Anorexia in child/adolescents

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

For this Assignment, you will document information about a patient that you examined, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

Answer

Patient Details: Ava Mia, 14 years old, Latin American, female.

Subjective:

CC (chief complaint): “I’m apprehensive about my weight and have no appetite. I do not like how my body looks.”

HPI: The patient, Ava Mia, a 14-year-old Latin American female, presents concerns about her weight and loss of appetite. The patient’s parents have reported that she has been refusing meals for the past six months and engaging in excessive exercise. Ava expressed that these issues began when she was around eight years old – sometimes restricting food intake and feeling guilty if she overate. She strongly avoids high-calorie foods due to fear of gaining weight. In addition, her parents have noticed a decline in her school performance and increased social withdrawal. Currently, it has reached a point where the patient takes frequent pictures of herself to monitor any progression related to weight loss; however, actual weighing is not done as there is no scale available. Her goal is to maintain a petite image without resorting to bingeing or purging behaviors such as vomiting. Instead, she closely monitors portion sizes and calorie intake; whenever feelings of guilt arise or she believes that weight gain might occur, Ava compensates by engaging in excessive workouts.

The patient denies any problems at home. She mentions that she experiences a solid aversion to looking at herself when her menstrual cycle begins. She admits neglecting personal hygiene because of feeling unwell and finds it unbearable to even glance at feminine products. Additionally, the patient reports experiencing emotional mood swings, crying spells, sadness, anxiety, and excessive sleepiness.

Past Psychiatric History: Ava denies any previous psychiatric diagnosis

Medication Trial: none

Psychotherapy or Previous Psychiatric Diagnosis: The patient has not received psychotherapy or any prior psychiatric diagnoses.

Substance Use History: None.

Family Psychiatric/substance Use History: There is no recorded familial background of psychiatric conditions, substance abuse issues, or past suicidal attempts.

Medical History

  • Current Medications: No current medications reported
  • Allergies: No food or drug allergy.
  • Reproductive Hx: LMP: July 1, 2023, not Pregnant, not lactating, no hx of contraceptive use, has not had sexual debut.

ROS (review of symptoms):

GENERAL: The patient does not experience any chills, fever, or fatigue—weight loss.

HEENT: 

  • Head: No headaches or head injuries

  • Eyes: No vision changes, eye pain, redness, discharge, or itchiness.  

  • Ears: No hearing loss. 

  • Nose: No nasal congestion or report of a runny nose.

  • Throat: The patient has no sore throat or difficulties with swallowing. 

SKIN: No rash, wounds, or cuts

CARDIOVASCULAR: Negative for palpitations and chest pain.

RESPIRATORY: No coughing, production of phlegm, or shortness of breath was reported. GASTROINTESTINAL: Reports abdominal distension and reduced appetite. No vomiting or diarrhea, stomach pain and no blood in the stool.

GENITOURINARY: No decreased urine volume, difficulty passing urine, frequency, or urgency.

NEUROLOGICAL: Denies weakness, dizziness, and headaches. MUSCULOSKELETAL: Free from joint/bone stiffness and discomfort and no fractures.

HEMATOLOGIC: No report of bruising/bleeding tendencies

LYMPHATICS: No swollen lymph nodes.

PSYCHIATRIC: The patient does not report any difficulties with sleep. However, they are experiencing nervousness and anxiety. They also have erratic emotional changes and feel panicked in social situations.

ENDOCRINOLOGIC: No excessive sweating, cold/hot intolerance, no polyuria or polydipsia.

REPRODUCTIVE: Not sexually active.

ALLERGIES: No allergic reaction reported

Objective:

Physical examination shows cold extremities, lanugo hair growth, and dry skin. Other systems are found to be completely normal. Vital signs are within normal range. Blood Pressure (BP): 100/70 mmHg, Heart Rate (HR): 80 bpm, Respiratory Rate (RR): 16 breaths per minute, Temperature (Temp): 98.6°F (37°C). The patient has a BMI of 16.2, below the 5th percentile for her age, and appears pale and malnourished.

Diagnostic results: Laboratory tests reveal lower serum potassium levels and metabolic alkalosis, consistent with electrolyte abnormalities and dehydration brought on by starvation. The total blood count and thyroid function are both within normal limits.

