on weight gain. For patients who are not acutely ill but have co-morbid psychiatric conditions such as generalized anxiety disorder or major depressive disorder, combination therapy with selective serotonin reuptake inhibitors (SSRIs) and therapy is best. Patients who do not respond to SSRIs may need a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are less-preferred due to concerns about cardiotoxicity, especially in malnourished patients. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures.[10][11][12]

Differential Diagnosis

  • Cancer
  • Chronic mesenteric ischemia
  • Achalasia
  • Malabsorption
  • Hyperthyroidism
  • Irritable bowel syndrome
  • Celiac disease

Prognosis

Remission in AN varies. Three-fourths of patients treated in out-patient settings remit within 5 years and the same percentage experience intermediate-good outcomes (including weight gain). Relapse is more common in patients who are older with longer duration of disease or lower body fat/weight at the end of treatment, have co-morbid psychiatric disorders, or receive therapy outside of a specialized clinic. Patients who achieve partial remission often develop another form of eating disorder (ex. bulimia nervosa or unspecified eating disorder).

All-cause mortality is greater in AN compared to the rest of the population. It has one of the highest mortality rates of all eating disorders due to medical complications, substance abuse, and suicide. Patients with AN have increased rates of suicide and this accounts for 25% of deaths associated.

Complications

  • Amenorrhea
  • Delayed puberty
  • Hypercarotenemia
  • Hypothermia
  • Hypoglycemia
  • Osteoporosis
  • Failure to thrive 
  • Cardiomyopathy
  • Bradycardia
  • Arrhythmias
  • Renal failure
  • Constipation
  • Peripheral neuropathy
  • Pancytopenia
  • Infertility

Deterrence and Patient Education

Anorexia nervosa is a psychiatric disease in which patients restrict their food intake relative to their energy requirements through eating less, exercising more, and/or purging food through laxatives and vomiting. Despite being severely underweight, they do not recognize it and have distorted body images. They can develop complications from being underweight and purging food. Diagnose by history, physical, and lab work that rules out other conditions that can make people lose weight. Treatment includes gain weight (sometimes in a hospital if severe), therapy to address body image, and management of complications from malnourishment.

Enhancing Healthcare Team Outcomes

Anorexia nervosa is a serious eating disorder which has a very high morbidity. The disorder is usually managed with an interprofessional team that consists of a psychiatrist, dietitian, social worker, internist, endocrinologist, gastroenterologist and nurses.  The disorder cannot be prevented and there is no cure. Hence patient and family education is key to preventing the high morbidity. The dietitian should educate the family on the importance of nutrition and limiting exercise. The mental health nurse should educate the patient on changes in behavior, easing stress and overcoming any emotional issues. The pharmacist should educate the patient and family on abuse of drugs like laxatives and weight loss pills. Only through close follow up and monitoring can patient outcomes be improved. [13][14](Level V)

Evidence-based Outcomes

Remission in anorexia nervosa varies. Three-fourths of patients treated in out-patient settings remit within five years and the same percentage experience intermediate-good outcomes, including weight gain. Relapse is more common in patients who are older with longer duration of disease or lower body fat/weight at the end of treatment, have co-morbid psychiatric disorders, or receive therapy outside of a specialized clinic. Often, patients who achieve partial remission develop another form of the eating disorder like bulimia nervosa or unspecified eating disorder.

All-cause mortality is greater in anorexia nervosa compared to the rest of the population. It has one of the highest mortality rates of all eating disorders due to medical complications, substance abuse, and suicide. Patients with anorexia nervosa have increased rates of suicide, and this accounts for 25% of deaths associated with the disorder. [15][16][9](Level V)


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    Contributed by Christine Moore, D.O.
Attributed To: Contributed by Christine Moore, D.O.

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Anorexia Nervosa - Questions

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A nutritional consult is obtained for a patient with anorexia nervosa. She has been eating 120 g of carbohydrates, 20 g of protein, and 15 g of fat a day. What is her estimated caloric intake?



