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EATING DISORDERS GUIDANCE 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) Gaunt , emaciated appearance. Pale (due to anaemia). Clothing: disguise, bulky clothing General Inspection 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. 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) Cardiorespiratory Chest Heart sounds (mid-systolic clicks/murmur) Irregular Rhythm Jugular venous pressure Abdominal Abdomen (stool/liver/spleen/mass) 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 Musculo-skeletal Muscle strength Bone Pain Neuroligical Sensation (touch, joint position sense, temperature sense) Reflexes (delayed relaxation phase of 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 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 Bradycardia Arrhythmias - may result in palpitation Oedema Abdo pain, constipation, heartburn feeling bloated, early satiety An abdominal mass that can be indented is always stool Assess for hydration 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 ankle jerk) Aneurin Bevan Local Health Board Specialist ED Lead T&F Group . EATING DISORDERS GUIDANCE NOTES GUIDANCE NOTE 3 PHYSICAL ASSESSMENT INVESTIGATIONS Body weight & height Urinalysis Blood pressure Pulse rate Lying and standing Temperature Musculo-skeletal Squat Test & Sit up Test A DXA scan ECG Full blood count Urea and Electrolyte Renal function Liver Function Test ESR Thyroid Function Test Phosphate Magnesium Calcium Albumin Creatinine Kinase Glucose FREQUENCY NOTES Within 24 hrs of admission. Then weekly weight in Kg or twice weekly as BMI = (height) Metres sqrd indicated by care plan Within 24 hrs of admission Elevated urine protein may indicate renal damage. Drug Screen, C & S Pregnancy Within 24 hrs of admission See physical risk Table 1 GN 2a daily if risk assessment indicates (e.g dehydration) Within 24 hrs of admission See physical risk Table 1 GN 2a Within 24 hrs of admission See physical risk Table 1 GN 2a Scoring: 0 – unable to rise 1 – Able to rise only with use of hands If amenorrhoea > six 2 – Able to rise with noticeable difficulty months 3 – Able to rise without difficulty Within 24 hrs of admission A prolonged QTc is associated with an increased risk of ventricular dysrhythmia and Repeat as indicated by risk 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 Within 24 hrs of admission See Table 1 GN 2a Repeat as indicated by risk (see GN2 a) If dehydrated repeat: renal function Electrolytes & Urea BP Pulse &Temp daily. Monitor refeeding from low weight see GN 2b Aneurin Bevan Local Health Board Specialist ED Lead T&F Group . EATING DISORDERS GUIDANCE NOTES GUIDANCE NOTE 3 PHYSICAL ASSESSMENT COMPLICATIONS FLUID AND ELECTROLYTES METABOLIC CARDIOVASCULAR PULMONARY GASTROINTESTINAL RENAL ENDOCRINE HAEMATOLOGICAL IMMUNOLOGICAL NEUROLOGICAL DERMATOLOGICAL MUSCULO-SKELETAL ANOREXIA NERVOSA Usually normal but may show low sodium, low chloride, low potassium and hypophosphatemia due to refeeding syndrome Fasting hypoglycaemia increases free fatty acids, with hyper/hypocholesterolemia, osteopenia with decreased bone mineral density 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 Decreased FEV1, rib fracture, subcutaneous emphysema pneumomediastinum Constipation, delayed gastric emptying, acute gastric dilation, dyspepsia, Transaminitis, decreased ALP, Superior mesenteric artery syndrome, pancreatic dysfunction Abnormal renal function tests, with elevated urea and creatinine, changes in urinary concentration, decreased glomerular filtration rate, polyuria 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. Anaemia, leucopoenia, thrombocytopenia, bone marrow hypocellularity, low ESR Decreased levels of complement factors CT, MRI, PET scan abnormalities Metabolic encephalopathy with seizures Brittle hair and nails, hair loss, yellowish skin due to hypercarotenemia, dry skin, lanugo hair Osteoporosis, Bone pain stress fractures lack of growth Muscle weakness and cramping Aneurin Bevan Local Health Board Specialist ED Lead T&F Group BULIMIA NERVOSA Hypokalemic, hypochloremic, metabolic alokalosis with dehydration and vomiting Hyponatremia, diarrhoea with laxative abuse. Rarely mineral changes. Same as for AN Low zinc levels Same as for AN Ipecac cardiomyopathy Pedal oedema Bradypnea, aspiration pneumonitis 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 Same as AN Kaliopenic nephropathy, pyuria, haematuria Menstrual irregularities, Polycystic ovaries Anaemia secondary to blood loss Metabolic seizures Russell’s sign muscle weakness .
