Posted: October 3rd, 2024

Anorexia Nervosa Nutritional Disorder/Eating Disorder

Anorexia Nervosa Nutritional Disorder/Eating Disorder.

Jenny is a 16-year-old girl who is in the 11th grade. This is her first visit to the Eating Disorders Clinic. Physicians at the emergency room had referred her to the clinic. She had fainted at school during gymnastics class and sustained several minor bruises on her arms and legs and a laceration on her forehead. When she was younger, Jenny was of normal weight and height and ate freely. Her father owns a construction business, spends a significant amount of time traveling, and drinks excessively when he is at home. He is also violent and quick to anger when he drinks. He shouts, uses abusive language, and has thrown plates and books at Jenny’s mother and the children. Jenny never knows what to expect from him and is terrified of him. Her mother always defends her father’s poor behavior and violent actions. “Your father works very hard and needs a few drinks to relax.”

Jenny has felt totally neglected in the family during the last several years. She is the only female and her father tends to get involved more in the activities of his two sons because “they can play sports.” Jenny has taken a part-time job at the ice cream shop, has become very involved in her studies and closest friendships, and rarely comes home before 10 PM. One year ago, she decided that she needed to lose several pounds but would not say exactly how many. She began to exercise by walking 45 minutes each day during lunchtime and tried out for both the girls’ track and volleyball teams. She started reading articles in Cosmopolitan magazine about weight loss, being thin, and being beautiful like the Hollywood actresses and supermodels. She experimented with Lasix for several weeks but decided that it was not helping her lose weight as she desired. She began skipping breakfast and lunch completely. For dinner, she would have a large bowl of cereal and would feel filled up. Several months ago, she bought online and began taking Metabo-Speed XXX, advertised as the “Diet Pill of the Stars, the Appetite Killer, Metabolism Booster, and Fat Blaster.” She denies using any laxatives or ipecac. She denies any forced vomiting.

Her mother informs the eating disorders specialist that “Jenny has not been herself lately. She has been losing too much weight and has been very touchy and argumentative lately. She is always a good girl, works hard on her schoolwork and job, and always does what’s expected of her.” Jenny confides in her healthcare provider that she “has one very good friend who also comes from a dysfunctional family. We understand one another and we support one another, but we have both grown up too fast.” She admits to feeling “very sad, ignored, and worried for almost two years.” She cries frequently at night and wakes up around 4 AM unable to go back to sleep. She often lies awake at night when she goes to bed, crying and tossing and turning for hours before falling asleep. She occasionally experiences nightmares about her father chasing her with a knife. Jenny admits to having suicidal thoughts but no plan. “I probably wouldn’t be able to go through with it.” More recently, she has had thoughts that she wishes she could “just go to sleep and wake up in heaven.” She denies any history of sexual abuse.

Patient Case Question 1. Identify one major risk factor for anorexia nervosa from this patient’s history of present illness.

Past Medical History

No previous psychiatric history or major medical problems or hospitalizations
Measles as a young child
History of urinary tract infections
One episode of iron deficiency anemia last year
Menarche began at age 12
Occasional headaches
Family History Jenny is the middle child of three children. She has an older brother and a younger brother. Father and paternal grandfather are alcoholics and smokers. Mother is in good health.

Social History

Straight “A” student who would like to go to college
Enjoys reading and writing
Very active in various student activities, including track and volleyball; a member of the student council and journal club; also a class officer
Denies use of tobacco, alcohol, or illicit drugs
Review of Systems

States that overall she is doing okay
Trying to lose weight so that she will be more attractive
Doesn’t like her size and shape
Doesn’t believe that she has lost too much weight
Complains of weakness and always feeling cold
Denies chest pain, but occasionally feels “heart flutters”
No history of seizures
Reports a decrease in both appetite and energy and has felt fatigued for the last 3 weeks
Has had no abdominal pain
Usually has one bowel movement daily, but admits that she has not had one in the past 3 days
Last menses was 6 months ago
Denies nausea, vomiting, diarrhea, shortness of breath, and hemoptysis
No blood in the stool
Patient Case Question 2. Identify a minimum of seven clinical manifestations from the review of systems above that are consistent with a diagnosis of anorexia nervosa.

Medications No prescribed medications but she has been taking Metabo-Speed XXX for weight loss and used furosemide from her parents’ medicine cabinet.

Allergies No known drug allergy.

Physical Examination and Laboratory Tests

General

The patient is a cooperative, pleasant, young female in no apparent distress
She is appropriately dressed with regard to clothing size
She is extremely thin
Easily engaged in conversation
She is not guarded with her answers and makes good eye contact
Answers all questions with a soft voice
No odd or inappropriate motor behavior
Vital Signs See Patient Case Table 96.1

Patient Case Table 96.1 Vital Signs

BP 125/80*
RR 15
Ht 62 in
P 52
T 95.3°F
Wt 89 lbs *A normal blood pressure for a 15–17-year-old female is 128/82.
Patient Case Question 3. Identify three vital signs that are consistent with a diagnosis of anorexia nervosa.