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A 16 year-old female is evaluated for amenorrhea of 5 months duration. Review of systems is positive for cold intolerance, dizziness, exertional dyspnea, and fatigue. Past medical history is unremarkable. She takes no medications and denies use of alcohol, illicit drugs, or tobacco. The patient is in her first year of college and is active on the cross country and track teams; she reports stress from her coarse load and trying to lose weight in order to run faster. She is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 84/52 mmHg, pulse rate is 36/min and regular, respiratory rate is 16/min, oxygen saturation is 95% on ambient air, and body mass index 16.5 kg/m2. Physical examination reveals a cachectic female in no acute distress with yellow skin hue. There is fine hair over her posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. Abdomen is scaphoid and nontender. Pelvic exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypoalbuminemia, low TSH and free T4, and macrocytic anemia. Serum prolactin and urine beta-hCG are negative. Which of the following is the primary goal in the treatment of this patient?



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A 16-year-old female presents to her primary care provider with hair loss and amenorrhea. She is on the dance team and states she has "a fear of becoming fat." The patient denies sexual activity. Vitals are notable for blood pressure 88/58 mmHg, pulse rate 38/min, and body mass index 16.9 kg/m2. Physical examination reveals a cachectic female with hair thinning over her head and fine hair over her chest. Parotid glands are enlarged. Heart rate is slow without murmurs or skipped beats. There is thickening over her third dorsal finger. Pelvic exam is unremarkable. Labs are notable for hypokalemia and metabolic alkalosis. Urine beta-hCG is negative. What is the most likely diagnosis?



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A 16-year-old male is evaluated for fatigue of 4 months duration. Review of systems is positive for cold intolerance, decreased libido, dizziness, and exertional dyspnea. Past medical history is unremarkable. He takes no medications and denies use of alcohol, illicit drugs, or tobacco. The patient is in his first year of college and is active on the wrestling team; he reports stress from trying to lose weight in order to compete in a different weight class. He is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 82/50 mmHg, pulse rate is 34/min and regular, respiratory rate is 16/min, oxygen saturation is 96% on ambient air, and body mass index 16.8 kg/m2. Physical examination reveals a cachectic male in no acute distress with yellow skin hue and diminished skin turgor. There is fine hair over his posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. The abdomen is scaphoid and nontender. Testicular exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypokalemia, metabolic alkalosis, low TSH and free T4, and macrocytic anemia. Serum prolactin is negative. Which of the following is the best measure of clinical improvement in this patient's most likely diagnosis?



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A 16-year-old female is evaluated for amenorrhea of 5 months duration. Review of systems is positive for cold intolerance, dizziness, exertional dyspnea, and fatigue. Past medical history is unremarkable. She takes no medications and denies use of alcohol, illicit drugs, or tobacco. The patient is in her first year of college and is active on the cross country and track teams; she reports stress from her coarse load and trying to lose weight in order to run faster. She is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 84/52 mmHg, pulse rate is 36/min and regular, respiratory rate is 16/min, oxygen saturation is 95% on ambient air, and body mass index 16.5 kg/m2. Physical examination reveals a cachectic female in no acute distress with yellow skin hue. There is fine hair over her posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. Abdomen is scaphoid and nontender. Pelvic exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypoalbuminemia, low TSH and free T4, and macrocytic anemia. Serum prolactin and urine beta-hCG are negative. Which is an appropriate form of behavior modification required in dealing with this patient's most likely diagnosis?



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A 17-year-old female patient with a BMI of 16.5 claims she recently started taking "antacids" because her stomach hurts. What would be an appropriate way to initiate conversation with this patient?



