WBR0037
| Author | [[PageAuthor::Gonzalo A. Romero, M.D. [1] (Reviewed by Will Gibson)]] |
|---|---|
| Exam Type | ExamType::USMLE Step 1 |
| Main Category | MainCategory::Behavioral Science/Psychiatry |
| Sub Category | SubCategory::General Principles |
| Prompt | [[Prompt::A 17-year-old female is brought to the outpatient clinic by her mother because she is refusing to eat and is exercising more than usual. She has earned several awards because of her athletic skills in the past, and is extremely competitive in school. 4 months ago her parents divorced. Shortly thereafter, the patient started a special diet and she has lost 15 pounds. Her mom has tried to enforce a regular diet with sufficient calories, but the patient is reluctant to increase her caloric intake. She reports a strong fear of gaining weight and feels fat in front of the mirror. Her mother states that she stopped having a menstrual cycle 5 weeks ago. On physical exam her vitals HR: 78, BP: 123/80, Temp: 37 C, BMI: 16.5. She has fine hair over her entire body, multiple dental cavities, and extremities are atrophied. What is the most likely diagnosis?]] |
| Answer A | AnswerA::Post traumatic stress disorder |
| Answer A Explanation | [[AnswerAExp::Post traumatic stress disorder It is defined as the flashbacks which are the re-experience of the stressful events or recollections, nightmares and the avoidance of the associated stimuli. It also has sleep disturbances, irritability, compulsive behaviors avoiding the stimuli, inability to concentrate. Symptoms last more than a month, if less than a month it is considered Acute Stress Disorder. It usually presents after a stressful event severe enough to disrupt the person's coping mechanisms which commonly is presented as a life threat to self, or surroundings. It is commonly presented in women. An example of this is a woman being raped.]] |
| Answer B | AnswerB::Obsessive compulsive personality disorder |
| Answer B Explanation | [[AnswerBExp::Obsessive compulsive personality disorder It is lifelong pattern of perfectionism that extends to all areas of life (pervasive). Persons with this type of personality often are extremely organized, use lists and order as a must in their lives. It is more common in males. This patient might present traits, but not as intense or chronically present to be considered an Obsessive Personality Disorder.]] |
| Answer C | AnswerC::Anorexia nervosa |
| Answer C Explanation | [[AnswerCExp::Anorexia nervosa It is an eating disorder frequently in female teenagers and young female adults. It is defined as a self restriction in caloric intake which causes significant weight loss 15 to 20% below ideal weight and the BMI <17.5. Characteristically they have a fear of gaining weight. Half percent of patients may develop binge and purge behaviors and could be depressed. They typically are resistant to accept the condition or deny the illness. On physical exam her BMI is less than 17.5, have lanugo or baby-like hair, could have dental cavities due to vomiting, and could have a lower stage of Tanner if presented in adolescence. Treatment usually is supportive to stabilize body weight and pharmacotherapy could be used like Mirtazapine which treats depression and also increases appetite as a side effect.]] |
| Answer D | AnswerD::Bulimia |
| Answer D Explanation | [[AnswerDExp::Bulimia It is an eating disorder that involves binging and purging behaviors defined as voluminous ingestion of food followed by vomiting, laxative use, dieting pills or exercise. On physical exam they could have signs of vomiting such as callous on hands, enlarged parotids and other glands, dental cavities, esophageal tears or esophagitis, and her BMI usually stays normal or above normal. The treatment involves SSRIs, Imipramine, and support therapy.]] |
| Answer E | AnswerE::Obsessive compulsive disorder |
| Answer E Explanation | [[AnswerEExp::Obsessive compulsive disorder It is a subtype of Anxiety disorder which involves obsessions defined as the focus in one thought; and compulsions which are repetitive actions to avoid the thoughts.
The patient usually recognizes the problem and tries to resist the obsessions. It is focal and acquired which help distinguishing from Obsessive Personality disorder which is lifelong and pervasive.]] |
| Right Answer | RightAnswer::C |
| Explanation | [[Explanation::Most of this patient's symptoms are consistent with a diagnosis of Anorexia nervosa, including the constant fear of gaining weight, body image disturbance, restriction in caloric intake, and excessive exercise. Important characteristics help distinguish Anorexia from Bulimia; Anorexia causes low BMI and amenorrhea due to the strict caloric intake.
Conversely, Bulimia is a syndrome that is characterized by episodes of binging (excessive eating) and purging, often by induced vomiting or laxative abuse. These patients tend to have a normal or higher BMI. They may display signs of vomiting induction such as callous on fingers, halitosis, enlarged parotids, dental and cavities. While this patient has signs of frequent vomiting, her low BMI, caloric restriction and excessive exercise make anorexia the more likely option. In both anorexic and bulimic patients, cardiac complications may arise due electrolyte disturbances and consequent conduction defects. A small percentage of these patients can die from fatal arrhythmias. |
| Approved | Approved::Yes |
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| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |