Class 4

Question 1

At risk anorexia

Answer 1

female, young, depression, medical comorbidities

Question 2

at risk bulimia

Answer 2

change in weight, bulimia, anxiety, vital signs, medical comorbidities

Question 3

at risk BED

Answer 3

not as young, increase in weight, male or female, anxiety, impulsivity, depression, GI problems, mestrual prb, metabolic syndrome

Question 4

What to ask screening

Answer 4

• Are you trying to lose weight, have you lost weight, are you still losing weight?
• What are you doing to lose weight?
• Do you ever lose control over how much you eat?
• Would you say that food dominates your life?
• Body image question

Question 5

Worrisome sx

Answer 5

loss of consciousness 
convulsions
weakness: get out of chair
BMI ≤ 15
Weight loss ≥ 1 kg /week x 3 months
Pregnancy
Type 1 diabetes
Weakness or syncope
Sodium < 130
Potassium < 3.0
Abnormal liver function tests
Bradycardia < 45; Prolonged QTc
Orthostatic changes : BP drops by ≥ 20; Pulse increases by ≥ 20
Hypothermia (≤ 35.0°C)
Contact us: Medical risk management

Question 6

basic labs to do

Answer 6

CBC
Albumin, Total Protein
Glucose Random
Creatinine
Sodium, Potassium, Chloride, Bicarbonate
ALT (Alanine aminotransaminase);
AST (Aspartate aminotransaminase) if alcoholic
CK (Creatinine kinase)
Calcium, Magnesium, Phosphate
B12
HbA1c (if diabetic)
TSH
Other recommended tests
Electrocardiogram (ECG)

Question 7

Elevated CK

Answer 7

intense exercise

Question 8

potassium low, increase Cl and CO2

Answer 8

induced vomiting

Question 9

increased ALT

Answer 9

liver damage because malnourished

Question 10

WBC low

Answer 10

bone marrow suppression in the case of chronic under eating. Not more prone to illness

Question 11

Physical consequences

Answer 11

Arrhythmia
Bradycardia
Osteoporosis
Amenorrhea
Hypokalemia
Hypothermia
Hypophosphatemia
Hypotension

Question 12

Starvation leads to

Answer 12

energy conservation: decrease in temperature, pulse, BP, turn off reproductive factors
dehydration: water conservation mechanisms turn on: decrease BP increase pulse

Question 13

Starvation uses up

Answer 13

reserves: fat, muscle and bone, other tissues

Question 14

Effect of vo

Answer 14

Teeth
Throat
Salivary glands
Stomach
Blood in vomit

Question 15

Effect of laxatives

Answer 15

Cramps
Bloating
Diarrhea
Blood in stool

Question 16

Most common s/symptoms: or purging

Answer 16

dizziness and poor concentration
Gastroesophageal reflux (heartburn); dental problems, parotid gland enlargement
Elevated amylase (normal lipase); metabolic alkalosis (elevated CO2)

Question 17

when weight decreases, what increases

Answer 17

compulsivity and hyperactivity

Question 18

PRIORITY 3

Answer 18

Normal weight
No daily bingeing or purging
No medical complications

Question 19

PRIORITY 2

Answer 19

BMI: 15-18 (women); 16 -19 (men) or sign of medical instability
With at least one symptom

Syncope
Laxatives > 10 co./day
Hypokalemia < 2.8 mmol/L
Fasting > 2 days/week
Multiple purging episodes per day

Question 20

PRIORITY 1

Answer 20

BMI: < 15 (women); < 16 (men) or Drastic weight loss
1 kg/week x 3 months
Significant medical instability i.e. syncope, bradycardia, ↓↓ potassium
Fasting : 2 days/week
Pregnancy
type 1 db
transfer from adolescent services

Question 21

Proposed criteria to send patient to ER

Answer 21

BMI < 12 (female) <13 (male) or rapid and drastic weight loss.
•Plus at least one or more of the following:
–Ongoing weight loss
–Syncope
–Weakness
–Bradycardia HR< 40 bpm or HR > 110 bpm
–Hypothermia <34.8 C
–Hyponatremia <120 mmol/L or <125 mmol/L and symptomatic

Regardless of weight:
–Hypokalemia < 2.8 mmol/L or hypokalemia with abnormal EKG and/or significant metabolic alkalosis (CO2 >38 mmol/L)
–Signs and symptoms of severe dehydration

Question 22

To ignore labs

Answer 22

• Low T3 (metabolic compensation)

* High cholesterol

Question 23

pharmaco bulimia

Answer 23

SSRIs and other antidepressants are useful.

Question 24

pharmaco BED

Answer 24

SSRIs, SNRIs, and medications associated with appetite and weight reduction, such as the stimulant LDX (Vyvanse), work.

Question 25

pharmaco anorexia

Answer 25

Olanzapine appears to have a small but significant effect on weight gain, but should not be used as a stand-alone treatment

Question 26

pharmaco arfid

Answer 26

Mirtazapine and Olanzapine are worth a try

Question 27

Not recommended: pharmaco

Answer 27

Tricyclics (cardiac risk; prolonged QTc interval), Paroxetine(weight gain), Mirtazapine (increased appetite), Bupropion (increased seizure risk)

Question 28

What doesn’t work pharmaco

Answer 28

• Manipulating appetite (↑ or ↓)
• Trying to decrease or stop bingeing and purging when a person is underweight
• Taking your medication and then throwing up

Question 29

K 3-3.5

Answer 29

a banana per day

if lower: give supplement, ask tonight in bed (less chance of purging)

Question 30

sx of low k:

Answer 30

cramps, fatigue, palpitations thirst, novo, thirst, partial or total paralysis, tingling of the extremities, fingertips, around the mouth and nostrils

Question 31

complications of hypok

Answer 31

arythmie, slowing of the heart, cardiac arrest

Question 32

Refeeding

Answer 32

•Increasing your intake can be painful
–Expect physical and psychological discomfort
–Bloating, early satiety, nausea, feeling uncomfortably full, gas, constipation…
•Refeeding syndrome is rare and only seen in hospitalized patients

Question 33

osteoporosis give

Answer 33

Ca and vit D:

Question 34

Weight loss: Common symptoms and signs

Answer 34

Sx:Cold intolerance; dizziness; hair loss; poor concentration, fatigue; insomnia ; early satiety (fullness); bloating; heartburn; amenorrhea; loss of libido
Signs: Metabolic profile different from other types of starvation (Normal protein and albumin); Sick euthyroid (normal TSH/T4; low T3; increased rT3); Anemia (~40%) often normochromic, normocytic but may be microcytic if iron deficient; low white count (~30%); high cholesterol (up to 75%)

Question 35

Hyponatremia

Answer 35

Low sodium: suspect water loading (<130 mmol/L high risk) or occult chest infection with associated SIADH

Question 36

Hypoglycemia:

Answer 36

• blood glucose <3 mmol/L (if present, suspect occult infection, especially with low albumin or raised C-reactive protein)
• Also seen in refeeding usually post-prandial (insulin surge in context of low glycogen stores in liver to offset). Treat only if patient is symptomatic

Question 37

Normal weight Bulimia: Common s/sx

Answer 37

Symptoms: Dizziness, Palpitations, Fatigue, Heartburn; Bloating
Signs: Dental caries, enamel erosion, loss of teeth, gingivitis, enlarged salivary glands, callous on the back of the hand (Russell’s Sign)

Question 38

Normal weight Bulimia: Worrisome

Answer 38

Orthostatic changes in blood pressure+ pulse:
BP decreases by≥ 20/Pulse increases by ≥ 20
Hypokalemia (potassium < 3.0); Pseudo-Bartter’s syndrome (hypochloremic hypokalemic metabolic alkalosis). CO2 > 38
Hyponatremia
Pancreatitis
Hematemesis (Mallory-Weiss tear)
Incontinent (severe laxative abuse)