Anorexia Nervosa Nutritional Disorder\/Eating Disorder.<\/p>\n
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\u2019s mother and the children. Jenny never knows what to expect from him and is terrified of him. Her mother always defends her father\u2019s poor behavior and violent actions. \u201cYour father works very hard and needs a few drinks to relax.\u201d<\/p>\n
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 \u201cthey can play sports.\u201d 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\u2019 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 \u201cDiet Pill of the Stars, the Appetite Killer, Metabolism Booster, and Fat Blaster.\u201d She denies using any laxatives or ipecac. She denies any forced vomiting.<\/p>\n
Her mother informs the eating disorders specialist that \u201cJenny 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\u2019s expected of her.\u201d Jenny confides in her healthcare provider that she \u201chas 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.\u201d She admits to feeling \u201cvery sad, ignored, and worried for almost two years.\u201d 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. \u201cI probably wouldn\u2019t be able to go through with it.\u201d More recently, she has had thoughts that she wishes she could \u201cjust go to sleep and wake up in heaven.\u201d She denies any history of sexual abuse.<\/p>\n
Patient Case Question 1. Identify one major risk factor for anorexia nervosa from this patient\u2019s history of present illness.<\/p>\n
Past Medical History<\/p>\n
No previous psychiatric history or major medical problems or hospitalizations
\nMeasles as a young child
\nHistory of urinary tract infections
\nOne episode of iron deficiency anemia last year
\nMenarche began at age 12
\nOccasional headaches
\nFamily 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.<\/p>\n
Social History<\/p>\n
Straight \u201cA\u201d student who would like to go to college
\nEnjoys reading and writing
\nVery active in various student activities, including track and volleyball; a member of the student council and journal club; also a class officer
\nDenies use of tobacco, alcohol, or illicit drugs
\nReview of Systems<\/p>\n
States that overall she is doing okay
\nTrying to lose weight so that she will be more attractive
\nDoesn\u2019t like her size and shape
\nDoesn\u2019t believe that she has lost too much weight
\nComplains of weakness and always feeling cold
\nDenies chest pain, but occasionally feels \u201cheart flutters\u201d
\nNo history of seizures
\nReports a decrease in both appetite and energy and has felt fatigued for the last 3 weeks
\nHas had no abdominal pain
\nUsually has one bowel movement daily, but admits that she has not had one in the past 3 days
\nLast menses was 6 months ago
\nDenies nausea, vomiting, diarrhea, shortness of breath, and hemoptysis
\nNo blood in the stool
\nPatient 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.<\/p>\n
Medications No prescribed medications but she has been taking Metabo-Speed XXX for weight loss and used furosemide from her parents\u2019 medicine cabinet.<\/p>\n
Allergies No known drug allergy.<\/p>\n
Physical Examination and Laboratory Tests<\/p>\n
General<\/p>\n
The patient is a cooperative, pleasant, young female in no apparent distress
\nShe is appropriately dressed with regard to clothing size
\nShe is extremely thin
\nEasily engaged in conversation
\nShe is not guarded with her answers and makes good eye contact
\nAnswers all questions with a soft voice
\nNo odd or inappropriate motor behavior
\nVital Signs See Patient Case Table 96.1<\/p>\n
Patient Case Table 96.1 Vital Signs<\/p>\n
BP 125\/80*
\nRR 15
\nHt 62 in
\nP 52
\nT 95.3\u00b0F
\nWt 89 lbs *A normal blood pressure for a 15\u201317-year-old female is 128\/82.
