HISTORY. Bulimic patients often report a family history of affective disorders, especially depression. The patient may describe patterns of weight fluctuation and frequent dieting, along with a preoccupation with food; this cluster of characteristics may be the first sign of bulimia. Complaints such as hematemesis, heartburn, constipation, rectal bleeding, and fluid retention may be the initial reasons the patient seeks healthcare from a primary healthcare provider. Patients may also have evidence of esophageal tears or ruptures, such as pain during swallowing and substernal burning. If patients seek treatment for bulimia, they usually have exhausted a variety of ways to control their binging and purging behavior. A detailed history of dieting, laxative and diuretic use, and the frequency and pattern of binging and purging episodes is essential. You may need to make a direct inquiry about binging and purging patterns for those patients who are seeking help but are ashamed to volunteer the information. Assess which foods and situations are most likely to trigger a binge.

PHYSICAL EXAMINATION. Often, no symptoms are noted on the physical examination. Obtain the patient's weight and compare it with the normal weight range for age and height. In patients with chronic vomiting, you may notice parotid swelling, which gives the patient a characteristic "chipmunk" facial appearance. Assess the patient for signs of dehydration such as poor skin turgor, dry mucous membranes, and dry skin. Note dental discoloration and caries from excessive vomiting, scars on the back of the hand from chronic self-induced vomiting, and con-junctival hemorrhages. Poor abdominal muscle tone may be evidence of rapid weight fluctuations. Tearing or fissures of the rectum may be present on rectal examination because of frequent enemas. A neurological assessment is important to rule out possible signs of a brain tumor or seizure disorder. Chronic hypokalemia from laxative or diuretic abuse may lead to an irregular pulse or even cardiac arrest and sudden death.

PSYCHOSOCIAL. Assess the patient's current career goals, peer and intimate relationships, psychosexual development, self-esteem, and perception of body image. Pay particular attention to any signs of depression and suicidal ideation and behavior. Assess the patient's ability to express feelings and anger; determine the patient's methods for coping with anxiety, as well as impulse control. Assess the family's communication patterns, especially how the family deals with conflict and solves problems. Assess the degree to which the family supports the patient's growth toward independence and separation.

Diagnostic Highlights

General Comments: No laboratory test is able to diagnose bulimia nervosa, but supporting

tests are used to follow the response to treatment and progression of the illness.

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