Scenario Title: Weight loss and amenorrhea in a 17–year ...



Scenario Title: Weight loss and amenorrhea in a 17–year-old female

Scenario Author: Dr Lisa Page and Dr Isabel McMullen

Updated (2017): Dr Carol Kan and Professor Janet Treasure

a) Learning objectives.

Please describe the learning objectives for this scenario under the following headings. Please add or remove sub-headings and add additional details as required. Please note not all of the Main Headings will be required for all scenarios so please delete if you do not wish to use.

|Main Heading |Sub-Heading |Details (please list any further headings under |

| | |this sub-heading) |

|1. Basic Science & Pathology |

|Normal and abnormal structure and function relevant to this scenario |

| |Anatomy | |

| |Histopathology | |

| |Immunology | |

| |Microbiology | |

| |Physiology |Secondary amenorrhea, other systemic changes secondary to |

| | |weight loss |

| |Genetics |Heritability of psychiatric disorder |

| |Biochemistry |Biochemical changes due to malnutrition |

| |Other | |

| | | |

|2. Clinical Science: Physical and Psychological |

|Clinical features of this scenario and related conditions to be covered here |

| |Symptoms |Weight loss, cessation of periods, social withdrawal, cold |

| | |intolerance |

| |Signs |Mental state examination & general physical examination |

| |Investigations |Weight & calculation of body mass index (BMI) |

| | |Full blood count |

| | |Biochemistry (including Calcium, phosphate) |

| | |Thyroid function tests |

| | |Inflammatory markers |

| | |Further history from school |

| |Management |Initial management in primary care |

| | |Weight monitoring |

| | |Dietician |

| | |Involvement of family and school |

| | |Clear plan for referral to specialist services if no |

| | |improvement |

| | |Specialist psychological therapies |

| |Prognosis and outcome |Prognosis of anorexia nervosa |

| |Other |Engaging a reluctant patient |

| | | |

|3. Population Sciences & Health Care |

|Public health issues related to this scenario in the UK or elsewhere. |

|For instance: why does this patient have this problem in this society? What is our response to it? |

| |Public health and clinical epidemiology (including|Prevalence |

| |statistics) |Prognosis |

| | |Sex differences |

| |Issues of access to health care |The patient may not present self |

| |Complementary medicine | |

| |Health care systems |Close multidisciplinary working |

| |Resource management |Referral for specialist treatment |

| |Health education |Educating the patient, family and school |

| |Environmental, economic, political influences | |

| |(both local and global) on the evolution of this | |

| |condition | |

| |This condition in other societies | |

| |Other | |

| | | |

|4. Skills |

|Practical and communication skills related to this scenario |

| |Communication |Engaging patient, family and school |

| |Aspects of history taking |Importance of history taking from those other than the |

| | |patient |

| |Aspects of clinical examination |Mental state examination |

| |Team working |Liaising with dietician and other professionals with clear |

| | |plan |

| |Other | |

| | | |

| | | |

|5. Professional Development & Practice |

|Responsibilities, ethical and legal issues, self and professional management issues |

| |Responsibilities and boundaries of a doctor |Balancing confidentiality with involvement of family and |

| | |school |

| |Values, impact of personal values on behaviour |Dieting and concern about body image are common in Western |

| | |society, disordered eating behaviours can gradually become |

| | |compulsive and slip into anorexia nervosa. |

| | | |

| | |The Mental Health Act is sometimes need to be considered in |

| | |patients with a severe, treatment-resistant form of anorexia |

| | |nervosa. There have been legal cases where repeated |

| | |inpatient care under the Mental Health Act was challenged. |

| |Other ethical issues |Difficulties of engaging a patient who would rather not be |

| | |treated |

| |Legal issues |Awareness that rarely the Mental Health Act is used to |

| | |enforce treatment in Anorexia Nervosa |

| |Clinical governance | |

| |Other | |

| | | |

| | | |

|6. The Individual in Society |

|The effect on the individual and on society of this scenario at this time |

| |Normal development and ageing |Effect on school attendance and work |

| |What does this condition mean for this patient and|Frustration and stress for rest of family |

| |her/his family? | |

| |Coping with illness and treatment |This is usually a chronic condition |

| |Lifestyle, behaviour and health | |

| |Other | |

b) Reading list

Please add any recommended reading and textbooks that you feel are relevant to this current scenario and the issues that it addresses.

