See Related Guidance Notes GN 1, 1A, 2A, 3, 3A, and Dietetic Assessment
EATING DISORDERSGUIDANCE NOTES
GUIDANCE NOTE 3
PHYSICAL ASSESSMENT
Many of the physical symptoms of Anorexia Nervosa and Bulimia Nervosa are directly related to the effect of semi- starvation, while other physical symptoms are associated mainly with behavioural problems such as bingeing, excessive exercising, vomiting and purging.
A FULL PHYSICAL EXAMINATION SHOULD BE CARRIED OUT WITHIN 24 HOURS OF ADMISSION.
SCHEMA FOR PHYSICAL EXAMINATION (Birmingham & Beumont 2004)General Inspection / Gaunt , emaciated appearance. Pale (due to anaemia). Clothing: disguise, bulky clothing to hide figure, skimpy clothes to display emaciation for cold exposure.
Vital Signs:
Temperature, Blood Pressure (appropriate cuff size) Pulse Rate Right Left sitting standing lying. Respiratory rate. / Patient will feel cold, possibly dizzy
Measure BP and associated heart rate. Take BP and Pulse with Pt lying down and standing up >10mm Hg drop in diastolic BP or 10 beats per min increase in heart rate, redo the BP & pulse every 15seconds until it stabilizes
Head & neck
Hair (alopecia)
Eyes
dark circles around the eyes
(lateral nystagmus)
Teeth (erosion)
Gums (recession, friable)
Parotid hypertrophy
Submandibular gland hypertrophy,
Thyroid (normal, enlarged nodule) / Common cause of Alopecia is hair loss due to malnutrition, generalised loss of scalp hair with no inflammation of abnormality of hair follicle.
Due to trauma & breakage of small blood vessels during forced vomiting
Wernicke’s encephalopathy, the most common gaze abnormality is lateral nystagmus (on lateral gaze the eye moves rapidly back and forth)
Resulting from erosion by gastric acid during vomiting.
With vomiting the parotid and submandibular glands are swollen bilaterally. Can occur with malnutrition alone although swelling is less marked. The glands are not swollen on one side of the body only
Cardiorespiratory
Chest
Heart sounds (mid-systolic clicks/murmur)
Irregular Rhythm
Jugular venous pressure / Bradycardia
Arrhythmias - may result in palpitation
Oedema
Abdominal
Abdomen (stool/liver/spleen/mass) / Abdo pain, constipation, heartburn feeling bloated, early satiety
An abdominal mass that can be indented is always stool
Skin
dryness, peeling of skin of hands and feet
Hypercarotenemia
Acrocyanosis
Lanugo Hair
Areas of Hyperpigmentation
Russell’s Sign
Self injury -burns cuts, hair loss, bruises
Substance misuse – needle track / Assess for hydration
Musculo-skeletal
Muscle strength
Bone Pain / Proximal weakness is due to myopathy. It can be due to potassium, magnesium, phosphate or calcium deficiencies.
Can be an indication of osteoporosis and stress fractures
Neuroligical
Sensation (touch, joint position sense, temperature sense)
Reflexes (delayed relaxation phase of ankle jerk)
INVESTIGATIONS / FREQUENCY / NOTES
Body weight & height / Within 24 hrs of admission. Then weekly or twice weekly as indicated by care plan / weight in Kg
BMI = (height) Metres sqrd
Urinalysis / Within 24 hrs of admission / Elevated urine protein may indicate renal damage.
Drug Screen, C & S
Pregnancy
Blood pressure Pulse rate
Lying and standing / Within 24 hrs of admission
daily if risk assessment indicates (e.g dehydration) / See physical risk Table 1 GN 2a
Temperature / Within 24 hrs of admission / See physical risk Table 1 GN 2a
Musculo-skeletal
Squat Test & Sit up Test
A DXA scan / Within 24 hrs of admission
If amenorrhoea > six months / See physical risk Table 1 GN 2a
Scoring:
0 – unable to rise
1 – Able to rise only with use of hands
2 – Able to rise with noticeable difficulty
3 – Able to rise without difficulty
ECG / Within 24 hrs of admission
Repeat as indicated by risk / A prolonged QTc is associated with an increased risk of ventricular dysrhythmia and death. An increase in the QTc > than 60ms or a QTc > than 450ms indicates an increased risk of dysrhythmia.
