Anorexia Nervosa
Doctor Information
Ellie Ribbing, age 16
PMH:
Acne
Medication:
No regular medication or allergies
Last Consultation:
2010; viral URTI, advice and reassurance given to mother and patient.
PMH:
Acne
Medication:
No regular medication or allergies
Last Consultation:
2010; viral URTI, advice and reassurance given to mother and patient.
Patient Information
Ellie Ribbin age 16
You are Ellie’s mother Joanne. She is with you today but did not want to come and will not speak to the doctor.
Opening sentence:
You are really worried about Ellie, as she is not eating.
Reveal readily:
Ellie has not been herself for a few months. She is quiet and doesn't get involved with family things, even meals. She is still doing really well at school has a couple of good friends, but something is definitely wrong. She seems so secretive all the time, even now she is rolling her eyes but knows exactly what you are talking about.
You initially just put this down to being a teenager, however your visit today was prompted by recent concerning references in your browser history.
Reveal only when asked:
Ellie has always been thin, however she looks thinner, maybe it is her clothes, the fashion is all this loose fitting trousers and tops. She definitely looks thinner. You used to eat together as a family. Now she does all her own meals and eats them on her own in her room. You have no idea what she eats, at school all the meals are done by the cafeteria, so she just takes money in. You know she eats a lot of vegetables, she munches carrots and celery sometimes. You don't think she vomits after food, you would have heard her.
You have heard Ellie make comments about her weight, saying that she was too fat.
You don’t think she is depressed, she still talks to you and her dad, and even gets on pretty well with her older brother Jack. As far as you know she has never hurt or cut herself, she wears short sleeves all the time and you would have noticed any marks. Ellie loves sports and she is good at it too- she is on the gymnastics team and plays county lacrosse. She does a lot of running, usually in the mornings before school, and at the weekends. No amount of heavy rain or snow would stop her. She hasn't complained of any dental problems, nor of any dizzy spells.
More worryingly, you found references to "weight loss" websites on your history, including ones with "pro-ana" tips.
You don’t know about her periods. She doesn't like to talk about that. She is generally healthy otherwise, no regular tablets, no illnesses. She doesn't smoke or drink alcohol. There is no mental history, and you don't think that Ellie takes any drugs.
Ellie will not talk to the doctor today.
Ideas:
Deep down you still hope that it's just a phase, and that its something she will grow out of.
Concerns:
you initially thought she was just a normal teenager, everyone goes through weird phases. Now you are worried it is something more. You are now worried with these recent website links.
Expectations:
you hope the doctor will reassure you that there is nothing wrong and you are just an overanxious parent. Although you would agree to any tests or seeing a specialist.
You are Ellie’s mother Joanne. She is with you today but did not want to come and will not speak to the doctor.
Opening sentence:
You are really worried about Ellie, as she is not eating.
Reveal readily:
Ellie has not been herself for a few months. She is quiet and doesn't get involved with family things, even meals. She is still doing really well at school has a couple of good friends, but something is definitely wrong. She seems so secretive all the time, even now she is rolling her eyes but knows exactly what you are talking about.
You initially just put this down to being a teenager, however your visit today was prompted by recent concerning references in your browser history.
Reveal only when asked:
Ellie has always been thin, however she looks thinner, maybe it is her clothes, the fashion is all this loose fitting trousers and tops. She definitely looks thinner. You used to eat together as a family. Now she does all her own meals and eats them on her own in her room. You have no idea what she eats, at school all the meals are done by the cafeteria, so she just takes money in. You know she eats a lot of vegetables, she munches carrots and celery sometimes. You don't think she vomits after food, you would have heard her.
You have heard Ellie make comments about her weight, saying that she was too fat.
You don’t think she is depressed, she still talks to you and her dad, and even gets on pretty well with her older brother Jack. As far as you know she has never hurt or cut herself, she wears short sleeves all the time and you would have noticed any marks. Ellie loves sports and she is good at it too- she is on the gymnastics team and plays county lacrosse. She does a lot of running, usually in the mornings before school, and at the weekends. No amount of heavy rain or snow would stop her. She hasn't complained of any dental problems, nor of any dizzy spells.
More worryingly, you found references to "weight loss" websites on your history, including ones with "pro-ana" tips.
You don’t know about her periods. She doesn't like to talk about that. She is generally healthy otherwise, no regular tablets, no illnesses. She doesn't smoke or drink alcohol. There is no mental history, and you don't think that Ellie takes any drugs.
Ellie will not talk to the doctor today.
Ideas:
Deep down you still hope that it's just a phase, and that its something she will grow out of.
Concerns:
you initially thought she was just a normal teenager, everyone goes through weird phases. Now you are worried it is something more. You are now worried with these recent website links.
Expectations:
you hope the doctor will reassure you that there is nothing wrong and you are just an overanxious parent. Although you would agree to any tests or seeing a specialist.
Examination Findings
Examination:
BMI 15.8
No other examination is permitted by Ellie.
Observations: Ellie appears thin and pale. She does not interact with you at all, and generally looks at the floor or around the room to avoid eye contact with you.
BMI 15.8
No other examination is permitted by Ellie.
Observations: Ellie appears thin and pale. She does not interact with you at all, and generally looks at the floor or around the room to avoid eye contact with you.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Attempts to engage with patient, but then takes organised history from guardian Performs risk assessment Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently but respects patient’s wishes |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem, does not attempt to engage with patient Is disorganised/unsystematic in gathering information Fails to make a risk assessment |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan that is appropriate and in line with current best practice Management approaches reflect an appropriate assessment of risk Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Incorrect diagnosis Does not suggest how the problem might develop or resolve Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed No risk management or safety netting |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / makes use of non-verbal cues. Works with the patient and guardian to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor-centred approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation |
Management
Explanation:
I suspect you may have an eating disorder called anorexia nervosa. This means that you try hard to lose weight, and often the thoughts about food and meals dominate your life. It is a common condition in people of all ages, but especially young adolescents. It can be very serious, even life threatening if not treated properly. If we get the right assessment and treatments early on, you can make a full recovery.