Patient Case Question 4. Calculate this patient’s body mass index to confirm that the patient is technically underweight.

Skin

Cool to touch
Dry with some scaling
Negative for rashes or lesions
Skin tone normal in color
Decreased turgor
Patient Case Question 5. Identify three clinical manifestations from the skin and HEENT examinations above that suggest Jenny is dehydrated.

Patient Case Question 6. Why did the eating disorders specialist examine the patient’s teeth, a procedure that is not common in a physical examination?

Neck/Lymph Nodes

Neck supple without lymphadenopathy or thyromegaly
No jugular vein distension or carotid bruits
Breasts Normal without masses, discoloration, discharge, or dimpling.

Lungs

Clear to auscultation bilaterally
No wheezing or crackles
Cardiac

Regular rate and rhythm, slow beat
No murmurs, rubs, or gallops
S1 and S2 normal; no additional cardiac sounds
Abdomen

Soft and non-tender
Hypoactive bowel sounds
No hepatosplenomegaly
No masses or bruits
No guarding or rebound tenderness
Patient Case Question 7. Which negative abdominal clinical sign parallels a single clinical symptom reported by the patient during the review of systems?

Genitalia/Rectum Stool heme-negative.

Patient Case Question 8. What is the significance of the rectal examination?

Musculoskeletal/Extremities

Extremities are slightly cool to touch
No cyanosis or clubbing but mild-to-moderate (1 level) peripheral edema
Range of motion within normal limits
Good peripheral pulses bilaterally
Age-appropriate strength
Neurologic

Alert and oriented to time, place, and person
Cranial nerves II–XII intact
Deep tendon reflexes 2 throughout
Negative Babinski sign
No gross motor-sensory deficits present
Laboratory Blood Test Results See Patient Case Table 96.2.

Urinalysis The patient’s urine was clear in appearance, but amber in color. Complete urinalysis is pending.

Electrocardiogram Except for bradycardia, no abnormalities were observed.

Patient Case Question 9. Which four laboratory blood test results in Table 96.2 are consistent with dehydration?

Patient Case Question 10. Do any of the laboratory data in Table 96.2 support a diagnosis of anemia?

Patient Case Table 96.2 Laboratory Blood Test Results

Na 148 meq/L
Hb 14.8 g/dL
AST 30 IU/L
K 2.9 meq/L
Hct 47%
ALT 38 IU/L
Cl 111 meq/L
Plt 170,000/mm3
Alk phos 123 IU/L
HCO3 22 meq/L
WBC 3,900/mm3
T protein 4.9 g/dL
BUN 30 mg/dL
Ca 8.3 mg/dL
TSH 2.1 µU/mL
Cr 1.1 mg/dL
Mg 1.7 mg/dL
T cholesterol 190 mg/dL
Glu, fasting 60 mg/dL
Phos 2.3 mg/dL
FSH 0.2 mU/mL
Patient Case Question 11. Is this patient at risk for developing infections?

Patient Case Question 12. This patient has many clinical manifestations that are associated with hypothyroid disease. Is this patient hypothyroid?

Patient Case Question 13. Based on the patient’s laboratory blood test results, provide one reasonable explanation for the observed level 1 peripheral edema.

Patient Case Question 14. Can the patient’s recent amenorrhea be explained by any of the laboratory blood test results shown in Table 96.2?

Patient Case Question 15. Which of the following findings from the laboratory blood tests has to be of greatest concern and why: hypernatremia, hypokalemia, hypoglycemia, hypomagnesemia, hypocalcemia, or hypophosphatemia?

Patient Case Question 16. Some patients with anorexia nervosa are hypercholesterolemic. Does the patient in this case study have a markedly elevated serum cholesterol concentration?

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Case Study Analysis Example.
Anorexia Nervosa: A Case Study Analysis
Introduction
Anorexia nervosa is a complex eating disorder characterized by an intense fear of gaining weight and a distorted body image, leading to restricted food intake and excessive weight loss. This paper examines the case of Jenny, a 16-year-old girl, to identify risk factors, clinical manifestations, and laboratory findings associated with anorexia nervosa. The analysis aims to provide insights into the diagnosis and implications of this disorder.

Risk Factors for Anorexia Nervosa
Jenny’s history reveals several risk factors for anorexia nervosa. A significant risk factor is her dysfunctional family environment, marked by her father’s alcoholism and abusive behavior. This environment likely contributes to her feelings of neglect and low self-esteem, which are common psychological precursors to eating disorders (Treasure et al., 2020).

