Review Question - QID 210744

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Bulimia Nervosa Presentation Physical exam QID: 210744 (M2.OMB.18.1)

QID 210744 (Type "210744" in App Search)

A 17-year-old girl presents to her primary care physician with a concern for a puffy cheek. She has noticed she has had a puffy cheek for the past month despite exercising more often and eating a healthy diet. The patient states she is an otherwise healthy student, does not smoke, and is not sexually active. Her temperature is 97.9°F (36.6°C), blood pressure is 114/74 mmHg, pulse is 105/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young woman with a nontender abdomen. Exam reveals the finding in Figure A as well as poor dentition. Her BMI is 26 kg/m^2 and she has normal development for her age. Laboratory values are ordered as seen below.

Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 12,900/mm^3 with normal differential
Platelet count: 191,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 3.0 mEq/L
HCO3-: 29 mEq/L
BUN: 23 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 10.2 mg/dL

Which of the following is the most likely diagnosis?

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Anorexia nervosa

0/11

Bulimia nervosa

64%

7/11

Sialolithiasis

18%

2/11

Suppurative parotitis

18%

2/11

Viral parotitis

0/11

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This patient is presenting with electrolyte abnormalities (hypokalemia and a metabolic alkalosis), parotitis, poor dentition, and an increased BMI (though normal can also be seen) which is concerning for bulimia nervosa.

Bulimia nervosa is an impulse control disorder which presents with binging/purging behavior. Patients may consume large amounts of food followed by purging which may take the form of vomiting, exercising, or fasting. If the patient induces vomiting, she may have cuts on the dorsum of her hand, stained teeth/dental caries, and parotitis. The BMI in bulimia nervosa is typically normal or can be elevated in contrast to anorexia nervosa where the BMI is low. The treatment of bulimia nervosa involves first stabilizing the patient's volume status and electrolytes. Outpatient management includes cognitive behavioral therapy (CBT) and high dose selective serotonin reuptake inhibitors (SSRIs).

Figure A is the physical exam finding of parotitis (the parotid gland) with the patient's right gland swollen.

Incorrect Answers:
Answer 1: Anorexia nervosa is another impulse control disorder which may present with decreased intake or can also present with binging/purging behavior. The BMI in anorexia nervosa is typically decreased.

Answer 3: Sialolithiasis can present with pain or tenderness over the cheek that is worse with salivation (such as during eating). It is usually unilateral but can be bilateral. It can progress to sialoadenitis (inflammation usually secondary to an infection of the salivary gland).

Answer 4: Suppurative parotitis is a bacterial infection of the parotid gland and presents with a more ill patient including fever, erythema, severe tenderness, and possible purulence. Antibiotics are required and surgical intervention may be indicated if there is an abscess.

Answer 5: Viral parotitis can be caused by mumps or other viruses and typically presents with a low-grade fever as well as a unilateral (or bilateral) swollen and tender parotid gland. Patients are typically better appearing with more mild symptoms when compared to suppurative parotitis.

Bullet Summary:
Bulimia nervosa presents with binging/purging behavior, dental caries, and parotitis.

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