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Managing Adolescent Bulimia: A PLAB 2 Mock Scenario

Updated: Jun 15

Summary:

This case involves a 16-year-old girl presenting indirectly through concerns expressed by her mother. The history reveals behaviors consistent with bulimia nervosa, including self-induced vomiting, distorted body image, and poor insight into the severity of her condition.


Key Points:


History Taking – Eating Disorder (Bulimia Nervosa)

  • Presenting Complaint: Self-induced vomiting once or twice weekly for 8 months.

  • Insight: Patient minimizes the issue, indicating poor insight—a hallmark in adolescents with eating disorders.

  • Body Image Disturbance: Patient perceives herself as fat despite others' reassurances.

  • Weight History: Minor weight loss of a few kilograms, with ongoing attempts to lose more.

  • SCOFF Questionnaire Indicators:

    1. Sick – Do you make yourself Sick because you feel uncomfortably full?

    2. Control – Do you worry you have lost Control over how much you eat?

    3. One stone – Have you recently lost more than One stone (6.35 kg or 14 lb) in a 3-month period?

    4. Fat – Do you believe yourself to be Fat when others say you are too thin?

    5. Food – Would you say that Food dominates your life?

Interpretation:

  • Each “Yes” answer = 1 point

  • A score of 2 or more suggests a likely eating disorder and warrants further evaluation


Risk Assessment

  • Vomiting Risks: Risk of electrolyte imbalance (potential for arrhythmia).

  • Medical Emergency Indicators: Electrolyte imbalance needs urgent evaluation—recommend immediate review.

  • Menstrual History: Regular periods, but important for monitoring signs of malnutrition.

  • Psychiatric Risk Factors:

    • Poor mood self-assessed at 6–7/10.

    • No suicidal ideation or severe depressive symptoms discussed, but continued monitoring is required.


Important Considerations:

  • Adolescent Mental Health: Use CAMHS (Child and Adolescent Mental Health Services) for psychiatric evaluation.

  • Electrolyte Imbalance: Must not delay investigations—arrhythmias from hypokalemia can be fatal.

  • Safeguarding: Assess for external influences like bullying, peer pressure, or unrealistic body ideals.

  • Follow-Up Plan: Should be prompt—within days, not weeks.

  • Parental Involvement: Engage mother appropriately, balancing confidentiality and safeguarding.


Diagnostic Approach:

  1. Confirm Nature and Frequency of Vomiting

  2. Assess SCOV Criteria (≥4 positives = likely eating disorder)

  3. Evaluate Nutritional Status

    • BMI

    • Menstrual status

    • Physical signs (dizziness, sore throat, fatigue)

  4. Screen for Psychiatric Comorbidities

    • Mood, anxiety, substance use

  5. Investigations

    • FBC, U&E, LFTs

    • ECG (check for QT prolongation)


Management:

  1. Immediate Actions

    • Arrange blood tests for electrolytes.

    • ECG for arrhythmia risk.

    • Ensure physical safety: exclude medical emergency.

  2. Referral

    • Urgent referral to CAMHS.

    • Eating disorder clinic if available.

  3. Therapy

    • Initiate discussion on CBT (Cognitive Behavioral Therapy) and its benefits.

  4. Monitoring

    • Close follow-up within days (not 2 weeks).

    • Reassess physical and mental health parameters.

  5. Education

    • Explain diagnosis and consequences (electrolyte disturbance, cardiac risks, menstrual disruption, dental erosion).


Communication Skills:

  • Non-Judgmental Attitude: Avoid making the patient feel labelled or dismissed.

  • Patient-Centered Language: Use empathetic, age-appropriate communication.

  • Explain Psychiatric Referral: Frame as a means to understand emotions and behaviors, not as a sign of being “crazy.”

  • Avoid Stock Phrases: Show genuine concern through active listening.

  • Clarify CBT: Explain it as talking therapy helping with thoughts, feelings, and actions.


Ethical Considerations:

  • Consent and Confidentiality: Navigate carefully given patient's age; involve parent where safeguarding is a concern.

  • Capacity: Assume capacity unless clearly lacking, per GMC standards.

  • Safeguarding: Evaluate for abuse, neglect, or peer pressure as possible contributing factors.


Additional Resources:

  • NICE Guidelines on Eating Disorders (NG69)

  • GMC “Good Medical Practice” (2024)

  • SCOV Questionnaire for screening eating disorders

  • RCPsych resources on adolescent mental health

  • CAMHS service protocols

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