What is the approach to diagnosing and treating bulimia in an Urgent Care setting, including presentation, questions to ask, treatment, warning signs, and tests?

Approach to Bulimia Nervosa in Urgent Care Setting

For patients with bulimia nervosa in an urgent care setting, eating disorder-focused cognitive-behavioral therapy (CBT) combined with fluoxetine 60 mg daily is the recommended first-line treatment to reduce morbidity and mortality. 1, 2

Presentation and Warning Signs

• Patients with bulimia nervosa typically present with recurrent episodes of binge eating followed by compensatory behaviors to prevent weight gain 1, 3
• Key warning signs include:
  • Frequent weight fluctuations despite normal or near-normal BMI 1
  • Dental erosion, especially on lingual and occlusal surfaces due to repeated vomiting 4
  • Russell's sign (calluses on knuckles from self-induced vomiting) 4
  • Parotid gland enlargement giving a "chipmunk cheek" appearance 4
  • Electrolyte abnormalities, particularly hypokalemia in severe purging 1, 4
  • Cardiac arrhythmias or ECG abnormalities (prolonged QTc) 1
  • Dehydration signs including orthostatic hypotension 1

Assessment in Urgent Care

• Vital signs assessment is critical - check temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure 1

• Physical examination should focus on:

  • Weight and BMI calculation 1
  • Signs of malnutrition or purging behaviors 1
  • Dental examination for erosion patterns 4
  • Salivary gland examination 4
  • Cardiac examination 1

• Laboratory assessment should include:

  • Complete blood count 1
  • Comprehensive metabolic panel with electrolytes, liver enzymes, and renal function tests 1
  • Electrocardiogram, especially for patients with severe purging behavior 1

Questions to Ask

• Quantify eating and weight control behaviors:

  • "How often do you binge eat in a week?" 1
  • "How often do you purge (vomit, use laxatives, exercise excessively) after eating?" 1
  • "What methods do you use to control your weight?" 1
  • "What percentage of your day do you spend thinking about food, weight, or body shape?" 1

• Assess for medical complications:

  • "Have you experienced dizziness, fainting, or heart palpitations?" 1, 4
  • "Do you have any dental problems or pain?" 4
  • "Have you noticed any swelling in your face or jaw area?" 4

• Evaluate for co-occurring conditions:

  • "Do you have any other medical or psychiatric conditions?" 1
  • "Are you currently taking any medications?" 1
  • "Do you use alcohol or other substances?" 1

Treatment Approach

• For adults with bulimia nervosa:

  • First-line treatment is eating disorder-focused cognitive-behavioral therapy (CBT) 1, 5
  • Fluoxetine 60 mg daily is recommended either initially or if there is minimal response to psychotherapy alone by 6 weeks 1, 2
  • Start fluoxetine at 20 mg daily and titrate up to 60 mg daily over several days 2

• For adolescents with bulimia nervosa:

  • Family-based treatment is suggested when an involved caregiver is available 1, 5
  • Fluoxetine may be considered but should be used cautiously in this population 2

• Urgent care management should focus on:

  • Addressing immediate medical complications (electrolyte abnormalities, dehydration) 1, 4
  • Providing referral to a multidisciplinary team that includes medical, psychiatric, psychological, and nutritional expertise 1, 5
  • Initiating medication if appropriate 1, 2

Referral and Follow-up

• All patients with bulimia nervosa should be referred to:

  • A mental health practitioner specialized in eating disorders for CBT 1, 5
  • A registered dietitian for nutritional rehabilitation and meal planning 5
  • A primary care physician for ongoing medical monitoring 5

• Patients requiring immediate hospitalization include those with:

  • Severe electrolyte disturbances 1, 4
  • Cardiac arrhythmias 1
  • Significant medical instability 1

Common Pitfalls to Avoid

• Failing to screen for eating disorders during initial psychiatric evaluations 1
• Not weighing patients due to sensitivity concerns - weight measurement is an essential part of assessment 1
• Overlooking medical complications that may require immediate intervention 1, 4
• Focusing solely on weight rather than on eating behaviors and psychological aspects 1
• Underestimating the chronicity of bulimia nervosa and the need for long-term treatment 6
• Neglecting to assess for co-occurring psychiatric disorders which may complicate treatment 1

Treatment Challenges

• If CBT fails, consider:

  • Interpersonal psychotherapy (IPT) as an alternative 7, 6
  • More intensive treatment settings (day hospital or inpatient) for severe cases 6
  • Modified CBT approaches tailored to individual needs 7

• Technology-based interventions may be helpful when access to specialized care is limited:

  • Guided computer-based interventions have shown improvements in core bulimia symptoms 1
  • Videoconferencing has shown promise for delivering therapy to patients in remote areas 1, 5

• Monitor for treatment response by tracking:

  • Frequency of binge eating and purging behaviors 1
  • Improvement in eating disorder psychopathology 1
  • Resolution of medical complications 4

Remember that bulimia nervosa is a serious condition with significant medical complications. Early intervention with evidence-based treatments is essential to reduce morbidity and mortality 1, 4.