A 15-year-old girl is brought to the office after falling in the shower. Her mother was outside of the bathroom when she heard a thud, and went in and found her daughter trying to get back up. The patient insists, "I just slipped. It's no big deal. I am fine." She reports that she had no loss of consciousness, tongue biting, incontinence, or confusion. Her parents are concerned that she lost her balance because she is thin and eats poorly. They also note that she seems depressed and has not been interested in seeing any friends. The patient admits, "I have been a little down since my boyfriend broke up with me, but I don't blame him because I am so fat." She takes no medications, has no allergies, and does not use tobacco, alcohol, or illicit drugs. Temperature is 35.6 C (96 F) , blood pressure is 100/60 mm Hg sitting and 80/48 mm Hg standing, pulse is 50/min, and respirations are 14/min. BMI is 16 kg/m². Examination shows an alert and cooperative girl with dry mucous membranes and emaciation. Calluses are present over the knuckles. The abdomen is soft, nontender, and nondistended. Urine hCG is negative. Laboratory results are as follows:
Item 1 of 2
Which of the following is the most appropriate next step in management of this patient?

Question

A 15-year-old girl is brought to the office after falling in the shower. Her mother was outside of the bathroom when she heard a thud, and went in and found her daughter trying to get back up. The patient insists, "I just slipped. It's no big deal. I am fine." She reports that she had no loss of consciousness, tongue biting, incontinence, or confusion. Her parents are concerned that she lost her balance because she is thin and eats poorly. They also note that she seems depressed and has not been interested in seeing any friends. The patient admits, "I have been a little down since my boyfriend broke up with me, but I don't blame him because I am so fat." She takes no medications, has no allergies, and does not use tobacco, alcohol, or illicit drugs. Temperature is 35.6 C (96 F) , blood pressure is 100/60 mm Hg sitting and 80/48 mm Hg standing, pulse is 50/min, and respirations are 14/min. BMI is 16 kg/m². Examination shows an alert and cooperative girl with dry mucous membranes and emaciation. Calluses are present over the knuckles. The abdomen is soft, nontender, and nondistended. Urine hCG is negative. Laboratory results are as follows:

Item 1 of 2
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c047_bcb2_8f63_0361ba85670d_MD0005_00 This patient's low body weight, distorted body image, and evidence of self-induced vomiting (knuckle calluses) are consistent with anorexia nervosa (AN), purging subtype. Although many patients with AN can improve with outpatient treatment programs, hemodynamic instability requires hospital admission and inpatient treatment. Self-induced vomiting can cause severe dehydration, resulting in lightheadedness or syncope, elevated blood urea nitrogen-to-creatinine ratio >20:1, and orthostatic hypotension (decrease in systolic blood pressure of ≥20 mm Hg and in diastolic blood pressure ≥10 mm Hg with standing). Other indications for hospitalization include arrhythmia, severe bradycardia, acute food refusal, electrolyte abnormalities, and suicidality. Once medically stabilized, the mainstay of treatment for AN is psychotherapy and nutritional rehabilitation (Choices B and D). (Choice A) Referral for ambulatory (outpatient) Holter monitoring is inappropriate. Instead, hemodynamically unstable patients require admission. Inpatient telemetry would be indicated for monitoring of arrhythmias if the patient has bradycardia or electrolyte derangements. (Choice E) Fluoxetine is a selective serotonin reuptake inhibitor that is useful for depression and bulimia but not for AN. Although this patient should be assessed further for comorbid depression, antidepressants would not treat her AN. Educational objective: The mainstay of treatment in anorexia nervosa is psychotherapy and nutritional rehabilitation. Indications for hospitalization include orthostatic hypotension, syncope, bradycardia, and electrolyte abnormalities. References: Identification and management of eating disorders in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/21115584) Cardiovascular complications of anorexia nervosa: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/26710932)

A 15-Year-Old Girl Is Brought to the Office After Falling