|Treasure, J., A.M. Claudino, and N. Zucker, Eating disorders. Lancet, 2010. 375(9714): p. 583-93. |

|Treasure, J. Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers, 1997. Psychology Press; 1 edition. |

|Eating disorders: recognition and treatment. NICE guideline [NG69] Published date: May 2017 |

| |

c) Useful links

Please indicate below any useful general links and references that you feel are relevant to the issues that are covered in this scenario. These can be links to government reports and guidelines, national and international policies, GMC recommendations etc (NB. These are not intended to be web links covering specific learning resources and topics as these will be covered during the scenario development). If you can please include the web address if available.

|b-eat.co.uk |

| |

|.au |

|freedfromed.co.uk |

|mengetedstoo.co.uk |

|.uk |

|.uk/whatsworryingyou |

|.uk/a-to-z/e/eating-disorders |

| |

Section 1. Scenario introduction

Please give a brief introduction to the scenario (bearing in mind that most patients present initially to a General Practitioner) that should include the initial complaints of the presenting patient, a brief indication of any previous treatment and history.

| |

|Gemma is a 17-year-old A-level student who is brought to your GP clinic by her mother in late August. Her mother is concerned because the |

|family have noticed that Gemma has lost a lot of weight over the past 6 to 9 months and she has not had a menstrual period for 6 months. Her |

|mother is also worried because Gemma has become much more withdrawn and quiet over the same period and no longer sees her friends outside of |

|school. Gemma is silent during the consultation unless you ask her a question directly. As far as you can tell from the GP records, Gemma has |

|been a healthy child and adolescent until now. She started her periods at the age of 12. |

From the description please add up to three questions for the student to answer based on the information they have been given above. At this stage the student will enter their own answers to the three questions. Only after they have completed this task will they be allowed to progress to see what they should have written and view the explanations and links to associated learning resources.

• One question might ask the student to list likely diagnoses based on their interpretation of the information they have been given at this stage.

e.g. “Give three likely diagnoses that you should consider at this stage”

and please add your question and three model answers (with explanations and indicate what areas in basic science, pathology and clinical science should be taken into account and explored further) below:

|Q1. What types of disorders should you consider at this stage in a 17-year-old female? |

|1. An eating disorder |

|2. Depression |

|3. An organic disorder such as thyroid disease |

• Another question might encourage the student to think about the major areas that they should be considering based on the information and symptoms that have been given so far. (questions could possibly cover severity, onset and pattern of symptoms if relevant)

e.g. “Give three important questions that you should explore about her symptoms”

and please add your questions and appropriate answers below:

|Q2. Give three areas of the history that you would like to clarify with the patient (and her mother) initially. |

| |

|Weight loss |

|Clarify how much weight Gemma has lost over the last 9 months. It is useful to record her current weight and her lowest and highest ever|

|weight. |

| |

|Patient’s attitude to weight loss |

|Who is worried about your weight loss? Are they right to be worried? What might they have noticed? Are you concerned about your current|

|weight? How about the amount of weight that you have lost? Do you have an ideal weight? Have your eating habits changed in the last |

|year? If so, how? |

| |

|Physical and other symptoms of starvation |

|Have you noticed any change to your body? For example, have you been feeling more dizzy/more tired/more weak/ more sensitive to the |

|cold recently? Sometimes people find it hard to focus at school/work, have you noticed any change in your concentration? Also, it can |

|be hard to find the energy to see friends and family, have things changed in any way? |

| |

|The SCOFF questionnaire (Morgan, Reid, Lacey et al., 1999) is a simple screening instrument developed for detecting eating disorders in |

|the community. It is designed to raise suspicion of a likely case rather than to diagnose eating disorder. It should not be used as |

|the sole method to determine whether or not a patient has an eating disorder. |

| |

|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 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? |

| |

|*One point for every “yes”; a score of ≥2 indicates a likely case of anorexia nervosa or bulimia |

|It can, however, be difficult to approach a patient about their eating disorders. |

| |

|Morgan John F, Reid Fiona, Lacey J Hubert. The SCOFF questionnaire: assessment of a new screening tool for eating disorders BMJ 1999; |

|319 :1467 |

a) A third question might ask the student to consider the underlying causes (basic science, pathology etc) of the main symptoms that the patient is presenting with and/or examine the likely causes.

