Doctors must ask probing questions
Dr. Erika Kube
Anna came to the emergency department with her boyfriend. She had been having abdominal pain with vomiting and constipation for several days.
She was carrying a small bucket that she had brought from home and was dry-heaving into it as the triage nurse assisted her into a wheelchair and helped her to her room in the department. Her boyfriend of hers said she frequently complained of abdominal pain, but this time seemed much worse.
What I first noticed about Anna was that she was quite thin and looked very withdrawn. It was clear she did not feel well but she really would not make eye contact with the nurse or me and she let her boyfriend speak for her. He seemed worried about her as he held her hand and rubbed her back.
I asked her if she could tell me what she was feeling and she pointed at her boyfriend to answer for her. I had her lay on her back so I could examine her abdomen. She did not have any surgical scars on her abdomen, and she was tending everywhere that I pushed on her.
I had her pull down her mask so I could look into her mouth and noticed that her lips were dry and cracked.
I had the nurse put an IV in her and gave her nausea medications and fluids. I asked her about her her past medical history and the date of her last menstrual period. She told me she couldn’t remember the last time she had a period, and she wasn’t on any birth control, which made me wonder if she was pregnant.
My list of potential diagnoses was quite long at this point and I awaited the results of Anna’s tests to decide what further testing would be necessary to figure out what was wrong.
I was surprised that Anna’s pregnancy test was negative since she hadn’t had a menstrual period in a long time. I went back in to see her and told her that she wasn’t pregnant.
I reexamined her abdomen, which was still tender when I touched her. The nausea medications had helped. I ordered a CT scan of her abdomen and asked the nurse to give her more IV fluids because she was so dehydrated.
I asked the nurse what she thought about Anna when we had both left the room. I was still bothered by how she seemed so disengaged. The nurse was having the same feeling. and so when Anna’s boyfriend went to the cafeteria to get some coffee, she let me know so that I could talk to Anna privately.
I was worried that maybe her boyfriend was being abusive to her, so I needed to talk to her without him in the room. I sat down next to Anna and got right to the point.
At first she was very resistant to answering any questions like she had been since she arrived. I explained to her my concerns about her, assured her that she was safe in the hospital, and asked her if she was feeling safe and if she was being abused.
She sat up in the bed, completely shocked at what I was asking, and adamantly denied it. I thoroughly explained to her why I had asked her those questions and asked her if there was anything else going on that she hadn’t been telling us. She said no as she pulled the blankets back up over her head and laid back down.
As I stepped out of her room I told her I’d be back once her CT scan had been interpreted by the radiologist. I quickly updated Anna’s nurse at the nurses’ station and then took care of a couple other things before Anna’s results were back.
Her CT showed that she was mildly constipated but didn’t show any other abnormalities.
When I went back to talk to Anna about her results, her boyfriend was back from the cafeteria. He asked her to sit up and talk to me about her results from her. I was relieved that there was n’t something serious on Anna’s lab tests and CT scan, but I expressed my concern that we did n’t have a diagnosis for her symptoms of her.
Her boyfriend was also very concerned. He told Anna that she needed to be completely honest with me and tell me what was going on, or he was going to. At first she stared at the wall and wouldn’t talk.
Tears started running down her cheek as she told me that she suffers from anorexia. She was worried about gaining weight and after not eating for several days, she binged and then started vomiting and could not stop.
Anorexia nervosa is behavior of self-starvation and weight loss, which is driven by an intense fear of gaining weight and becoming fat. Some patients with anorexia lose weight by dieting, fasting or exercising excessively while others also engage in intermittent binge eating followed by purging.
Anorexia has the second-highest mortality of any psychiatric diagnosis (second to opioid use disorder) and can have numerous other health consequences, such as constipation, brittle hair and nails, dizziness from dehydration, lack of normal menstrual periods, depression, anxiety, poor concentration and fatigue.
It made sense to me now why Anna wasn’t having regular menstrual periods.
The treatment for severely underweight and malnourished patients with anorexia is to normalize their eating and weight control behaviors. It is also important to address the issues of body dissatisfaction as this is the root of the problem.
I was so grateful that Anna was able to be honest about her eating disorder. I was able to help her to get into an intensive treatment program with the assistance of our psychiatry team.
I thank her boyfriend for being supportive and helping her to get medical attention. I encouraged Anna to enlist the support of her boyfriend, family, and friends of ella to help her with the challenges that lay before her, and I told her that I knew she was strong enough to get better.
As she left the emergency department with her boyfriend she made eye contact with me, smiled, and said thank you.