A 28-year-old woman comes to the office for a routine evaluation. During the review of systems she reports weight gain, fatigue, bloating, flatulence, constipation, mild acne, and menstrual irregularity. The patient describes difficulty losing weight despite trying numerous low-calorie diets. She is depressed about her weight and feels that her appearance has always been a source of insecurity. She is also unhappy with her current position as an administrative assistant but lacks the motivation to look for another job. The patient has an active social life with friends but is not in a relationship. She smokes marijuana 1 or 2 times a month and has used cocaine at parties twice in the past year.
Temperature is 37.1 C (98.8 F) , blood pressure is 110/60 mm Hg, and pulse is 68/min. On physical examination, the patient has mild facial acne and is slightly overweight. BMI is 27 kg/m². The oropharynx is remarkable for painless, mildly swollen parotid glands. The remainder of the physical examination is normal.
Complete blood count is normal and serum electrolytes are notable for mildly decreased serum potassium, slightly elevated serum bicarbonate, and mildly decreased serum chloride levels. Thyroid function tests, liver function tests, and urinalysis are unremarkable.
Which of the following is the most likely diagnosis in this patient?

Question

Quizplus · Accepted Answer

11ec193a_98c3_827e_853d_9f3ed8d5dc9e_MD0002_00 Patients with bulimia nervosa (BN) may be reluctant to disclose their binging and purging behavior, requiring the physician to be alert to physical signs, symptoms, and laboratory findings suggestive of the disorder. This patient's bilateral parotid gland hypertrophy and mild electrolyte abnormalities, as well as her preoccupation with her appearance and weight, are suggestive of BN. Parotid gland hypertrophy (sialadenosis) due to self-induced vomiting occurs in up to 25% of patients with BN and is typically bilateral and painless. Patients with BN are usually normal weight to slightly overweight and frequently have comorbid substance use, depression, and anxiety disorders. Common medical symptoms of BN include lethargy, menstrual irregularities, abdominal bloating, and constipation. Chronic purging can also lead to mild electrolyte abnormalities, including hypokalemia, slightly elevated serum bicarbonate, and slightly decreased serum chloride levels. Hypokalemia in otherwise healthy young adults is highly specific for covert BN. Other signs suspicious for this disorder include oropharyngeal ulcers, erosion of dental enamel, and scars and calluses on the back of the hand. (Choice B) This patient enjoys an active social life and her depressive symptoms revolve around dissatisfaction with her appearance and weight. Persistent depressive disorder (dysthymia) requires depressed mood and at least 2 other depressive symptoms for ≥2 years and would not explain this patient's physical examination and electrolyte abnormalities. (Choice C) Although this patient has some features of polycystic ovary syndrome (eg, weight gain, irregular menses), there would also be evidence of hyperandrogenism, such as hirsutism or inflammatory rather than mild acne. Her preoccupation with weight, coupled with parotid enlargement and electrolyte abnormalities, makes BN more likely. (Choice D) Patients with somatic symptom disorder are preoccupied with ≥1 unexplained physical symptoms, leading to high health care utilization. This patient's somatic symptoms and findings are consistent with BN. (Choice E) Surreptitious laxative ingestion may cause hypokalemia, but BN with self-induced vomiting is a more likely explanation of this patient's parotid hypertrophy. Educational objective: Bulimia nervosa should be suspected in otherwise healthy patients who present with bilateral parotid gland enlargement and mild electrolyte abnormalities. Other suspicious findings include oropharyngeal ulcers, erosion of dental enamel, and scars and calluses on the back of the hand. __________ References: Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/25591200)

A 28-Year-Old Woman Comes to the Office for a Routine