e.g. “What is the physiological explanation for the symptom of…..”.

|Q3. What other factors in the history would you be interested in obtaining during this initial interview? |

| |

|Long explanation: |

| |

|Attempts to lose weight |

|Once you have enquired about the patient’s attitude to weight loss, it is important to clarify whether she is attempting to use any of |

|the following means to lose weight [compensatory behaviours]: |

|Restriction of food or calorie intake |

|Excessive exercising |

|(Self induced) vomiting |

|Use of laxatives or diuretics |

| |

|Depression |

|Weight loss can be associated with depression. The patient’s mother has also told you that she has become socially withdrawn in the |

|past few months – why is this? It is important to determine if she has other significant symptoms of depression (such as low mood, |

|anhedonia [loss of pleasure in daily activities] and anergia). In any case, it would be advisable to establish whether she feels life |

|is worth living – if her answer is ambivalent or she tells you that her life is not worth living then a fuller assessment of suicidal |

|risk is required. See ‘Out of Sorts’ module for further details on assessment of depression. |

| |

|Social factors |

|In any female adolescent with secondary amenorrhea it is important to ensure she is not pregnant. This will need to be enquired about |

|tactfully and you may wish to ask the mother to leave for this part of the interview1. This could also be an opportunity to ask about |

|difficulties with relationships, problems at school (social or academic) and problems within the family. |

| |

|1There are no firm rules about whether you should ask the mother to leave in order to cover these more sensitive questions. In general,|

|it is useful to minimise the potential for there to be ‘secrets’ between family members, but this will be balanced by your judgement as |

|to whether you will get truthful answers to questions about sexual activity etc with the mother present. You will be informed by your |

|knowledge of the family. |

Section 2: Further history

This section will provide the student with a further history of the patient based on an interview. Please indicate below the relevant areas of the patient history that you feel the student should need in order to carry on. You can provide a simple bulleted list of relevant findings from the history or if you prefer present the history in the form of a very short interview (no more that 1 – 1.5 sides of A4 paper). See Appendix 1 for an example. This transcript might then be converted into a video interview that the students will subsequently have to watch before they are presented with the correct points from the interview that they should have picked up.

|Please enter the relevant information to be obtained from the patient history below: |

| |

|Amount of weight loss |

|The patient has lost 11kg over 9 months (weight 9 months ago and highest ever weight = 58kg; current weight = 47kg). This loss started |

|gradually but has increased in rate over the past 2 months. She weighs herself at least daily using her mother’s scales. |

| |

|Attitude towards weight loss |

|The patient does not see her weight loss as problematic. In fact, she currently considers herself to be considerably heavier than she would |

|like. |

| |

|Attempts to lose weight [compensatory behaviours] |

|She says that she is ‘watching what she eats’ to control her weight, but denies that this constitutes dieting. Her mother, however, tells you |

|that the patient routinely misses breakfast and now insists on preparing her own evening meal which she eats alone (rather than joining the |

|rest of the family). It is not clear whether she eats at school. She does not binge eat. |

| |

|In addition to deliberately restricting her food intake, the patient admits that she is exercising to lose weight but denies using other |

|methods of weight loss. She is jogging most days before school and her mother suspects that she is exercising in her room in the evenings. |

|This interest in exercise started about 3 or 4 months ago. |

| |

|Physical symptoms |

|The patient admits that her periods have stopped, but she is unconcerned by this. She has never been sexually active and therefore denies that|

|she could be pregnant. Other physical symptoms include general tiredness and an intolerance of cold (she uses a hot water bottle most of the |

|time at home), but she denies other specific physical symptoms. Her mother expresses surprise that her daughter says she is tired because the |