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A 16 year-old male is evaluated for fatigue of 4 months duration. Review of systems is positive for cold intolerance, decreased libido, dizziness, and exertional dyspnea. Past medical history is unremarkable. He takes no medications and denies use of alcohol, illicit drugs, or tobacco. The patient is in his first year of college and is active on the wrestling team; he reports stress from trying to lose weight in order to compete in a different weight class. He is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 82/50 mmHg, pulse rate is 34/min and regular, respiratory rate is 16/min, oxygen saturation is 96% on ambient air, and body mass index 16.8 kg/m2. Physical examination reveals a cachectic male in no acute distress with yellow skin hue and diminished skin turgor. There is fine hair over his posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. Abdomen is scaphoid and nontender. Testicular exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypokalemia, metabolic alkalosis, low TSH and free T4, and macrocytic anemia. Serum prolactin is negative. Which is an example of an appropriate behavior modification for the most likely diagnosis?



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Which of the following differentiates anorexia nervosa from bulimia nervosa?



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A 17-year-old competitive figure skater complains of diffuse weakness, fatigue, amenorrhea, and muscle cramps. She was previously healthy and denies substance use or abuse. The patient is thin with systolic blood pressure that decreases to 80 from 104 mmHg upon standing. There are erosions of the enamel of the teeth. The rest of the exam is normal. CBC is normal. Urine hCG is negative. Creatinine is 0.7 mg/dL, bicarbonate is 28 meq/L, and potassium is 2.8 meq/L. What is the next step in evaluation?



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A 16 year-old female is evaluated for amenorrhea of 5 months duration. Review of systems is positive for cold intolerance, dizziness, exertional dyspnea, and fatigue. Past medical history is unremarkable. She takes no medications and denies use of alcohol, illicit drugs, or tobacco. The patient is in her first year of college and is active on the cross country and track teams; she reports stress from her coarse load and trying to lose weight in order to run faster. She is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 84/52 mmHg, pulse rate is 36/min and regular, respiratory rate is 16/min, oxygen saturation is 95% on ambient air, and body mass index 16.5 kg/m2. Physical examination reveals a cachectic female in no acute distress with yellow skin hue. There is fine hair over her posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. Abdomen is scaphoid and nontender. Pelvic exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Urine beta-hCG is negative. Which one of the following endocrine abnormalities are commonly associated with the most likely diagnosis?



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A 16-year-old presents with amenorrhea for 6 months and enhanced weight loss after increasing her exercise up to 4 hours per day. What is the most likely diagnosis?



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A patient with anorexia nervosa is hospitalized and seen by an occupational therapist. During the assessment, the therapist collects data about the patient's history, self-confidence, and values. Which of the following would be the best initial method?



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What is the likely diagnosis for a patient with distorted self-image, fear of weight gain, and choosing not to work toward ideal body weight?



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A 16-year-old male is evaluated by his internist for fatigue of 4 months duration. Review of systems is positive for cold intolerance, decreased libido, dizziness, and exertional dyspnea. Past medical history is unremarkable. He takes no medications and denies use of alcohol, illicit drugs, or tobacco. The patient is in his first year of college and is active on the wrestling team; he reports stress from trying to lose weight in order to compete in a different weight class. He is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 82/50 mmHg, pulse rate is 34/min and regular, respiratory rate is 16/min, oxygen saturation is 96% on ambient air, and body mass index 16.8 kg/m2. Physical examination reveals a cachectic male in no acute distress with yellow skin hue and diminished skin turgor. There is fine hair over his posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. Abdomen is scaphoid and nontender. Testicular exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypokalemia, metabolic alkalosis, low TSH and free T4, and macrocytic anemia. Serum prolactin is negative. This patient is admitted to the hospital for further evaluation and treatment. Which of the following would be the best OT activity for this patient's most likely diagnosis?