Assessment:

Mental Status Examination: The patient looks older than her age, she is dressed for the weather, but the clothes appear small for her. The patient sat quietly and was guarded. Her speech was slowed but displayed logic and appropriate thought content. The patient showed a noticeable and persistent depressed mood. The individual also demonstrates diminished interest in previously enjoyed activities, which indicates decreased motivation and pleasure.

Furthermore, there appeared to be an intense preoccupation with body weight and shape. Ava was oriented to time, place, and person, and her short-term and long-term memory was intact. Her concentration appeared to be distraught. She had good insight and judgment as she was aware of her condition and that she needed help.

Diagnostic Impression:

Anorexia Nervosa R63.0

The primary diagnosis is established based on the patient’s significant reduction in weight, distorted body image, and restrictive eating habits. These symptoms are consistent with the diagnostic criteria for anorexia nervosa outlined in the DSM-5. Anorexia nervosa is a complex disorder characterized by physical and psychological manifestations that reflect its severity. Individuals diagnosed with anorexia nervosa often experience amenorrhea, which is the absence of menstrual periods due to extreme weight loss and nutritional deficiencies (Moore & Bokor, 2019). They may also exhibit cold intolerance, constipation, swelling in extremities (edema), fatigue, and irritability (van Eeden et al., 2021). These physical symptoms arise from inadequate calorie consumption and malnutrition. Psychologically, individuals suffering from anorexia nervosa frequently engage in various restrictive behaviors surrounding food intake. This can include meticulously tracking calories or strictly controlling portion sizes to perpetuate their weight loss regimen while maintaining a distorted perception of their body.

In addition, numerous individuals adopt purging techniques to control their weight further, such as inducing vomiting or misusing diuretics and laxatives. Another prevalent characteristic of anorexia nervosa is compulsive exercise, where patients participate in excessive physical activity for prolonged durations to eliminate any perceived surplus calories (Kaufmann et al., 2023). Consequently, this contributes to their continued weight loss and decline in physical well-being. The physical and psychological manifestations exhibited by the individual align with the diagnosis of anorexia nervosa.

Major depressive Disorder:

According to recent research, it is common for individuals with anorexia nervosa also to experience concurrent depressive Disorder (Fornaro et al., 2020). Therefore, both conditions must be addressed simultaneously to provide comprehensive treatment and improve patient outcomes. The persistent low mood and diminished interest in activities exhibited by the patient strongly suggest the presence of a comorbid depressive disorder alongside their anorexia symptoms.

Generalized Anxiety Disorder F41.9

Although excessive exercise and fear of weight gain can indicate an anxiety disorder, they are often secondary features in individuals with anorexia nervosa (Ramírez-Cifuentes et al., 2021). The main aspects of anorexia nervosa include severe food restriction, distorted body image, and significant weight loss, which align with the criteria outlined in DSM-5. Hence, the primary diagnosis continues to be anorexia nervosa. It is essential to comprehensively address both disorders to ensure effective treatment and patient recovery.

Case Formulation and Treatment Plan: 

Case formulation:

Ava Mia, a 14-year-old Latina girl who meets the DSM-5 criteria for anorexia, has a primary diagnosis of anorexia nervosa due to her weight loss, distorted body image, and restrictive eating patterns. She has avoided high-calorie foods, exercised vigorously, and refused meals for the past six months out of a dread of gaining weight and a desire for a slim, petite frame. Her depression raises the possibility of a coexisting major depressive disorder because emotional mood swings and sensations of despair accompany it. Ava’s exaggerated exercise and terror may also be a sign of a secondary aspect of generalized anxiety disorder. The Anorexia Nervosa, however, necessitates thorough treatment addressing physical and psychological issues to enhance her overall well-being and chances of recovery.

Treatment plan:

A multidisciplinary strategy comprising medical, dietary, and psychosocial therapies is necessary to care for anorexia nervosa. Hospitalization is required for medical stabilization and nutritional rehabilitation due to the patient’s severe malnutrition and electrolyte abnormalities. Addressing urgent medical conditions and safeguarding the patient’s safety need hospitalization.

Medication: Medical interventions aim to restore and preserve the patient’s physical health. This includes monitoring and treating any medical issues caused by the patient’s malnutrition, such as electrolyte imbalances, heart irregularities, and osteoporosis. Given the comorbidity of depressive symptoms, selective serotonin reuptake inhibitors (SSRIs) may ameliorate symptoms (Bains & Abdijadid, 2022).

