Assessment

HISTORY. The patient typically claims to feel well and appears unconcerned about his or her weight loss. Obtain a diet and weight history. Assess the patient for both gradual and abrupt weight loss, and compare the values with normals for her or his age and height. Assess the current food intake; develop a diet history; elicit a description of exercise patterns; and assess for the amount and frequency of binging, purging, and laxative and diuretic use.

Assess the patient's perception of his or her body image. Although patients appear emaciated, they view themselves as fat. Hunger is not a complaint. Complaints include difficulty sleeping, abdominal discomfort and bloating after eating, constipation, cold intolerance, and polyuria; therefore, assess all of these dimensions. Unlike other starving individuals, anorexic people are not fatigued until malnutrition is severe. Most are restless and active, and some exercise excessively. Assess how the patient views food to determine the intensity of the fear of weight gain and her or his preoccupation with restricting food. Obtain a history of menses in females because usually the patient has a history of amenorrhea or a delayed onset of menses.

PHYSICAL EXAMINATION. On examination, the person appears extremely thin—if not emaciated—but animated. Obtain the patient's weight, which for diagnosis should be 15% below normal body weight for his or her age and height. You may note bradycardia, postural hypotension, and hypothermia. The patient's skin may appear dry, pale, and yellow-tinged, and the face and arms may be covered by a fine, downy hair (lanugo). The nails are generally brittle, and there is a loss of or thinning of hair. There is usually delayed sexual maturation. Breasts may be atrophied or poorly developed. Amenorrhea may precede or accompany the weight loss. Bowel sounds may be hypoactive.

86 Anorexia Nervosa

PSYCHOSOCIAL. Psychosocial assessment should include assessment of self-esteem, peer relationships, changes in school performance, involvement in sports, perception of self as a sexual being, fear of sexual maturity, and perception of body image. Because anorexic patients are preoccupied with food, they often isolate themselves from peers and friends. When assessing body image, it is helpful to have the female patient take a female body outline and color in those areas that are pleasing and those that are displeasing.

Assess family communication patterns to determine who talks for whom, how decision-making and conflict are handled, and how parents view the current problem. Assess recent family crises and recent counseling experiences.

Diagnostic Highlights

General Comments: No laboratory test Is able to diagnose anorexia nervosa, but supporting tests are used to follow the response to treatment and the progression of the Illness.

Test

Normal Result

Abnormality with Condition

Explanation

Complete blood count

Red blood cells (RBC) 4.0-5.5 million/mL; white blood cells (WBC) 4500-11,000/mL; hemoglobin (Hg) 12-18 g/dL; hematocrit (Hct) 37%-54%; reticulocyte count 0.5%-2.5% of total RBCs; platelets 150,000-400,000/mL

Anemia; RBC < 4.0; hematocrit < 35%; hemoglobin < 12 g/dL

Caused by protracted undernutrition

Albumin

3.5-5.0 g/dL

Hypoalbuminemia; albumin < 3.5 g/dL

Caused by protracted undernutrition

Other Tests: Serum electrolytes may show hypokalemia, hypochloremia, hypomagne-semia, hypocalcemia, or hypoglycemia. Other laboratory tests include cholesterol (elevated), serum amylase (elevated), luteinizing hormone (decreased), testosterone (decreased), thyroxine (mildly decreased), electrocardiogram, blood urea nitrogen.

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