|family have noticed that she seems to be unusually active around the home (for example they have noticed her jogging on the spot whilst |

|watching TV) and Gemma is usually awake and busy well before the rest of the family. |

| |

|Depression |

|You ask about other depressive symptoms. The patient tells you that she is feeling a bit low in mood and lacking in energy. She is also |

|sleeping rather less than previously and is usually waking at about 6am (in order to go jogging). She denies deliberately avoiding her |

|friends, saying that she still gets on with them but would rather spend her time on school work and with her family. It seems clear that her |

|mood has only lowered in the past couple of months and prior to that was fine. She still feels that life is worth living and has no thoughts |

|of harming herself. |

| |

|Social factors |

|You decide to keep the mother in the room whilst you enquire about other social factors. The patient denies any problems at school and points |

|out that she performed extremely well in her recent summer exams. She is about to apply to university and is hoping to train as a vet. When |

|you enquire about family problems, the patient denies that there are any. However, after a pause the mother admits that there have been |

|difficulties between the mother and Gemma’s father. It seems that about a year ago, Gemma’s father left the family home after it came to light|

|that he had been having an affair. About 9 months ago he returned to live with the family, but Gemma’s mother is worried that he may still be |

|having an affair. It is clear that she has discussed this possibility at length with Gemma. There are frequent arguments between the parents.|

| |

| |

|Family history |

|When you ask about family history, the mother says that she is aware that Gemma’s (paternal) grandmother had a chronic unexplained ‘wasting’ |

|disease throughout her 20s and 30s (which started after she gave birth to Gemma’s father). The grandmother apparently saw a series of doctors |

|at the time who were unable to explain why she could not put on weight. She eventually improved spontaneously in her early 40’s but died |

|before she was 50. |

| |

| |

|After this interview your main differential diagnosis is of an Eating Disorder (namely Anorexia Nervosa). However, you wish to exclude thyroid|

|disease, particularly hyperthyroidism (although symptoms such as cold intolerance do not fit with this). Other endocrine or gastrointestinal |

|diseases seem unlikely. |

Point to note at this point if you include them:

• ask for key extra questions on the history

• ask for a differential diagnosis

• what will be the key elements you require on examination to refine your differential?

You will also need to provide information on:

• key questions and answers

• differential diagnosis including links

• learning resources on each of the differentials

Section 3. Patient examination

The next stage that the students will progress to is the patient examination, they will not be required to choose which examination to do but will be presented with all the examination results relevant to this scenario. We have divided the examinations into 10 areas. If you have any examinations that do not fit into these categories please include it under “Other”

In the list below please fill in the relevant examination findings for each system. If you do not feel that examination of a particular system is relevant to this scenario please indicate by putting “Not Necessary” beside the appropriate examination. Please see the example scenario for information on the style of data that is required.

|Examination |Examination results |

|1. General examination |Weight 47.2kg |

| |Height 1.68m |

| |Pale and underweight, wearing 3 layers of warm clothes |

| |Well-hydrated |

| |Apyrexial |

| |Lanugo hair on face |

| |Tooth enamel appears intact |

| |Hands are cold and mildly cyanosed at fingertips, but no calluses (ie. Russell’s sign for |

| |self-induced vomiting is absent). |

| |Nose is also mildly cyanosed |

| |No central cyanosis and no lymphadenopathy |

| |

|2. Cardiovascular system |Pulse 60 |

| |Blood pressure 90/60 (standing) BP 85/57 (lying) |

| |No other abnormalities |

| |

|3. Gastrointestinal system |No organomegaly |

| |No other abnormalities |

| |

|4. Genitourinary system |Secondary sexual characteristics present |

| |Not examined further |

| |

|5. Mental/psychiatric exam |Appearance and behaviour: |

| |Appears reluctant to participate in assessment, but is co-operative with direct questioning. Eyes |

| |cast downwards during much of consultation. Not obviously agitated. |

| | |

| |Speech |

| |Quiet but normal in form and content, |

| | |

| |Mood |

| |Subjectively and objectively low. Admits to tiredness but activity/energy levels are high. No |

