Elemental EM: Eating Disorders

It is challenging to incorporate core topics into a shift, especially uncommon core topics. Elemental EM aims to provide 5-minute rapid review of core topics that could be translated into interactive sessions with learners. Here is how to turn a simple syncope case into a brief learning session on eating disorders.

Author: Courtney Cassella, MD (@Corablacas, EM Resident Physician, Icahn SoM at Mount Sinai) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

Clinical Case:

A 16-year-old female with no medical history presents to the ED after an episode of syncope. The patient was sitting at her desk studying for a prolonged period and when she stood up, felt dizzy, nauseated, and sweaty and passed out onto the ground. Her sister was in the room and helped her to the floor. She had no abnormal movements, tongue biting, or incontinence and regained consciousness within 30 seconds. Review of systems is otherwise negative. There is no significant family history. Physical exam is within normal limits. EKG demonstrates normal sinus rhythm. Urine pregnancy test is negative. Basic metabolic panel and complete blood count are within normal limits. The patient is discharged with prompt primary care physician follow-up.

This case is a low risk syncope that is relatively straightforward. See emDocs post on syncope for more: http://www.emdocs.net/syncope-the-latest-on-clinical-work-up-and-management/

One method to make this a “teachable” moment would be to go through a “what-if scenario”. The following is an example:

Shortly before discharge the patient’s mother pulls you aside to tell you she is concerned her daughter has been losing a lot of weight and appears more tired recently.

What history and physical exam findings would indicate the patient had an eating disorder?

• Vague symptoms: Weakness, fatigue, pallor, dizziness, syncope, confusion, bloating, edema, persistent nausea
• Complaints from complications
  • Purging: chest pain or hematemesis from Mallory-Weiss tear
  • Electrolyte induced dysrhythmia: Palpitations
  • Disrupted HPA axis: Dysmenorrhea
  • Osteoporosis/malnutrition: fractures
  • Depression, anxiety, substance abuse, self-injurious behavior, suicidality
• Anorexia: thin body habitus, hypotension, bradycardia, hypothermia, flaking skin
• Bulimia or binge eating disorder: Normal weight or even slightly overweight: hypertrophy of parotid glands, dental erosion, trauma or callous to dorsal hands, facial petechiae, subconjunctival hemorrhage, halitosis

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How would your work-up differ for a patient with an eating disorder? 

• Screening questionnaire for detecting eating disorders: SCOFF questionnaire (Score 2 or more)³
  • Do you make yourself sick because you feel uncomfortably full?
  • Do you worry 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?
• Labs
  • CBC
  • BMP, magnesium, calcium, phosphorous
  • LFT
  • Lipase, amylase
  • Urinalysis
  • Pregnancy test
  • TSH
• Lab Abnormalities
  • Purging:
    • Hypokalemic, hypochloremic metabolic alkalosis
    • Elevated LFTs, lipase, amylase
    • Hyponatremia
  • Laxative/diuretics: Hypokalemia, hyponatremia
  • Starvation ketosis
  • Severe: anemia, leukopenia, hypoglycemia, hypophosphatemia
• EKG for prolonged QT, electrolyte imbalance

What reasons would you admit a patient with an eating disorder?

American Psychiatric Association Criteria for Admission⁴

• Medical instability
  • Adults: HR <40bpm; BP <90/60 mmHg; glucose <60mg/dL; K <3 mEq/L; electrolyte imbalance
  • Children and Adolescents: HR near 40bpm; orthostatic BP changes; BP <80/50 mmHg; hypokalemia; hypophosphatemia; hypomagnesemia
  • All: Temperature <97˚F; dehydration; hepatic, renal, or cardiovascular organ compromise; poorly controlled diabetes
• Weight <85% of ideal or acute decline with food refusal even if not <85%
• Comorbid psychiatric conditions or suicidality
• Severe family conflict or problems, absence of family or adequate support
• Poor motivation or high resistance to treatment interventions unless highly structured
• Absence of alternative treatment settings

References/Resources

1. Lewis GC. Eating Disorders. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://eresources.library.mssm.edu:2744/content.aspx?bookid=1658&sectionid=109448456. Accessed May 23, 2017.
2. American Psychiatric Association, DSM-5 Task Force: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: 2013.
3. Morgan  JF, Reid  F, Lacey  JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med. 2000; 172(3): 164-5. PMID: 18751246.
4. Yager, J. et al. Practice Guideline for the Treatment of Patients with Eating Disorders, 3^rd Am J Psychiatry. 20006; 163(7 Suppl):4-54. PMID: 16925191