WBR0037

Author	[[PageAuthor::Gonzalo A. Romero, M.D. [1]]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Behavioral Science/Psychiatry
Sub Category	SubCategory::General Principles
Prompt	[[Prompt::A 17 year old female is brought to the Outpatient Clinic by her mother because she is refusing to eat and is exercising a lot more than usual. She has gotten several awards because of her athletic skills in the past, is extremely competitive in school, is one of the best students in the class. She started a special diet 4 months ago which has made her loose weight over this period of time after her parents divorce. Her mom has tried to make her eat a regular diet in calories, but she is reluctant to increase her body caloric intake due to a strong fear of gaining weight and feels fat in front of the mirror as described. Her mother states that she stopped having a menstrual cycle 5 weeks ago and that she has been drinking more water than usual and exercising more than before. On physical exam her vitals HR: 78, BP: 123/80, Temp: 37 C, BMI: 16.5. She has fine hair over her entire body, multiple dental cavities, her breasts look atrophied, extremities are atrophied. What is the most likely diagnosis?]]
Answer A	[[AnswerA::Post traumatic stress disorder]]
Answer A Explanation	[[AnswerAExp::Incorrect. It is defined as the flashbacks which are the re-experience of the stressful events or recollections, nightmares and the avoidance of the associated stimuli. It also has sleep disturbances, irritability, compulsive behaviors avoiding the stimuli, inability to concentrate. Symptoms last more than a month, if less than a month it is considered Acute Stress Disorder. It usually presents after a stressful event severe enough to disrupt the person's coping mechanisms which commonly is presented as a life threat to self, or surroundings. It is commonly presented in women. An example of this is a woman being raped.]]
Answer B	[[AnswerB::Obsessive compulsive personality disorder]]
Answer B Explanation	[[AnswerBExp::Incorrect. It is lifelong pattern of perfectionism that extends to all areas of life (pervasive). Persons with this type of personality often are extremely organized, use lists and order as a must in their lives. It is more common in males. This patient might present traits, but not as intense or chronically present to be considered an Obsessive Personality Disorder.]]
Answer C	[[AnswerC::Anorexia nervosa]]
Answer C Explanation	[[AnswerCExp::Correct. It is an eating disorder frequently in female teenagers and young female adults. It is defined as a self restriction in caloric intake which causes significant weight loss 15 to 20% below ideal weight and the BMI <17.5. Characteristically they have a fear of gaining weight. Half percent of patients may develop binge and purge behaviors and could be depressed. They typically are resistant to accept the condition or deny the illness. On physical exam her BMI is less than 17.5, have lanugo or baby-like hair, could have dental cavities due to vomiting, and could have a lower stage of Tanner if presented in adolescence. Treatment usually is supportive to stabilize body weight and pharmacotherapy could be used like Mirtazapine which treats depression and also increases appetite as a side effect.]]
Answer D	[[AnswerD::Bulimia nervosa]]
Answer D Explanation	[[AnswerDExp::Incorrect. It is an eating disorder that involves binging and purging behaviors defined as voluminous ingestion of food followed by vomiting, laxative use, dieting pills or exercise. On physical exam they could have signs of vomiting such as callous on hands, enlarged parotids and other glands, dental cavities, esophageal tears or esophagitis, and her BMI usually stays normal or above normal. The treatment involves SSRIs, Imipramine, and support therapy.]]
Answer E	[[AnswerE::Obsessive compulsive disorder]]
Answer E Explanation	[[AnswerEExp::Incorrect. It is a subtype of Anxiety disorder which involves obsessions defined as the focus in one thought; and compulsions which are repetitive actions to avoid the thoughts. The patient usually recognizes the problem and tries to resist the obsessions. It is focal and acquired which help distinguishing from Obsessive Personality disorder which is lifelong and pervasive.]]
Right Answer	RightAnswer::C
Explanation	[[Explanation::This is an interesting case as it involves a teenager dealing with a strong stressful event, such a recent divorce. Most of her symptoms and signs fall into the category of Anorexia Nervosa due to the constant fear of gaining weight, the body image disturbance, the restriction in caloric intake, exercising more than usual. Important characteristics help distinguish Anorexia from Bulimia; Anorexia causes low BMI due to the strict caloric intake and also Amenorrhea. She is drinking more water than usual to fulfill herself and inhibit the hunger. Bulimic patients often have a normal or higher BMI or weight, may have signs of vomiting induction such as callous on fingers and hands, halitosis, enlarged parotids, dental cavities due to the vomiting and could have cardiac abnormalities. Both of them could cause electrolyte imbalances which could lead to Arrhythmia and also Binge and purge could be present in Anorexic patients as well. Educational Objective: References: ]]
Approved	Approved::Yes
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