A 16 year old high school cheerleader is brought to the emergency department by her mother after falling on her back during a stunt.
She strongly believes that the accident happened because
her team couldn’t catch her “enormous and bloated” body.
Lately, she has been in a lot of stress as dance regionals
are coming soon and she wants to lose 15 pounds.
She is also experiencing intermittent
palpitations and dizziness, even at rest.
Physical examination reveals a slender female
with bilateral swelling on her cheeks,
and abrasions on the dorsum of her right hand.
When her mother left the room, she admitted to taking
furosemide that she found in the medicine cabinet.
The temperature is 36.2 Celsius, blood pressure
is 90/60 mmHg, pulse is 50 beats per minute,
respirations are 12 per minute, and she is 5 feet 4
inches tall and weighs 40.9 kilos or 90 pounds.
An MRI of the thoracic spine is obtained which
revealed vertebral compression fracture.
What is the most appropriate next step in
the management of this patient’s symptoms?
(A) - admit and start parenteral nutrition
(B) - stabilize the fracture with
a brace and discharge the patient
(C) - switch furosemide to hydrochlorothiazide
(D) - start bisphosphonates
or (E) - refer to a psychiatrist for
outpatient cognitive behavioral therapy
Now take a moment to come to your own answer.
Now let’s discuss the question characteristics.
Now we have a girl who has several problems
regarding her own view of her body
and several concerning physical exam findings.
So this patient falls under the category
of behavioral science/psychiatry.
This is also a 2-step question.
We have the step 1 - know what’s going on and 2 -
then figure out what's the next best step in management.
And 3- the stem is required for this case, we can’t
just read the last sentence and know the answer.
We have to use the details in the clinical
vignette to come to our conclusion.
Now let’s walk through the answer.
Step 1- we need to determine the diagnosis of this
patient based on the signs and symptoms provided.
Now this patient presents with a combination
of both psychological and physical symptoms.
This patient has a psychological disorder, and we can suggest
this by the patient’s distorted perception of her weight.
She is significantly underweight, but refers to
herself as “enormous” and having a “bloated” body,
and she even is self-medicating with a diuretic
called furosemide to lose body weight.
Now, this patient also has signs and symptoms of what we would call
severe malnutrition, which is a protein and vitamin deficiency
and the differential diagnosis here includes various
GI disorders but also possibly psychiatric disorders.
Now the combination of these psychological
things we see and the physical exam findings
really strongly suggest the
diagnosis of anorexia nervosa.
Now if you’re not sure with that diagnosis, you can
see that she has bilateral swelling of her cheeks,
in which vomiting could cause the parotid glands to swell.
She has abrasions in the dorsum of her right hand, which
if the patient’s inducing vomiting in herself via gagging,
the teeth will scrape on the
back or the dorsum of the hand.
Now that we have the diagnosis of
anorexia nervosa, we can go to step 2.
We need to determine the severity of her disease stage
to determine then the next step in her management.
This patient is what we would call, “unstable”.
She is hypothermic - 36.2, she is hypotensive-
90/60 mmHg, she is bradycardic - heart rate is 50.
And there really at this point is a high risk of severe
complications in patients who are unstable with anorexia nervosa,
and in particular what we care about the most is heart related
conditions due to electrolyte abnormalities in these patients.
So the best next step in management here is to admit the
patient to the hospital and start her on parenteral nutrition,
which is answer choice (A), to treat
a physically unstable patient.
Now let’s discuss some of the other signs and symptoms
of anorexia nervosa- really high-yield topics.
So patients that have anorexia can
have signs and symptoms of depression.
They can have depression, anxiety, or insomnia.
Given their body, they may endorse fatigue, they
don’t have a lot of calories, they feel deficit.
They can have cold intolerance.
Classically, you will see bodies of these
patients with a low body mass index.
Patients can endorse to you a distorted perception
of their body image, as we saw with this patient.
She was very small but she thought
she was huge and bloated.
Now these patients can also have a significant fear of
gaining weight and they all really take extreme measures to
decrease their caloric intake of eating less food or even
taking things such as diuretics to lose water weight.
Other things that we can see
are brittle hair, dry skin.
Patients can also have eroded teeth enamel, and that
occurs because as the repeated vomiting occurs,
the acid in the vomit actually
eats away at the teeth enamel.
We can also have halitosis which means bad breath, given the
destruction of the flora in the mouth from the repeated vomiting.
Now as in this patient, when it’s severe, you can have vital
instability, with hypothermia, hypotension and even bradycardia.