Bulimia Nervosa: New Diagnosis
Where you are:
You are an FY2 in the GP surgery.Who your patient is:
Sarah Taylor is a 24 year old has come for her blood test review.Other Information you have about the patient:
Full blood count:
HB 18g/l
WCC 7.0 x 1/9
Neutrophil 2.0 x10/9
MCV 88ft.
Na 135 mmol/l (135-145)
K 3.1 mmol/l (3.5 - 5.1)
Urea 5mmol/1
Creatinine 120mmol/l
Liver function test: Normal.What you must do:
Take a history and discuss your next plan with the patient.
A 24 Year old university student Tessa Robert, who lives alone had been noticed by her mother to be intentionally vomiting. On further questioning it is apparent that she has been intentionally vomiting for the last 2 months and she has the perception of being overweight and experiences intense guilt. She doesn’t have low mood nor thoughts of self-harm. On social history, does not drink alcohol, no drug abuse, doesn’t have a partner. Menstruation is regular.
Case Discussion
APPROACH:
On assessment, BMI is 22
- Paraphrase and Explore the vomiting
- Duration, Frequency, Contents, Colour, On what occasions, Blood in vomit, Triggers ( was it intentional), any specific Timing e.g after meal
If Intentional,
What triggers: Eating certain foods, thoughts Mechanism of vomit: How do you vomit?
- Do you use your hands?
- Do you use any medications to cause vomiting?
- Do you take any medications to cause diarrhea or make you pee?
SPECIFIC HISTORY
Ask about perception - shape and weight of her body
Complication of repeated vomiting:
- Low potassium and Arrhythmia: Do you experience any racing of the heart?
- Muscular paralysis: Feeling weakness in arms and legs?
Questions about eating habit unavoidable urge to overeat? (urge )
When you eat a lot, do you eat alone? (isolation)
Immediately after eating, do you feel a sense of relief?
After that do you feel disgusted?
Because of that do you vomit? ( This question will decide the nature of the vomit)
Exercise:
Do you exercise regularly?
How many times and how long?
What sort of exercises do you do?
Can include SCOFF!
Psychopathology:
Mood: Depressed mood
Impaired concentration
Social withdrawal ( friends and social circle)
Thoughts of self-harm
DIFFERENTIALS:
Malignancy
ТВ
Hyperthyroid
Schizophrenia
Pregnancy
Primary Ovarian failure
PCOS
EXAMINATIONS:
Observation, BMI, Mouth (sore throat), teeth, face (parotid glands), hands (marks, colors formation,
DIAGNOSIS:
People with this condition in their mind they may believe that they are overweight or may be preoccupied with their body image and because of this they may secretly binge eat (eat large amounts of food) with a loss of control over eating then try to get rid of the extra amount of food in they way by self-inducing vomiting or misuse medications, weight loss supplements or by exercise.
MANAGEMENT
URGENT referral to Community
Medical Health team
Seen by-Eating disorder specialist
Wait for blood test results in meanwhile to rule out anything else-Blood works including K+. TFT, Kidney functions
Self-help programme
Advise:
- Wash mouth with water after vomiting: do not brush
- Reduce laxative use: it doesn’t reduce calorie absorption
Note: If BMI is LOW - Anorexia
N.B: This consultation is taking place in the GP.
Bulimia Nervosa: Hyponatremia
Where you are :
You are an FY2 in the GP surgery.
Who your patient is:
Sarah Taylor is a 24 year old has come for her blood test review.
Other Information you have about the patient:
Full blood count:
ĐťB 18g/l
WCC 7.0 x 1/9
Neutrophil 2.0 x10/9
MCV 88ft.
Na 135 mmol/l (135-145)
K 3.1 mmol/l (3.5 - 5.1)
Urea 5mmol/1
Creatinine 120mmol/l
Liver function test: Normal.
What you must do:
Take a history and discuss your next plan with the patient.
Case Discussion
Opening
Paraphrase
What test done? And why they were done? Feeling tired a month
nausea? (Self induced) Vomiting? How did you induce? By finger
diarrhea? (use laxative) Why use laxative? I want to loose weight
Tummy pain? Fever?
The SCOFF questions
Do you make yourself Sick because you feel uncomfortably full?
Do you worry that you have lost Control over how much you eat?
Have you recently lost more than One stone (14 lb) in a 3-month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that Food dominates your life?
Any concerns about body shape?
Hypokalemia symptoms: constipation, tingling and numbness, muscle weakness
Mood? Self harm?
PMH: dx with bulimia when she was 16
Ask about bulimia, suicide and depression
MAFTOSA: Meds: antidepressants
Examination: BMI (to differentiate anorexia nervosa)
Explain test result, Na quite low, another salt called K low, at borderline, because of vomiting and diarrhoea. “It’s an eating disorder, that causes you to eat large amount of food at a time (binge) and then get ready of it (purge).”
Mx
Send her to hospital to acute medicine she is symptomatic
CBT, Dietician, Antidepressant
Refer to eating disorder clinic
Na correction via specific fluid
Potassim needs correction - Sando-k
