A 17-year-old student is brought to your office by her mother who is concerned about her daughter's 6-month history of weight loss and anorexia. The girl states that she feels perfectly well. She is able to maintain her normal activities, including a rigorous exercise program at the university. She measures 162 cm and weighs 38 kg. Her skin is dry, and there is bilateral, painless swelling in both parotid regions.
Investigations are most likely to show:
Correct Answer A:
Serum luteinizing hormone level and serum follicle-stimulating hormone is low in patients with anorexia nervosa. These hormonal alterations in the hypothalamic-pituitary axis in patients with anorexia nervosa represent adaptive and protective mechanisms for chronic starvation and weight loss.
A 15-year-old white female is brought to you by her parents. They report a 30-lb (14-kg) weight loss over the last 10-12 months; her current weight is 39 kg (86 lb). The patient denies any problem exists and says she is very active in school activities and simply doesn’t fell hungry. The patient is extremely thin; the physical examination is otherwise normal.
The most likely diagnosis at this time is:
Correct Answer C:
Anorexia nervosa is an eating disorder seen mainly in young women, usually beginning in adolescence. There are no specific tests to confirm the diagnosis. Findings include refusal to maintain normal weight, denial of any physical problems, amenorrhea, and the absence of findings that suggest organic illness. There may be several physical and laboratory abnormalities, but these are not consistent with other diagnoses.
The lack of specific findings on the history and examination rules out the other problems listed. Hyperthyroidism might be suspected if the pulse rate were high. In anorexia nervosa the pulse is frequently slower than normal. Diabetes severe enough to produce such large amounts of weight loss would present with the classic symptoms of polyphagia, polydipsia, and polyuria. Addison’s disease would produce skin pigmentation changes that would be apparent on examination. Occult neoplasms would produce some subjective symptoms such as fatigue or malaise.
A 14-year-old female is brought to your office by her parents because of concerns regarding her low food intake, excessive exercise, and weight loss. Her weight is less than 75% of ideal for her height.
Which one of the following sets of additional findings would indicate that the patient suffers from severe anorexia nervosa?
Correct Answer E:
Characteristic vital signs in patients with severe anorexia nervosa include hypotension, bradycardia, and hypothermia. Criteria for hospital admission include a heart rate < 40 beats/min, blood pressure < 80/50 mm Hg, and temperature < 36°C (97°F). Increased cardiac vagal hyperactivity is thought to cause the bradycardia.
A 5-year-old boy with Down syndrome is seen because of torticollis, clumsiness and gait difficulties for the past month.
Which one on the following is the most likely diagnosis?
Correct Answer D:
Up to 14 percent of persons with Down syndrome have evidence of atlantoaxial instability on plain radiographs of the neck. From 1 to 2 percent of all persons with Down syndrome have symptoms of atlantoaxial subluxation and, in some cases, symptoms have appeared after surgery for other conditions.
Family members or supervising staff should be advised to monitor for symptoms and an annual neurologic examination should be performed to look for upper motor neuron signs of spinal cord compression.
To assess for spinal cord compression from atlantoaxial instability, test gait, tone, Babinski responses, deep tendon reflexes and clonus. Assess for neck pain, torticollis, gait disturbances, spasticity and weakness.
A 15-year-old female with Down syndrome will compete in Special Olympics gymnastics. She should be evaluated prior to completion due to the potential risk for subluxation of her:
People with Down syndrome have a 15% increased incidence of atlantoaxial instability (AAI). There is a resulting risk of spinal cord injury in these patients. Certain sports are contraindicated for those with AAI, including gymnastics, and radiographs should be obtained prior to participation.
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