Your patient is a 20-year-old woman named Linda Luckey. Her mother
has scheduled this appointment because she feels her daughter is overly
concerned with her weight. The mother is afraid that her daughter may
have an eating disorder.
Upon entering the examination room, you see a cachectic-appearing
young woman with thin, fine hair. She is approximately 5 feet 7 inches
tall and weighs 105 pounds.
Vital Signs:
Temperature 96.0°F
Blood pressure 85/60 mmHg
Heart rate 48 beats per minute
Respirations 12 breaths per minute,HISTORY—Include significant positives and negatives from the history
of present illness, past medical history, review of systems, and social
and family history.
Twenty-year-old Ms. Linda Luckey is brought to your office by her
mother for evaluation of weight loss. The patient does not feel that
she has lost any weight and is unsure why her mother has scheduled
the appointment. Ms. Luckey’s diet consists mainly of fruits and vegetables; she stays away from foods high in fats and carbohydrates.
She sometimes fasts and often skips meals. She has secret food binges
on weekends but denies inducing vomiting or using laxatives or
diuretics in an attempt to lose weight. She counts her daily calories
and tries not to go above 1000 calories per day and often runs 5 miles
a day to stay in shape. She is preoccupied with food and diet; she collects recipes and likes to cook. Her self-image is such that she feels
that her thighs and arms are fat; she has a fear of gaining any more
weight. She has few friends and no sexual relationships because she
is too busy studying to get into an Ivy League law school. Her last
menstrual period was 3 months ago and she feels that the stress of
school has made her periods irregular. She does not think she is
depressed and denies insomnia, sadness, or episodes of crying.
PHYSICAL EXAMINATION—Indicate only the pertinent positive and negative findings related to the patient’s chief complaint.
The patient is a cachectic-appearing young woman with thin, fine
hair. She is approximately 5 feet 7 inches tall and weighs 105 pounds.
She looks older than her stated age of 20 years. She is hypothermic,
hypotensive, and bradycardic.
324 MASTERING THE USMLE STEP 2 CS
DIFFERENTIAL DIAGNOSIS
In order of likelihood, write no
more than five differential diagnoses for this patient’s current
problems.
1. anorexia nervosa
2. hypothyroidism
3. major depression
4. hypothermia
5. bradycardia
DIAGNOSTIC WORKUP
Immediate plans for no more
than five diagnostic studies.
1. CBC
2. electrolytes
3. BUN and creatinine
4. TSH
5. ECG

Ms. Linda Luckey is a 20-year-old college student who wishes to become
an attorney. Her dream is to attend an Ivy League law school and be a
corporate lawyer like her parents. She is described by family and
friends as a goal-oriented perfectionist driven by her desire for success
and achievement. She has little time for social relationships and is
focused on performing well in school.
This cachectic young woman weighs 105 pounds, which is less than
85 percent of her expected body weight. She limits her daily caloric
intake and avoids foods high in fats and carbohydrates. She secretly
binges on food on weekends but denies self-induced vomiting or the
use of laxatives and diuretics in an attempt to lose weight. She tries to
remain thin by fasting and exercising to excess. She has a distorted
image of her underweight body and considers specific areas (thighs
and arms) to be fat. Recently, she has become amenorrheic. All the
information obtained in the history is consistent with the diagnosis of
anorexia nervosa.
Anorexia nervosa is 20 times more common in women than in men.
A patient will present after having lost a significant percentage of his
or her expected body weight and will typically be preoccupied with
food, body weight, and daily caloric intake.
Ms. Luckey feels herself to be a healthy, average young woman and
denies her symptoms (denial of the problem is frequently seen in eating disorders). Her parents, however, are concerned about anorexia
nervosa and have coerced their daughter into seeking psychiatric help.
On presentation, the patient is hypothermic, bradycardic, and hypotensive. Her hair is fine and thin (lanugo). This presentation is consistent with severe malnutrition secondary to anorexia nervosa.
The treatment of anorexia nervosa includes family counseling, nutritional support, medication use, and hospitalization. Ms. Luckey will
need these interventions to achieve and maintain an adequate weight.
Death in patients with anorexia nervosa may occur secondary to cardiac
arrhythmias, electrolyte abnormalities, or suicide. S.O.A.P charting