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A 20-year-old male is evaluated by his provider for fatigue of 4 months duration. Review of systems is positive for cold intolerance, decreased libido, dizziness, and exertional dyspnea. Past medical history is unremarkable. He takes no medications and denies use of alcohol, illicit drugs, or tobacco. The patient is in his first year of college and is active on the wrestling team; he reports stress from trying to lose weight in order to compete in a different weight class. He is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 82/50 mmHg, pulse rate is 34/min and regular, respiratory rate is 16/min, oxygen saturation is 96% on ambient air, and body mass index 16.8 kg/m2. Physical examination reveals a cachectic male in no acute distress with yellow skin hue and diminished skin turgor. There is fine hair over his posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. Abdomen is scaphoid and nontender. Testicular exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypokalemia, metabolic alkalosis, low TSH and free T4, and macrocytic anemia. Serum prolactin is negative. The patient is admitted to the hospital for further evaluation and treatment. Which of the following would be performance components of occupational therapy for this patient's most likely diagnosis?



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An emaciated girl is brought in by her parents. Her blood pressure is 70/50 mmHg, her heart rate is 47 beats per minute, potassium is 2.5 mEq/L, and bicarbonate is 42/L. She is a high school cheerleader and eats only small amounts of low-calorie food. She runs 2 hours every day and is under 80 percent of her ideal weight. What other behaviors must be watched for in this patient?



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A 16-year-old female is evaluated for amenorrhea of 5 months duration. Review of systems is positive for cold intolerance, dizziness, exertional dyspnea, and fatigue. Past medical history is unremarkable. She takes no medications and denies the use of alcohol, illicit drugs, or tobacco. The patient is in her first year of college and is active on the cross country and track teams; she reports stress from her course load and trying to lose weight in order to run faster. She is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 84/52 mmHg, pulse rate is 36/min and regular, respiratory rate is 16/min, oxygen saturation is 95% on ambient air, and body mass index 16.5 kg/m2. Physical examination reveals a cachectic female in no acute distress with yellow skin hue. There is fine hair over her posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. The abdomen is scaphoid and nontender. The pelvic exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypoalbuminemia, low TSH and free T4, and macrocytic anemia. Serum prolactin and urine beta-hCG are negative. Which of the following symptoms are most concerning in this patient?



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A 19-year-old female is evaluated by her provider for amenorrhea of 5 months duration. Review of systems is positive for cold intolerance, dizziness, exertional dyspnea, and fatigue. Past medical history is unremarkable. She takes no medications and denies the use of alcohol, illicit drugs, or tobacco. The patient is in her first year of college and is active on the cross country and track teams; she reports stress from her course load and trying to lose weight in order to run faster. She is not currently sexually active. Temperature is 35.5°C (95.9°F), blood pressure is 84/52 mmHg, pulse rate is 36/min and regular, respiratory rate is 16/min, oxygen saturation is 95% on ambient air, and body mass index 16.5 kg/m2. Physical examination reveals a cachectic female in no acute distress with yellow skin hue. There is fine hair over her posterior neck. Heart rate is slow without murmurs or skipped beats. Lungs are clear to auscultation. The abdomen is scaphoid and nontender. Pelvic exam is unremarkable. Electrocardiogram reveals sinus bradycardia. Results of laboratory studies are notable for hypoalbuminemia, low TSH and free T4, and macrocytic anemia. Serum prolactin and urine beta-hCG are negative. The patient is admitted for further evaluation and treatment. After two weeks, he is re-evaluated by the therapy team. Which of the following indicates improvement in this patient's most likely diagnosis?



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A 17-year-old female presents complaining of cold intolerance and amenorrhea for 3 months. She has to wear jackets in lectures though everyone else wears t-shirts. She reports losing 20 pounds in the past 4 months so she can run faster on her cross country team. Her BMI is 15. What abnormality is not associated with this disease?



