Patients with anorexia or picky eaters may present to the ED with extreme weight loss, food refusal, dehydration, weakness, or shock. Many present at the urging of family members or friends and are in deep denial of their malnutrition and illness.
- Patients should be questioned about their current weight, highest weight, lowest weight, exercise habits, and menstrual cycles. Further questioning should inquire with regard to eating habits, presence or absence of self-induced vomiting/binge eating, etc.
- Major depression and dysthymic disorder have been reported in up to 50% of patients with anorexia nervosa. Patients should be asked about early morning awakening, tearfulness, and thoughts of suicide or a plan.
- Review of systems is often positive for constipation, early satiety, hypothermia, nausea, hair loss, and fatigue.
Obtain patient history with the goal of developing a treatment plan and not with the thought of merely ruling out an eating disorder. With medical assessment, focus on the medical complications of altered nutrition. Seek a careful history detailing weight changes, dietary patterns, and excessive exercise. Determine weight and height.
A review of systems may reveal many positive responses. The following are symptoms commonly observed in patients with anorexia nervosa:
- Physical health concerns
- Mental health concerns
- Concentration concerns
- Cold hands or feet
- Decision-making concerns
- Dry skin or hair loss
- Social withdrawal
- Fainting or dizziness
- Obsessiveness (food)
Focus the physical examination on the changes commonly observed in anorexia nervosa. Vital sign changes include hypotension, bradycardia, and hypothermia. Other changes include dry skin, hypercarotenemia, lanugo body hair, acrocyanosis, atrophy of the breasts, and swelling of the parotid and submandibular glands. ECG reveals a prolonged cardiac output (QT) interval, and echocardiography (ECHO) reveals a decreased ventricular mass and mitral valve prolapse (see Other Tests). GI signs include intestinal dilation from constipation and diminished intestinal motility.
Patients with anorexia nervosa may present anywhere along the spectrum of weight loss. They may attempt to hide their weight loss by wearing bulky clothing or many layers.
- Physical examination may reveal hypothermia, peripheral edema, thinning hair, and obvious emaciation.
- Behaviorally, a patient may demonstrate a flat affect and display psychomotor retardation, especially in the later stages of the disease.
- Vital sign abnormalities may include hypothermia, bradycardia, and hypotension.
- Cardiac examination may reveal the mid-systolic click of mitral valve prolapse.
- Patients with purging behavior may have parotid gland hypertrophy, dental enamel erosion and, in extreme cases, seizures from electrolyte disturbances.
- Dermatologic examination reveals dry skin, lanugo (a fine, downy covering of hair on the extremities), and poor skin turgor.
Mental health assessment
When performing a mental health assessment, focus on making a diagnosis, identifying concurrent emotional-behavioral illnesses, evaluating for the risk of suicide, and exploring the psychosocial context of the symptoms.
The following are characteristic signs of inadequate energy (caloric) intake observed in patients with anorexia nervosa that are due to starvation-induced changes:
- Resting bradycardia (resting heart rate often 40-49 beats per minute)
- Orthostatic lowered blood pressure or pulse
- Loss of muscle mass
- Low blood glucose (impaired insulin clearance)
- Low parathyroid hormone levels
- Elevated liver function
- Low WBC count
- Normal fundi or visual fields
- No organomegaly
- No lymphadenopathy
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