\nPatient Case Question 3. Identify three vital signs that are consistent with a diagnosis of anorexia nervosa.<\/p>\n
Patient Case Question 4. Calculate this patient\u2019s body mass index to confirm that the patient is technically underweight.<\/p>\n
Skin<\/p>\n
Cool to touch
\nDry with some scaling
\nNegative for rashes or lesions
\nSkin tone normal in color
\nDecreased turgor
\nPatient Case Question 5. Identify three clinical manifestations from the skin and HEENT examinations above that suggest Jenny is dehydrated.<\/p>\n
Patient Case Question 6. Why did the eating disorders specialist examine the patient\u2019s teeth, a procedure that is not common in a physical examination?<\/p>\n
Neck\/Lymph Nodes<\/p>\n
Neck supple without lymphadenopathy or thyromegaly
\nNo jugular vein distension or carotid bruits
\nBreasts Normal without masses, discoloration, discharge, or dimpling.<\/p>\n
Lungs<\/p>\n
Clear to auscultation bilaterally
\nNo wheezing or crackles
\nCardiac<\/p>\n
Regular rate and rhythm, slow beat
\nNo murmurs, rubs, or gallops
\nS1 and S2 normal; no additional cardiac sounds
\nAbdomen<\/p>\n
Soft and non-tender
\nHypoactive bowel sounds
\nNo hepatosplenomegaly
\nNo masses or bruits
\nNo guarding or rebound tenderness
\nPatient Case Question 7. Which negative abdominal clinical sign parallels a single clinical symptom reported by the patient during the review of systems?<\/p>\n
Genitalia\/Rectum Stool heme-negative.<\/p>\n
Patient Case Question 8. What is the significance of the rectal examination?<\/p>\n
Musculoskeletal\/Extremities<\/p>\n
Extremities are slightly cool to touch
\nNo cyanosis or clubbing but mild-to-moderate (1 level) peripheral edema
\nRange of motion within normal limits
\nGood peripheral pulses bilaterally
\nAge-appropriate strength
\nNeurologic<\/p>\n
Alert and oriented to time, place, and person
\nCranial nerves II\u2013XII intact
\nDeep tendon reflexes 2 throughout
\nNegative Babinski sign
\nNo gross motor-sensory deficits present
\nLaboratory Blood Test Results See Patient Case Table 96.2.<\/p>\n
Urinalysis The patient\u2019s urine was clear in appearance, but amber in color. Complete urinalysis is pending.<\/p>\n
Electrocardiogram Except for bradycardia, no abnormalities were observed.<\/p>\n
Patient Case Question 9. Which four laboratory blood test results in Table 96.2 are consistent with dehydration?<\/p>\n
Patient Case Question 10. Do any of the laboratory data in Table 96.2 support a diagnosis of anemia?<\/p>\n
Patient Case Table 96.2 Laboratory Blood Test Results<\/p>\n
Na 148 meq\/L
\nHb 14.8 g\/dL
\nAST 30 IU\/L
\nK 2.9 meq\/L
\nHct 47%
\nALT 38 IU\/L
\nCl 111 meq\/L
\nPlt 170,000\/mm3
\nAlk phos 123 IU\/L
\nHCO3 22 meq\/L
\nWBC 3,900\/mm3
\nT protein 4.9 g\/dL
\nBUN 30 mg\/dL
\nCa 8.3 mg\/dL
\nTSH 2.1 \u00b5U\/mL
\nCr 1.1 mg\/dL
\nMg 1.7 mg\/dL
\nT cholesterol 190 mg\/dL
\nGlu, fasting 60 mg\/dL
\nPhos 2.3 mg\/dL
\nFSH 0.2 mU\/mL
\nPatient Case Question 11. Is this patient at risk for developing infections?<\/p>\n
Patient Case Question 12. This patient has many clinical manifestations that are associated with hypothyroid disease. Is this patient hypothyroid?<\/p>\n
Patient Case Question 13. Based on the patient\u2019s laboratory blood test results, provide one reasonable explanation for the observed level 1 peripheral edema.<\/p>\n
Patient Case Question 14. Can the patient\u2019s recent amenorrhea be explained by any of the laboratory blood test results shown in Table 96.2?<\/p>\n
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?<\/p>\n
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?<\/p>\n
============<\/p>\n
Case Study Analysis Example.
\nAnorexia Nervosa: A Case Study Analysis
\nIntroduction
\nAnorexia 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.<\/p>\n
Risk Factors for Anorexia Nervosa
\nJenny’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).<\/p>\n
Clinical Manifestations
\nThe review of systems highlights multiple clinical manifestations consistent with anorexia nervosa:<\/p>\n
Weight Loss: Jenny has been losing significant weight, which she perceives as necessary to be attractive.
\nAmenorrhea: Her last menstrual period was six months ago, a common symptom in anorexia nervosa (American Psychiatric Association, 2018).
\nFatigue and Weakness: She reports feeling fatigued and weak, which are typical symptoms due to malnutrition.
\nCold Intolerance: Always feeling cold is indicative of low body fat and metabolic rate.
\nBradycardia: A heart rate of 52 beats per minute suggests bradycardia, often seen in anorexia nervosa (Mehler & Brown, 2015).