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A 16-year-old female is evaluated at her family provider office for decreased exercise tolerance, easy bruising, frequent sinus infections, irregular periods and rash. She has a history of depression and takes a multivitamin daily. The patient runs cross country. She denies using alcohol, illicit drugs, or tobacco and is not sexually active. Vital signs are temperature 95.9 F, heart rate 41 bpm, blood pressure 92/62 mmHg sitting, and 70/54 mmHg standing, respirations 14/minute, and BMI 16.5 kg/m2. Physical exam reveals a thin female with conjunctival pallor. Nasal mucosa is boggy with blood-tinged discharge. Parotid glands are enlarged bilaterally. Cardiac auscultation reveals bradycardia without murmurs or rubs. Ecchymoses cover her back and chest and petechiae cover bilateral anterior tibias. There is soft hair over her posterior neck. Labs are notable for potassium 3.0 mmol/L, bicarbonate 29 mmol/L, hemoglobin 6.7 mg/dL, platelets 31,000/microL, reticulocyte count 0.8%, white blood cells 1400/microL (30% PMNs). Peripheral blood smear demonstrates hypochromic red blood cells and no white cell blasts or schistocytes. The remainder of lab studies, including coagulation profile, creatinine, and liver enzymes, are within normal limits. Bone marrow biopsy is shown below. Which of the following is the most appropriate next step in management?

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  • Image 5742 Not availableImage 5742 Not available
    Contributed by Ruozhi Xiao
Attributed To: Contributed by Ruozhi Xiao



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A 17-year-old female is evaluated at her family physician's office for decreased exercise tolerance, easy bruising, frequent sinus infections, irregular periods and rash. She has a history of depression and takes a multivitamin daily. The patient runs cross country. She denies using alcohol, illicit drugs, or tobacco and is not sexually active. Her vital signs are temperature 95.9 F, heart rate 41 bpm, blood pressure 92/62 mmHg sitting, and 70/54 mmHg standing, respirations 14/minute, and BMI 16.5 kg/m2. Physical examination reveals a thin female with conjunctival pallor. The nasal mucosa is boggy with blood-tinged discharge. Parotid glands are enlarged bilaterally. Cardiac auscultation reveals bradycardia without murmurs or rubs. Ecchymoses cover her back, and chest and petechiae cover bilateral anterior tibias. There is soft hair over her posterior neck. Labs are notable for potassium 3.0 mmol/L, bicarbonate 29 mmol/L, hemoglobin 6.7 mg/dL, platelets 31,000/microL, reticulocyte count 0.8%, white blood cells 1400/microL (30% PMNs). Peripheral blood smear demonstrates hypochromic red blood cells and no white cell blasts or schistocytes. The remainder of lab studies, including coagulation profile, creatinine, and liver enzymes, are within normal limits. Bone marrow biopsy is shown below. What is the most likely diagnosis?

(Move Mouse on Image to Enlarge)
  • Image 5742 Not availableImage 5742 Not available
    Contributed by Ruozhi Xiao
Attributed To: Contributed by Ruozhi Xiao



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A client is on the behavioral health unit receiving treatment for anorexia nervosa. Which of the following would be appropriate? Select all that apply.



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A nurse working in a behavioral health unit is caring for a client with a diagnosis of anorexia nervosa. One nursing diagnosis listed on the chart is imbalanced nutrition less than body requirements. Which nursing interventions would support the plan of care formulated from this nursing diagnosis? Select all that apply.



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A patient presents to the office with foot pain. The patient says that about one week ago, she noticed that the top of her foot began to hurt whenever she went on her daily jogs. On exam, the patient is noted to have point tenderness above the fifth metatarsal on her left foot. She is also noted to have fine, soft, white hairs on her arms. What other finding is likely to be present in this individual?



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Anorexia Nervosa - References