Clinical Manifestations
The review of systems highlights multiple clinical manifestations consistent with anorexia nervosa:

Weight Loss: Jenny has been losing significant weight, which she perceives as necessary to be attractive.
Amenorrhea: Her last menstrual period was six months ago, a common symptom in anorexia nervosa (American Psychiatric Association, 2018).
Fatigue and Weakness: She reports feeling fatigued and weak, which are typical symptoms due to malnutrition.
Cold Intolerance: Always feeling cold is indicative of low body fat and metabolic rate.
Bradycardia: A heart rate of 52 beats per minute suggests bradycardia, often seen in anorexia nervosa (Mehler & Brown, 2015).
Body Image Distortion: Despite significant weight loss, she does not believe she has lost too much weight.
Depression and Anxiety: Jenny experiences sadness, worry, and sleep disturbances, which are psychological symptoms associated with anorexia nervosa.
Vital Signs
Three vital signs consistent with anorexia nervosa include:

Bradycardia: Heart rate of 52 beats per minute.
Hypothermia: Body temperature of 95.3°F.
Low Blood Pressure: Although her blood pressure is within normal limits, it is on the lower side for her age group.
Body Mass Index Calculation
Jenny’s height is 62 inches, and her weight is 89 pounds. The Body Mass Index (BMI) is calculated as follows:

[
\text{BMI} = \left(\frac{\text{Weight in pounds}}{\text{Height in inches}2}\right) \times 703 = \left(\frac{89}{622}\right) \times 703 \approx 16.3
]

A BMI of 16.3 confirms that Jenny is underweight, as a BMI below 18.5 is considered underweight (World Health Organization, 2019).

Dehydration Indicators
Clinical manifestations suggesting dehydration include:

Cool, Dry Skin: Indicates poor hydration status.
Decreased Skin Turgor: Suggests fluid loss.
Bradycardia: Can be exacerbated by dehydration.
Dental Examination
The specialist examined Jenny’s teeth to check for enamel erosion, which can occur with self-induced vomiting, a behavior sometimes associated with eating disorders (Westenhoefer, 2018).

Abdominal Examination
The absence of abdominal pain parallels Jenny’s report of no abdominal discomfort, despite her restricted diet and potential gastrointestinal issues.

Rectal Examination Significance
The rectal examination’s significance lies in assessing for fecal impaction or gastrointestinal bleeding, which can occur in severe cases of anorexia nervosa due to malnutrition and dehydration.

Laboratory Findings
Dehydration Indicators
Laboratory results consistent with dehydration include:

Elevated Sodium (Na) Level: 148 meq/L indicates hypernatremia.
Elevated Blood Urea Nitrogen (BUN): 30 mg/dL suggests dehydration.
Low Potassium (K) Level: 2.9 meq/L indicates hypokalemia, often due to dehydration.
Low Total Protein: 4.9 g/dL can be associated with malnutrition and dehydration.
Anemia Diagnosis
The laboratory data do not support a diagnosis of anemia, as hemoglobin (Hb) and hematocrit (Hct) levels are within normal ranges.

Infection Risk
Jenny’s low white blood cell (WBC) count of 3,900/mm³ suggests a potential risk for infections due to compromised immune function (Misra et al., 2020).

Hypothyroidism Assessment
Despite symptoms resembling hypothyroidism, Jenny’s thyroid-stimulating hormone (TSH) level is normal, indicating she is not hypothyroid.

Peripheral Edema Explanation
The observed peripheral edema could be due to low protein levels, leading to decreased oncotic pressure and fluid retention.

Amenorrhea Explanation
Jenny’s amenorrhea can be explained by low follicle-stimulating hormone (FSH) levels, indicating hormonal imbalances due to malnutrition.

Laboratory Concern
Hypokalemia is of greatest concern due to its potential to cause cardiac arrhythmias, which can be life-threatening (Mehler & Brown, 2015).

Cholesterol Levels
Jenny’s cholesterol level is not markedly elevated, indicating that hypercholesterolemia is not a concern in this case.

Conclusion
Jenny’s case illustrates the multifaceted nature of anorexia nervosa, encompassing psychological, physiological, and environmental factors. Early intervention and a comprehensive treatment plan are crucial for recovery.

References
American Psychiatric Association. (2018). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Mehler, P. S., & Brown, C. (2015). Anorexia nervosa – medical complications. Journal of Eating Disorders, 3(1), 11.

Misra, M., Klibanski, A., & Miller, K. K. (2020). Endocrine effects of anorexia nervosa. The Lancet Diabetes & Endocrinology, 8(7), 579-592.

Treasure, J., Duarte, T. A., & Schmidt, U. (2020). Eating disorders. The Lancet, 395(10227), 899-911.

Westenhoefer, J. (2018). Eating disorders: A review of the literature. European Eating Disorders Review, 26(1), 1-10.

World Health Organization. (2019). Body mass index – BMI. Retrieved from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

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Tags: Adolescent Health, Anorexia Nervosa, Eating Disorder, Nutritional Disorder