| |anhedonia. Few symptoms of anxiety. Sleep disturbed – no initial insomnia but sleeping poorly at |

| |night and awakening at 6am (without alarm). Appetite diminished. No evidence of suicidal ideation |

| | |

| |Thoughts |

| |Overvalued idea that she is overweight and needs to lose weight. Preoccupied with her weight. No |

| |persecutory or grandiose thoughts and no delusions. |

| | |

| |Abnormal Perceptions |

| |None |

| | |

| |Cognitive state |

| |Not specifically tested, but no concern noted during assessment. |

| |

|6. Musculoskeletal system |No evidence of significant proximal muscle weakness |

| |

|7. Nervous system |Normal |

| |

|8. Respiratory system |Normal |

| |

|9. Reticuloendothelial system |Normal |

| |

|10. Urinalysis |Normal |

| |

|11. Other |No other examinations performed |

The students are usually asked to consider their answers to the questions introduced so far as individuals. They then come together as the group of 8 students to discuss their own views on the interpretation of the examination finding, the diagnosis and the investigations to be done.

They are joined by the tutor who reviews their initial ideas on differential diagnosis, helps them with this discussion on examination findings and plans for investigations, and then gives them the results of the investigations as set out below.

Explanation of the examination findings.

Please indicate the meaning of the relevant findings and how they relate to this case. Indicate where suitable links to learning resources occur.

| |

|Examination Findings: |

| |

|Body mass index (BMI) |

|It is essential that you weigh the patient on your scales and record your findings. You must also establish the patient’s height in metres |

|as this allows you to calculate her BMI. The BMI is important as it tells you how underweight / overweight an individual is for their |

|height. The BMI can be calculated as follows: |

| |

|BMI = Weight in kilograms |

|(Height in metres)2 |

| |

|For Gemma, BMI = 47.2/1.682 |

|= 16.7kg/m2 (link to PDF_resource_1) |

| |

|The diagnostic criteria for Anorexia Nervosa in International Classification of Diseases - 10th Edition (ICD-10) state that the patient |

|should have a BMI of less than 17.5kg/m2. |

| |

|BMI can be less reliable as a marker in Anorexia Nervosa: |

|if rapid change in weight |

|at extremes of height |

|if bulimic features |

|if fluid restriction |

|if physical comorbidity, such as type 1 diabetes |

|Children have a BMI range which changes developmentally. The cut off for BMI to make the diagnosis is a weight and height below the second |

|centile of BMI (Growth chart: ) |

| |

|In addition, weight loss at a rate of 1kg/week is of concern. |

| |

|General examination |

|Significant weight loss can lead to the growth of pale, downy hair on the face – this is known as lanugo hair. A patient with Anorexia |

|Nervosa usually feels the cold more than others. Gemma is noted to be wearing layers of warm clothing and yet still her peripheries are cold|

|to touch. |

| |

|A patient who chronically self-induced vomiting may have eroded her tooth enamel. Another characteristic sign is the formation of a callus |

|on the back of the proximal inter-phalangeal joint due to repeated use of that finger to cause vomiting (Russell’s sign). It is relatively |

|rare in clinical practice. In this case, Gemma does not use vomiting to control her weight and therefore lacks these clinical signs. |

| |

|In addition, patients who are severely malnourished, can have a low core body temperature. |

| |

|Cardiovascular system |

|In severe Anorexia Nervosa the patient can become bradycardic or develop (postural) hypotension. |

| |

|Mental/psychiatric examination |

|It is common for a patient with Anorexia Nervosa to be very reluctant to accept that she has a problem. In this case the patient has been |

|brought to you by her mother – her reluctance to see you is manifest in her behaviour during the interview. She has some symptoms consistent|

|with depression, such as low mood and early morning wakening. |

| |

|However, on taking a careful history, it is clear that the weight loss preceded the depressive symptoms and the depression is likely to be |

|secondary to this. It is extremely common to experience worsening depressive and anxiety symptoms as weight decreases. A patient with |

|Anorexia Nervosa will usually, but not always, tell you that they are fearful of gaining weight and becoming fat – in the UK psychiatrists |

|call this an ‘overvalued idea’ which is said to be less intense and fixed than a delusion1. |

| |

|Musculoskeletal system |

|A sign of severe Anorexia Nervosa is the development of a proximal muscle weakness. This can be quickly assessed by asking the patient to |

|stand up from squatting without using their arms to support them. |

| |

|1The ‘fear of fatness’ may be absent in patients with Anorexia Nervosa who are from non-Western cultures. |