References

Strand M,von Hausswolff-Juhlin Y,Welch E, [ARFID: food restriction without fear of weight gain]. Lakartidningen. 2018 Sep 11     [PubMed]
Phillipou A,Rossell SL,Castle DJ, Anorexia Nervosa or Starvation? The European journal of neuroscience. 2018 Sep 15     [PubMed]
Burton AL,Mitchison D,Hay P,Donnelly B,Thornton C,Russell J,Swinbourne J,Basten C,Goldstein M,Touyz S,Abbott MJ, Beliefs about Binge Eating: Psychometric Properties of the Eating Beliefs Questionnaire (EBQ-18) in Eating Disorder, Obese, and Community Samples. Nutrients. 2018 Sep 14     [PubMed]
Gander M,Sevecke K,Buchheim A, Disorder-specific attachment characteristics and experiences of childhood abuse and neglect in adolescents with anorexia nervosa and a major depressive episode. Clinical psychology     [PubMed]
Zayas LV,Wang SB,Coniglio K,Becker K,Murray HB,Klosterman E,Kay B,Bean P,Weltzin T,Franko DL,Eddy KT,Thomas JJ, Gender differences in eating disorder psychopathology across DSM-5 severity categories of anorexia nervosa and bulimia nervosa. The International journal of eating disorders. 2018 Sep 7     [PubMed]
Levinson CA,Zerwas SC,Brosof LC,Thornton LM,Strober M,Pivarunas B,Crowley JJ,Yilmaz Z,Berrettini WH,Brandt H,Crawford S,Fichter MM,Halmi KA,Johnson C,Kaplan AS,La Via M,Mitchell J,Rotondo A,Woodside DB,Kaye WH,Bulik CM, Associations between dimensions of anorexia nervosa and obsessive-compulsive disorder: An examination of personality and psychological factors in patients with anorexia nervosa. European eating disorders review : the journal of the Eating Disorders Association. 2018 Aug 22     [PubMed]
Nagata JM,Garber AK,Tabler JL,Murray SB,Bibbins-Domingo K, Prevalence and Correlates of Disordered Eating Behaviors Among Young Adults with Overweight or Obesity. Journal of general internal medicine. 2018 Aug     [PubMed]
Sacco B,Kelley U, Diagnosis and Evaluation of Eating Disorders in the Pediatric Patient. Pediatric annals. 2018 Jun 1     [PubMed]
Dittmer N,Voderholzer U,von der Mühlen M,Marwitz M,Fumi M,Mönch C,Alexandridis K,Cuntz U,Jacobi C,Schlegl S, Specialized group intervention for compulsive exercise in inpatients with eating disorders: feasibility and preliminary outcomes. Journal of eating disorders. 2018     [PubMed]
Hale MD,Logomarsino JV, The use of enteral nutrition in the treatment of eating disorders: a systematic review. Eating and weight disorders : EWD. 2018 Sep 8     [PubMed]
Lock J, Family therapy for eating disorders in youth: current confusions, advances, and new directions. Current opinion in psychiatry. 2018 Jul 30     [PubMed]
Grenon R,Carlucci S,Brugnera A,Schwartze D,Hammond N,Ivanova I,Mcquaid N,Proulx G,Tasca GA, Psychotherapy for eating disorders: A meta-analysis of direct comparisons. Psychotherapy research : journal of the Society for Psychotherapy Research. 2018 Jun 29     [PubMed]
Vust S,Cook-Darzens S,Lier F,Ambresin AE, [Adolescents suffering from anorexia nervosa: an evidence-based approach of the parent's role in 2018]. Revue medicale suisse. 2018 Apr 18     [PubMed]
Gómez-Candela C,Palma Milla S,Miján-de-la-Torre A,Rodríguez Ortega P,Matía Martín P,Loria Kohen V,Campos Del Portillo R,Martín-Palmero Á,Virgili Casas MªN,Martínez Olmos MÁ,Mories Álvarez MªT,Castro Alija MªJ,Martín-Palmero Á, [Consensus document about the nutritional evaluation and management of eating disorders: anorexia nervosa]. Nutricion hospitalaria. 2018 Mar 7     [PubMed]
Vásquez N,Urrejola P,Vogel M, [An update on inpatient treatment of anorexia nervosa: practical recommendations]. Revista medica de Chile. 2017 May     [PubMed]
Ziser K,Mölbert SC,Stuber F,Giel KE,Zipfel S,Junne F, Effectiveness of body image directed interventions in patients with anorexia nervosa: A systematic review. The International journal of eating disorders. 2018 Sep 6     [PubMed]

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