\nBody Image Distortion: Despite significant weight loss, she does not believe she has lost too much weight.
\nDepression and Anxiety: Jenny experiences sadness, worry, and sleep disturbances, which are psychological symptoms associated with anorexia nervosa.
\nVital Signs
\nThree vital signs consistent with anorexia nervosa include:<\/p>\n
Bradycardia: Heart rate of 52 beats per minute.
\nHypothermia: Body temperature of 95.3\u00b0F.
\nLow Blood Pressure: Although her blood pressure is within normal limits, it is on the lower side for her age group.
\nBody Mass Index Calculation
\nJenny’s height is 62 inches, and her weight is 89 pounds. The Body Mass Index (BMI) is calculated as follows:<\/p>\n
[
\n\\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
\n]<\/p>\n
A BMI of 16.3 confirms that Jenny is underweight, as a BMI below 18.5 is considered underweight (World Health Organization, 2019).<\/p>\n
Dehydration Indicators
\nClinical manifestations suggesting dehydration include:<\/p>\n
Cool, Dry Skin: Indicates poor hydration status.
\nDecreased Skin Turgor: Suggests fluid loss.
\nBradycardia: Can be exacerbated by dehydration.
\nDental Examination
\nThe 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).<\/p>\n
Abdominal Examination
\nThe absence of abdominal pain parallels Jenny’s report of no abdominal discomfort, despite her restricted diet and potential gastrointestinal issues.<\/p>\n
Rectal Examination Significance
\nThe 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.<\/p>\n
Laboratory Findings
\nDehydration Indicators
\nLaboratory results consistent with dehydration include:<\/p>\n
Elevated Sodium (Na) Level: 148 meq\/L indicates hypernatremia.
\nElevated Blood Urea Nitrogen (BUN): 30 mg\/dL suggests dehydration.
\nLow Potassium (K) Level: 2.9 meq\/L indicates hypokalemia, often due to dehydration.
\nLow Total Protein: 4.9 g\/dL can be associated with malnutrition and dehydration.
\nAnemia Diagnosis
\nThe laboratory data do not support a diagnosis of anemia, as hemoglobin (Hb) and hematocrit (Hct) levels are within normal ranges.<\/p>\n
Infection Risk
\nJenny’s low white blood cell (WBC) count of 3,900\/mm\u00b3 suggests a potential risk for infections due to compromised immune function (Misra et al., 2020).<\/p>\n
Hypothyroidism Assessment
\nDespite symptoms resembling hypothyroidism, Jenny’s thyroid-stimulating hormone (TSH) level is normal, indicating she is not hypothyroid.<\/p>\n
Peripheral Edema Explanation
\nThe observed peripheral edema could be due to low protein levels, leading to decreased oncotic pressure and fluid retention.<\/p>\n
Amenorrhea Explanation
\nJenny’s amenorrhea can be explained by low follicle-stimulating hormone (FSH) levels, indicating hormonal imbalances due to malnutrition.<\/p>\n
Laboratory Concern
\nHypokalemia is of greatest concern due to its potential to cause cardiac arrhythmias, which can be life-threatening (Mehler & Brown, 2015).<\/p>\n
Cholesterol Levels
\nJenny’s cholesterol level is not markedly elevated, indicating that hypercholesterolemia is not a concern in this case.<\/p>\n
Conclusion
\nJenny’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.<\/p>\n
References
\nAmerican Psychiatric Association. (2018). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.<\/p>\n
Mehler, P. S., & Brown, C. (2015). Anorexia nervosa – medical complications. Journal of Eating Disorders, 3(1), 11.<\/p>\n
Misra, M., Klibanski, A., & Miller, K. K. (2020). Endocrine effects of anorexia nervosa. The Lancet Diabetes & Endocrinology, 8(7), 579-592.<\/p>\n
Treasure, J., Duarte, T. A., & Schmidt, U. (2020). Eating disorders. The Lancet, 395(10227), 899-911.<\/p>\n
Westenhoefer, J. (2018). Eating disorders: A review of the literature. European Eating Disorders Review, 26(1), 1-10.<\/p>\n
World Health Organization. (2019). Body mass index – BMI. Retrieved from https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/obesity-and-overweight<\/p>\n","protected":false},"excerpt":{"rendered":"
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