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Decreased chloride, decreased potassium, decreased bicarbonate
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Decreased chloride, decreased potassium, increased bicarbonate
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Decreased chloride, increased potassium, increased bicarbonate
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Increased chloride, decreased potassium, decreased bicarbonate
Increased chloride, increased potassium, increased bicarbonate
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This patient has bulimia nervosa. Bulimia nervosa is a serious eating disorder, which if involves purging, may manifest with hypochloremic, hypokalemic metabolic alkalosis. Bulimia nervosa manifests as uncontrolled eating with a compensatory response, which may involve vomiting, excessive exercise, laxative or diuretic abuse. Patients who induce vomiting may demonstrate hypochloremic, hypokalemic metabolic alkalosis. Purging results in the direct loss of hydrogen and chloride ions with subsequent dehydration. Dehydration activates the renin-angiotensin-aldosterone system, which causes loss of bicarbonate and potassium. If the patient undergoes acute laxative abuse, chloride levels may actually increase secondary to rapid loss of bicarbonate through diarrhea. Harrington et al. discuss the diagnosis of bulimia nervosa. Initial workup should include the investigation for any life-threatening medical conditions. Patients should have vitals taken, paying attention to blood pressure and for signs of orthostatic hypotension. When measuring weight, patients should be in their underwear, as patients may attempt to wear extra layers of clothing. Urine and blood should be analyzed along with electrocardiography performed. During physical examination physicians should be weary of callused or scars on the hands (Illustration A; Russell's sign), edema, and enlarged parotid glands. Mehler et al. discuss some of the other medical complications seen with purging (vomiting, laxative abuse, diuretic abuse) in bulimia nervosa. Cardiac manifestations include prolonged QTc and arrhythmias (due to hypokalemia) and orthostatic hypotension (due to volume depletion). Pulmonary issues may include pneumomediastinum (secondary to retching), foreign body obstruction (object used to force vomiting) and aspiration. Gastrointestinal complications may include gastroesophageal reflux disease and cathartic colon (due to chronic laxative abuse). Illustration A demonstrates a callus and abrasion to the hand secondary to induced vomiting, also known as Russell's sign. Incorrect Answers: Answer 1: This patient has hypochloremic, hypokalemic metabolic acidosis, which would not be seen with vomiting. Answer 3 & 5: Increased potassium would not be observed in vomiting, laxative or diuretic abuse. Answer 4: Increased chloride, decreased potassium and decreased bicarbonate may be observed in acute diarrhea secondary to infection or abuse.
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