A 20-year-old man comes to the emergency department due to worsening right leg pain. The patient runs 5 miles daily, but several weeks ago, he began having dull pain at the right lower shin during runs. Now, the pain occurs even with light walking. He has had no trauma, fever, chills, or redness in the affected area. The patient has no prior medical conditions and takes no medications. Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, pulse is 56/min, and respirations are 16/min. BMI is 17 kg/m². Physical examination reveals tenderness of the right lower anterior tibia. X-ray of the right lower extremity reveals a small tibial stress fracture. When the findings are explained and treatment with analgesics and limited physical activity is discussed, the patient becomes distressed that he has to stop running. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d2b4_bd84_bc81_dfa57a10aab8_MD0003_00 This patient's low body weight (BMI <18.5 kg/m²), stress fracture, and distress in response to the recommendation to limit his physical activity are concerning for anorexia nervosa (AN). Although AN is more common in female patients, male patients are also affected and at risk for bone loss. Decreased bone mineral density, which is caused by a number of factors (eg, endocrine abnormalities, hypercortisolism, growth hormone resistance), results in an increased risk of bone fractures. Other medical complications associated with AN include bradycardia, hypotension, and cardiac atrophy. The most important next step in management of this patient is to obtain a comprehensive dietary history. Caloric intake and meal patterns, attitudes about food and weight, and history of bingeing and efforts to control weight with compensatory behaviors (eg, exercise, fasting, self-induced vomiting, misuse of laxatives, diuretics) should be assessed. In addition, AN in male patients may present with a focus on muscularity rather than thinness. In these cases, dietary history may reveal dietary restrictions aimed at muscle building and the use of protein supplements at the expense of balanced nutrition. (Choice A) Advising participation in another sport would not treat an underlying eating disorder. (Choice B) Although exogenous steroid use (eg, androgen) can predispose to decreased bone mineral density and fractures, it is typically associated with increased muscle strength and mass, and other typical signs of steroid use could be seen (eg, hypertension, acne, gynecomastia, testicular shrinkage). Obtaining a dietary history would take priority in this patient with significantly low body weight and no other signs of steroid use. (Choice D) Hyperthyroidism can result in decreased bone mineral density and weight loss. However, these symptoms are typically accompanied by increased appetite and signs of sympathetic hyperstimulation such as tachycardia, hypertension, heat intolerance, tremor, and hyperreflexia, which are not evident in this patient. Hyperthyroidism would not explain this man's distress at having to limit his physical activity. (Choice E) The initial management of small tibial stress fractures includes rest, analgesia, and stabilization with a splint or brace if necessary. Surgical intervention could be considered for severe fractures or for lack of healing or severe pain despite conservative treatment. Educational objective: A dietary history to assess for anorexia nervosa should be obtained in any patient with a stress fracture, low body weight, and distress at having to limit physical activity. Patients with anorexia nervosa are at risk for stress fractures due to decreased bone mineral density. References: Bone health in eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/24165231) Eating disorders in males: how primary care providers can improve recognition, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/31184292) The enigma of male eating disorders: a critical review and synthesis. (http://www.ncbi.nlm.nih.gov/pubmed/28800416)

A 20-Year-Old Man Comes to the Emergency Department Due to Worsening