Assessment:
Remember that Anorexia Nervosa is a devastating disease, with eating disorders having the highest mortality rate of any mental health disorder. Eating disorders have a tendency to overlap with other mental health conditions, with up to 50% of sufferers having co morbid depression. Anorexia was associated with a 6 fold increase in death risk [link]
I suspect you may have an eating disorder called anorexia nervosa. This means that you try hard to lose weight, and often the thoughts about food and meals dominate your life. It is a common condition in people of all ages, but especially young adolescents. It can be very serious, even life threatening if not treated properly. If we get the right assessment and treatments early on, you can make a full recovery.
Assessment:
Remember that Anorexia Nervosa is a devastating disease, with eating disorders having the highest mortality rate of any mental health disorder. Eating disorders have a tendency to overlap with other mental health conditions, with up to 50% of sufferers having co morbid depression. Anorexia was associated with a 6 fold increase in death risk [link]
Symptoms to enquire about
Menstruation problems
Sleep disturbance
Dizzy spells
Dental problems
Examination:
Measure height / weight - beware of excessive water ingestion prior to consultations by patients
calculate BMI - or use centile charts if under 18
CV exam - checking for postural hypotension
Muscular power
Peripheral circulation
The principle symptom of anorexia is deliberate weight loss combined with excessive control over food content and intake. It may take the form of restricting diet, avoiding anything calorific, excessive exercises, even laxative abuse. This is coupled with compensating behaviour - perhaps wearing loose clothing, vomiting after meals, secretive behaviour. BMI is typically below 17.5.
Low BMI is associated with several health risks: (taken from NICE CKS - see here)
Physical Risk Assessment Guide: (from NICE)
NICE produced some guidance to help assess the persons physical risk of complications - see below
Moderate Risk
High Risk
In this case, it is important to try and engage with the child first, and see if you can get any history from her. If not, you will have to continue the consultation with the mother. In practice you may suggest talking to the child alone, as they may feel more comfortable discussing personal matters without a parent present. Make sure you do a risk assessment for self harm or suicide, and a depression screen.
Management
Try and explain your suspicions to both parties, and gauge their understanding. In terms of management, as the patient is a minor, she would require an urgent referral to the mental health team in the area. It varies from place to place: in some areas CAMHS will make a same day assessment and can involve psychiatry, in other areas you will need to refer directly to psychiatry. If they want to know more, the recovery process often takes several months and may involve therapy, counselling, CBT, medication. It would be wise to do urgent bloods (fbc/u+e/ca/mg/phos/ck/glucose) and an ECG.
Those at particularly high risk may warrant urgent admission - see above criteria.
Low BMI is associated with several health risks: (taken from NICE CKS - see here)
- Musculoskeletal — weakness, loss of muscle strength, loss of bone density,growth impairment
- Endocrine — infertility, thyroid abnormalities, incomplete development of secondary sexual characteristics, impaired temperature regulation.
- Cardiovascular — arrhythmias, hypotension, mitral valve prolapse, peripheral oedema, sudden death.
- Gastrointestinal — slowed gastrointestinal motility, constipation, abnormal liver function tests.
- Haematologic — low white blood cell count (particularly neutrophils), anaemia (rarely), thrombocytopenia.
- Metabolic — dehydration, electrolyte disturbance in those who misuse laxatives or diuretics or induce vomiting, re-feeding syndrome (a complication of rapid re-feeding treatment).
- Neurological — cognitive impairment (which may affect the person's ability to drive), seizures (rarely).
- Renal — kidney stones and acute or chronic kidney disease (chronic hypokalaemia and chronic volume depletion can lead to the development of kidney disease).
- Dental — erosion of tooth enamel from vomiting.
Physical Risk Assessment Guide: (from NICE)
NICE produced some guidance to help assess the persons physical risk of complications - see below
Moderate Risk
- BMI <15 in adults, or BMI centiles < 3
- weight loss per week of > 0.5kg
- BP of less than 90 / 60 or a postural drop of > 10 mmHg
- Pulse rate < 50
- Unable to stand up from squatting without using arms for balance
- Unable to sit up from lying without using arms as leverage
- temp<35
High Risk
- BMI <13 in adults
- weight loss per week >1kg
- Purpuric rash
- BP under 80 / 50 or a postural drop of > 20 mmHg
- Pulse < 40
- cold extremities
- Unable to stand from squatting without using arms for leverage
- Unable to sit up from lying at all
- temp <34.5
In this case, it is important to try and engage with the child first, and see if you can get any history from her. If not, you will have to continue the consultation with the mother. In practice you may suggest talking to the child alone, as they may feel more comfortable discussing personal matters without a parent present. Make sure you do a risk assessment for self harm or suicide, and a depression screen.
Management
Try and explain your suspicions to both parties, and gauge their understanding. In terms of management, as the patient is a minor, she would require an urgent referral to the mental health team in the area. It varies from place to place: in some areas CAMHS will make a same day assessment and can involve psychiatry, in other areas you will need to refer directly to psychiatry. If they want to know more, the recovery process often takes several months and may involve therapy, counselling, CBT, medication. It would be wise to do urgent bloods (fbc/u+e/ca/mg/phos/ck/glucose) and an ECG.
Those at particularly high risk may warrant urgent admission - see above criteria.