Diagnostic Evaluation of Anorexia Nervosa

Initial Clinical Assessment

• The American Academy of Family Physicians recommends measuring temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure at every evaluation to assess for signs of malnutrition and dehydration 1, 2
• Documenting height, weight, and calculating BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents) is essential for assessing nutritional status 1, 2
• Determining total weight loss and weight status (percent below ideal body weight) helps identify the severity of malnutrition 3, 4
• Assessing for physical signs of malnutrition or purging behaviors, including Russell's sign, parotid gland enlargement, and dental erosion, is crucial for diagnosis 1
• Calculating the types and frequency of purging behaviors (vomiting, laxative use, excessive exercise, starvation) helps understand the patient's behavior and its impact on their health 3, 4
• Evaluating the degree of obsession with food and weight, understanding of diagnosis, and willingness to receive help is essential for developing an effective treatment plan 3, 4
• Assessing functioning at home, school, and with peers helps identify the patient's support system and potential areas of struggle 3, 4
• Screening for comorbid psychiatric diagnoses, including depression, anxiety, obsessive-compulsive disorder, and suicidal ideation, is critical for providing comprehensive care 3, 4
• Assessing history of physical or sexual abuse is essential for understanding the patient's emotional and psychological state 3, 4

Essential Laboratory Tests

• The American Academy of Family Physicians recommends ordering a complete blood count to detect anemia, leukopenia, and thrombocytopenia 1, 2
• Obtaining a comprehensive metabolic panel, including sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, and liver enzymes, helps identify electrolyte imbalances and other metabolic abnormalities 1, 2
• Hypokalemia and hypochloremic alkalosis may indicate purging behaviors 3, 4
• Hyponatremia or hypernatremia may suggest fluid manipulation for weight control 3, 4
• Performing an electrocardiogram in all patients with restrictive eating disorders or severe purging behaviors helps assess for QTc prolongation, which predicts risk of sudden cardiac death 1, 2
• Monitoring QTc intervals serially in patients with ongoing restrictive eating or severe purging is essential for identifying potential cardiac complications 1

Endocrine Testing

• Obtaining thyroid function tests (TSH and free T4) in patients with oligomenorrhea or amenorrhea helps identify potential thyroid abnormalities 1
• Considering a hormonal workup for hypothyroidism, hypercortisolism, and hypogonadotropic hypogonadism may be necessary, although these conditions typically resolve with nutritional rehabilitation 1

Bone Health Assessment

• Considering a DXA scan for patients with prolonged amenorrhea (>6 months) helps identify potential osteopenia and osteoporosis 1, 2
• Measuring 25-hydroxyvitamin D levels if low bone mineral density or bone stress injury is suspected helps identify potential vitamin D deficiencies 1

Psychosocial Evaluation Components

• Assessing suicidality at every visit is crucial, as 25% of anorexia nervosa deaths result from suicide 1
• Evaluating parents' reaction to illness, as denial or disagreement about treatment approach can exacerbate the condition, is essential for developing an effective treatment plan 3, 4

Swollen Cheeks or Jawline as a Sign of Eating Disorders

Clinical Presentation

• The British Journal of Sports Medicine recommends recognizing parotid gland enlargement, appearing as swollen cheeks or jawline, as a direct sequela of purging behavior causing Russell's sign, which is a pathognomonic finding for bulimia nervosa 5, 6
• Parotid gland enlargement is specifically listed as a key physical warning sign for eating disorders in multiple guidelines, including the British Journal of Sports Medicine, and is caused by repeated self-induced vomiting stimulating salivary gland hypertrophy 5, 6

Differential Diagnosis

• The American Academy of Family Physicians notes that limb casts for recent bone fractures could suggest osteoporosis from prolonged malnutrition and amenorrhea, but this is a long-term complication requiring months to years of illness 7
• The British Journal of Sports Medicine states that good dentition and gum health would be inconsistent with eating disorders, as self-induced vomiting causes dental enamel erosion, dental caries, and poor gum health due to repeated acid exposure from gastric contents 5, 6
• The British Journal of Sports Medicine also notes that thick hair with typical hairlines contradicts eating disorder sequelae, as patients typically present with alopecia, hair thinning, and fine lanugo-like hair growth on the face due to malnutrition 5, 6