Some medications can increase the QT interval e.g Tricylic antidepressants, antipsychotics, macrolide antibiotics some antihistamines
Full blood count
Urea and Electrolyte
Renal function
Liver Function Test
ESR
Thyroid Function Test
Phosphate
Magnesium
Calcium
Albumin
Creatinine Kinase
Glucose / Within 24 hrs of admission
Repeat as indicated by risk (see GN2a)
If dehydrated repeat:
renal function
Electrolytes & Urea
BP Pulse &Temp daily.
Monitor refeeding from low weight see GN 2b / See Table 1 GN 2a
COMPLICATIONS / ANOREXIA NERVOSA / BULIMIA NERVOSA
FLUID AND ELECTROLYTES / Usually normal but may show low sodium, low chloride, low potassium and hypophosphatemia due to refeeding syndrome / Hypokalemic, hypochloremic, metabolic alokalosis with dehydration and vomiting
Hyponatremia, diarrhoea with laxative abuse.
Rarely mineral changes.
METABOLIC / Fasting hypoglycaemia increases free fatty acids, with hyper/hypocholesterolemia, osteopenia with decreased bone mineral density / Same as for AN
Low zinc levels
CARDIOVASCULAR / Bradycardia, hypotension with orthostatic changes.
ECG changes T wave, ST segment, and QT abnormalities Sudden cardiac death,
Mitral valve prolapse, Pericardial effusions
Congestive cardiomyopathy Refeeding oedema / Same as for AN
Ipecac cardiomyopathy
Pedal oedema
PULMONARY / Decreased FEV1, rib fracture, subcutaneous emphysema pneumomediastinum / Bradypnea, aspiration pneumonitis
GASTROINTESTINAL / Constipation, delayed gastric emptying, acute gastric dilation, dyspepsia, Transaminitis, decreased ALP, Superior mesenteric artery syndrome, pancreatic dysfunction / Parotid swelling, palate lacerations, impaired taste, enamel erosion, increased caries, periodontal disease, Gastroesophageal reflux, gastric and duodenal ulcers, oesophageal tearing and perforation, acute gastric dilatation, Hyperamylasemia, pancreatitis, Paralytic ileus, constipation, cathartic colon, rectal bleeding Gall bladder stones
RENAL / Abnormal renal function tests, with elevated urea and creatinine, changes in urinary concentration, decreased glomerular filtration rate, polyuria / Same as AN
Kaliopenic nephropathy,
pyuria, haematuria
ENDOCRINE / Amenorrhoea Low LH, FSH oestradiol, TSH, T3 and T4 Increased reversed T3 High cortisol and growth hormone levels, erratic antidiuretic hormone secretion, low peripheral catecholamines. / Menstrual irregularities,
Polycystic ovaries
HAEMATOLOGICAL / Anaemia, leucopoenia, thrombocytopenia, bone marrow hypocellularity, low ESR / Anaemia secondary to blood loss
IMMUNOLOGICAL / Decreased levels of complement factors
NEUROLOGICAL / CT, MRI, PET scan abnormalities
Metabolic encephalopathy with seizures / Metabolic seizures
DERMATOLOGICAL / Brittle hair and nails, hair loss, yellowish skin due to hypercarotenemia, dry skin, lanugo hair / Russell’s sign
MUSCULO-SKELETAL / Osteoporosis,
Bone pain stress fractures
lack of growth
Muscle weakness and cramping / muscle weakness
Aneurin Bevan Local Health Board
Specialist ED Lead T&F Group.