Section 4. Investigations & Results

The students are next required to decide what are the most relevant patient investigations that need to be carried out immediately and the most appropriate investigations to be carried out later. Students will not be allowed to progress through the scenario unless they have selected the correct investigations to perform at this stage. When they select the correct investigation the student will be given additional information about the investigation they have selected and it’s relevance to this scenario.

The students are asked:

1. What ‘n’ investigations would you do now, to have results available within the next two hours (choose from the list)?

2. 2. What would you consider the ‘n’ most important investigations on the list to be sent off at this stage?

• The list of investigations has been divided into 11 categories with each of these containing further containing specific investigations. If the investigation does not fit into any of these categories please include it under “Other”

• Please select a set number of the most appropriate investigations to do immediately and later from the list below. Please tick the appropriate options from the column labelled “Immediate investigation” and those from the column “Later investigation”.

• Could you please provide brief explanations behind each investigation chosen.

• You may insert ‘red herrings’ if you wish but again please also explain why these are not appropriate investigations at this time.

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|1) Haematology |Full blood count |Y | |

| |ESR | | |

| |Coagulation studies | | |

| |Cross-match | | |

| |Blood Film | | |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|2) Clinical biochemistry |Electrolytes, urea, creatinine |Y | |

| |Liver function tests | |Y |

| |Calcium, phosphate, alkaline phosphatase |Y | |

| |C reactive protein | |Y |

| |Creatine kinase | |Y |

| |Troponin | | |

| |D-dimers | | |

| |Thyroid function tests | | |

| |Arterial blood gases | | |

| |Oxygen saturation | | |

| |Alpha1-antitrypsin concentration | | |

| |Glucose | | |

| |Lipid Profile | | |

| |Glycated haemoglobin, HbA1c | |Y |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|3) Microbiology |Sputum culture | | |

| |Blood culture | | |

| |mid stream urine | | |

| |HIV test | | |

| |Pneumococcal antigen in urine | | |

| |Sputum for acid fast bacilli | | |

| |CSF: culture and sensitivity, polymerase chain reaction | | |

| |CSF: Gram stain | | |

| |CMV PCR | | |

| |Throat swab: culture and sensitivity | | |

| |Serological testing for hepatitis A, B and C viruses | | |

| |Stool Culture | | |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|4) Histopathology |Cytology | | |

| |Histology | | |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|5) Immunology |Mycoplasma, legionella, chlamydia antibody titres | | |

| |Autoantibodies | | |

| |Anti-nuclear factor | | |

| |Anti-neutrophil cytoplasmic antibody | | |

| |Anti glomerular basement membrane antibody | | |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|6) Drug monitoring |Phenytoin level | | |

| |Antibiotic levels | | |

| |Theophylline level | | |

| |Paracetamol & salicylate levels | | |

| |Digoxin level | | |

| |Laxative screen | |Y |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|7) Imaging |Chest X-ray | | |

| |Other plain X-rays by site | | |

| |Contrast studies (barium meal, enema, IVU) | | |

| |CT chest | | |

| |CT by anatomical site | | |

| |CT chest (high resolution) | | |

| |CT chest (spiral) | | |

| |MRI by anatomical site | | |

| |Ultrasound by anatomical site | | |

| |PET scan | | |

| |Ventilation/perfusion lung scan | | |

| |Thyroid scan | | |

| |Bone scan | | |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|8) Cardiology investigations |Echocardiogram | | |

| |24 hour ECG | | |

| |ECG | |Y |

| |Treadmill exercise test | | |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|9) Endoscopy |Gastroscopy | | |

| |Colonoscopy | | |

| |Sigmoidoscopy | | |

| |Bronchoscopy | | |

| |Cystoscopy | | |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|10) Psychiatric |Informant history/old case notes | | |