Psychological therapies are critical in addressing the underlying psychological problems contributing to anorexia nervosa development and maintenance. Individual therapy, group therapy, and family-based therapy are examples of interventions. Following medical stabilization, the patient should receive individual and family-based CBT to address the behavioral and cognitive patterns typical of anorexia nervosa (Muratore & Attia, 2020). CBT has shown efficacy in treating anorexia nervosa by confronting erroneous attitudes and behaviors.

Nutritional therapies aim to restore the patient’s weight and help them build a healthy connection with food. Working with a qualified dietitian to develop a meal plan that fulfills the individual’s nutritional needs and promotes weight restoration is part of this process. Nutritional Counseling: A licensed dietician will educate and support the patient to help them establish a healthy and balanced eating pattern.

Follow-up plan: During the patient’s stay in the hospital, their vital signs, electrolytes, and weight will be closely monitored. Once they are discharged from the hospital, therapy sessions and medical check-ups will be scheduled weekly. The frequency of these appointments may gradually decrease as determined by the treatment team.

Referrals: The patient will be referred to a specialized eating disorder treatment facility for continuous outpatient care and assistance.

Social Determinant of Health (HealthyPeople, 2030): Disparities in diagnosing and treating anorexia nervosa among different populations may be affected by socioeconomic status, which can impact access to treatment resources.

Health Promotion Activity: Work with school staff to increase knowledge about eating disorders, encourage a healthy body image, and offer education on identifying early warning signs to facilitate prompt identification and intervention.

Patient Education Consideration for Improving Health Disparities and Inequities: Patients with anorexia nervosa limit their food intake concerning their energy needs by eating less, exercising more, and/or purging food through laxatives and vomiting (Moore & Bokor, 2019). Despite being significantly underweight, they have erroneous perceptions of what their bodies should look like. As a result of expelling food and being underweight, they may experience difficulties (Moore & Bokor, 2019). Treatment entails weight gain (sometimes in a hospital if severe), body image counseling, and management of malnutrition-related problems.

Reflection: Considering Ava Mia’s situation, I am deeply concerned about the obstacles she encounters at such a young age. Her distorted body image and severe food restriction have negatively impacted her physical and mental health. The co-occurrence of depressive and anxious symptoms highlights the complexity of her condition, necessitating an integrative treatment approach. Early intervention and family participation are essential to her recovery journey. This case illustrates eating disorders’ complex relationship between physical and psychological factors. In my future practice, I am committed to fostering a compassionate and understanding attitude and advocating for early detection and intervention to improve the lives of those confronting comparable obstacles.

References

Bains, N., & Abdijadid, S. (2022). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Fornaro, M., Sassi, T., Novello, S., Anastasia, A., Fusco, A., Senatore, I., & de Bartolomeis, A. (2020). Prominent autistic traits and subthreshold bipolar/mixed features of depression in severe anorexia nervosa. Brazilian Journal of Psychiatry, 42(2), 153–161. https://doi.org/10.1590/1516-4446-2019-0500

Kaufmann, L.-K., Jürgen Hänggi, Lutz Jäncke, Baur, V., Piccirelli, M., Kollias, S., Schnyder, U., Martin-Soelch, C., & Milos, G. (2023). Disrupted longitudinal restoration of brain connectivity during weight normalization in severe anorexia nervosa. 13(1). https://doi.org/10.1038/s41398-023-02428-z

Moore, C. A., & Bokor, B. R. (2019). Anorexia nervosa. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459148/

Muratore, A. F., & Attia, E. (2020). Current therapeutic approaches to anorexia nervosa: State of the art. Clinical Therapeutics, 43(1). https://doi.org/10.1016/j.clinthera.2020.11.006

Ramírez-Cifuentes, D., Freire, A., Baeza-Yates, R., Lamora, N. S., Álvarez, A., González-Rodríguez, A., Rochel, M. L., Vives, R. L., Velazquez, D. A., Gonfaus, J. M., & Gonzàlez, J. (2021). Characterization of anorexia nervosa on social media: Textual, visual, relational, behavioral, and demographical analysis. Journal of Medical Internet Research, 23(7), e25925. https://doi.org/10.2196/25925

van Eeden, A. E., van Hoeken, D., & Hoek, H. W. (2021). Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry, 34(6), 515–524. https://doi.org/10.1097/yco.0000000000000739

 

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