A 15-year-old girl is brought to the clinic by her mother, who became concerned after hearing her daughter vomit in the bathroom on 2 separate occasions last week. The patient is preparing for a debate competition and says that she occasionally vomits from nervousness before an event. She describes intense pressure to perform well in school and gain admission to a prestigious college. Her mother adds that the patient is very self-conscious and frequently worries that her classmates dislike her and that her school uniform makes her stomach look "huge." The patient takes no medications and has no drug allergies. Temperature is 36.2 C (97.2 F), blood pressure is 112/68 mm Hg, pulse is 60/min, and respirations are 16/min. BMI for age is at the 4th percentile. The patient appears slightly anxious and wears baggy clothing. Physical examination shows dental caries, bilateral parotid gland enlargement, scars on the dorsum of the right hand, and a scaphoid abdomen with normal bowel sounds. Which of the following is the most likely diagnosis?

Question

A 15-year-old girl is brought to the clinic by her mother, who became concerned after hearing her daughter vomit in the bathroom on 2 separate occasions last week.  The patient is preparing for a debate competition and says that she occasionally vomits from nervousness before an event.  She describes intense pressure to perform well in school and gain admission to a prestigious college.  Her mother adds that the patient is very self-conscious and frequently worries that her classmates dislike her and that her school uniform makes her stomach look "huge."  The patient takes no medications and has no drug allergies.  Temperature is 36.2 C (97.2 F), blood pressure is 112/68 mm Hg, pulse is 60/min, and respirations are 16/min.  BMI for age is at the 4th percentile.  The patient appears slightly anxious and wears baggy clothing.  Physical examination shows dental caries, bilateral parotid gland enlargement, scars on the dorsum of the right hand, and a scaphoid abdomen with normal bowel sounds.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d791_6661_bc81_45e93fbbd2f2_MD0003_00 This patient's significantly low body weight, distorted body perception, and physical signs consistent with self-induced vomiting are suggestive of anorexia nervosa. Patients with anorexia nervosa can have a range of abnormal eating behaviors, which are classified as the restricting subtype (ie, dieting and fasting without binge/purge behavior) and the binge/purge subtype, as seen in this patient. Significantly low body weight (BMI generally ≤18.5 kg/m² in adults) is a core symptom of anorexia nervosa and the key feature that distinguishes it from bulimia nervosa, in which BMI is at or above normal. Anorexia nervosa has a typical onset in adolescence and is associated with participation in activities with pressure to be thin (eg, gymnastics, ballet). ² On physical examination, the most striking finding is emaciation. Other findings include bradycardia, hypotension, hypothermia, hair loss, dry skin, and lanugo (ie, fine, downy body hair). Although common, amenorrhea is not required for diagnosis. Findings related to self-induced vomiting in the binge/purge subtype include parotid gland hypertrophy, pharyngeal erythema, dental caries, scars or calluses on the hand from contact with the teeth (ie, Russell sign), and electrolyte abnormalities. (Choice B) Binge eating disorder is characterized by recurrent binges with no compensatory behaviors (eg, purging, fasting). (Choice C) Body dysmorphic disorder is characterized by preoccupation with a perceived bodily defect (eg, shape of nose, body hair). This patient's preoccupation is confined to her weight/size (ie, "huge" stomach), which when combined with her significantly low body weight and purging behaviors, is most consistent with anorexia nervosa. (Choice D) The key difference in differentiating anorexia nervosa from bulimia nervosa in adolescents is weight that is significantly lower than expected for age and developmental course. In contrast, patients with bulimia nervosa typically maintain a normal weight. (Choice E) Generalized anxiety disorder is characterized by excessive preoccupation with multiple worries and does not explain this patient's low weight, distorted body image, or evidence of repeated purging. Educational objective: Signs of self-induced vomiting include parotid gland hypertrophy, pharyngeal erythema, dental caries, scars or calluses on the hand, and electrolyte abnormalities. The binge/purge subtype of anorexia nervosa can be differentiated from bulimia nervosa by significantly low body weight. References: Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/25591200) Medical complications of anorexia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/27166107)

A 15-Year-Old Girl Is Brought to the Clinic by Her