|investigations | | | |

| |Risk Assessment | | |

| |Collateral history | | |

| |Additional History from School | |Y |

| |

| |Immediate |Later |

| |investigation |investigation |

| |(Y) |(Y) |

|11) Other tests |Respiratory function tests | | |

| |Electroencephalogram | | |

| |Electromyogram | | |

| |DMSA renogram | | |

| |Sensory nerve conduction studies | | |

| |Motor nerve conduction studies | | |

| |Lumbar Puncture | | |

| |Oral glucose tolerance test | | |

Please now provide the clinical reasoning for each of the investigations you selected and indicate where relevant possible links to additional learning resources and areas of study:

a) Immediate investigations

|Investigation 1 | |

|Investigation category |Clinical Biochemistry |

|Investigation title |Urea, electrolytes and creatinine |

|Explanation |Electrolytes may be dangerously disturbed in eating disorders. The main concern is inadequate fluid |

| |intake in combination with poor eating. Dehydration may occur causing an elevated urea. |

| | |

| |In addition, if the patient is using laxatives, diuretics or vomiting as methods to control their |

| |weights, in which case potassium can be dangerously low - predisposing to cardiac arrhythmias. (see |

| |guide to medical risk assessment for eating disorders - PDF_resource_2). |

|Results & explanation | |

| |Result |

| |Normal Range |

| | |

| |Na |

| |136 mmol/L |

| |137-145 |

| | |

| |K |

| |3.6 mmol/L |

| |3.5-4.9 |

| | |

| |Urea |

| |6.8 mmol/L |

| |2.5-7.5 |

| | |

| |

|Investigation 2 | |

|Investigation category |Clinical Biochemistry |

|Investigation title |Thyroid function tests |

|Explanation |Although this patient is unlikely to have either hypothyroidism or thyrotoxicosis, it is worth |

| |excluding in cases of new onset weight change particularly when accompanied by changes in heat |

| |tolerance and/or mood. |

|Results & explanation | |

| |Result |

| |Normal Range |

| | |

| |Thyroid stimulating hormone |

| |1.43 mU/L |

| |0.30-5.00 |

| | |

| |Free T4 |

| |10.8 pmol/L |

| |10.3-21.0 |

| | |

| |

|Investigation 3 | |

|Investigation category |Insert category here |

|Investigation title |Insert investigation name here |

|Explanation |Insert brief explanation of the investigation here |

|Results & explanation | |

| |

|Investigation 4 | |

|Investigation category |Insert category here |

|Investigation title |Insert investigation name here |

|Explanation |Insert brief explanation of the investigation here |

|Results & explanation | |

b) Later investigations

|Investigation 1 | |

|Investigation category |Haematology |

|Investigation title |Full Blood Count |

|Explanation |Haemoglobin may be slightly low, reflecting a normocytic, normochromic anaemia. If weight loss is |

| |severe then white cell count and platelets may diminish, leading to patients being at risk of |

| |infection. |

|Results & explanation | |

| |Result |

| |Normal Range |

| | |

| |Hb |

| |11.2 g/dL |

| |11.5-16.5 |

| | |

| |White Blood Cell |

| |3.6 x 109/L |

| |4-11 |

| | |

| |Neutrophil |

| |1.1 x 109/L |

| |1.5-7 |

| | |

| |Lymphocyte |

| |2.2 x 109/L |

| |1.5-4 |

| | |

| |Eosinophil |

| |Mean cell vol. |

| |Platelets |

| |0.3 x 109/L |

| |96.8 fl |

| |208 x 109/L |

| |0.04-4 |

| |82-99 |

| |150-400 |

| | |

| |

| |

|Investigation 2 | |

|Investigation category |Clinical Biochemistry |

|Investigation title |CRP |

|Explanation |CRP is usually normal in Anorexia Nervosa, but it is important to rule out a potential cause of weight |

| |loss such as inflammatory bowel disease (which would elevate CRP), particularly if there are symptoms |

| |such as diarrhoea. |

|Results & explanation | |

| |Result |

| |Normal Range |

| | |

| |CRP |

| |4 mg/dL |

| | ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download