What is the workup for a 15-year-old girl with shortness of breath and a history of an eating disorder?

Workup for a 15-Year-Old Girl with Shortness of Breath and Eating Disorder History

This patient requires immediate cardiovascular and metabolic assessment alongside comprehensive eating disorder evaluation, as shortness of breath in an adolescent with an eating disorder may represent life-threatening cardiac complications from malnutrition or electrolyte disturbances. 1, 2

Immediate Vital Signs and Physical Assessment

Obtain orthostatic vital signs immediately - measure temperature, resting heart rate, blood pressure, orthostatic pulse changes, and orthostatic blood pressure, as cardiovascular compromise (bradycardia, hypotension, hypothermia) can develop rapidly in malnourished adolescents. 1

• Document current height, weight, and BMI percentile for age, comparing to previous growth charts to identify weight loss patterns and growth trajectory changes. 1
• Examine for physical signs of malnutrition including muscle wasting, lanugo hair, and signs of purging behaviors such as Russell's sign (calluses on knuckles), dental erosion, or parotid gland enlargement. 1
• Assess for peripheral edema and signs of cardiac compromise, as these indicate severe malnutrition. 2

Essential Laboratory Testing

Order an electrocardiogram immediately - this is critical in any patient with restrictive eating or severe purging behaviors presenting with shortness of breath, as QTc prolongation and arrhythmias are potentially fatal complications. 1, 2

• Obtain complete blood count to assess for anemia and leukopenia from malnutrition. 1
• Order comprehensive metabolic panel including electrolytes (particularly potassium, sodium, chloride), liver enzymes, and renal function tests - hypokalemia and hypochloremic alkalosis from purging can cause respiratory symptoms and cardiac arrhythmias. 1
• Include magnesium and phosphate levels, as these electrolyte abnormalities contribute to cardiac dysfunction and respiratory muscle weakness. 3

Detailed Eating Disorder History

Quantify specific eating and compensatory behaviors - document frequency and intensity of dietary restriction, binge eating episodes, self-induced vomiting, laxative use, diuretic use, and compulsive exercise patterns. 1

• Establish weight history including maximum weight, minimum weight, recent weight changes, and timeline of weight loss. 1
• Determine types and frequency of purging behaviors (vomiting, laxatives, starvation), as these directly correlate with electrolyte abnormalities causing shortness of breath. 1
• Assess percentage of time preoccupied with food, weight, and body shape. 1

Comprehensive Review of Systems

Perform detailed cardiopulmonary assessment - shortness of breath may represent cardiac complications (pericardial effusion, mitral valve prolapse, arrhythmias), respiratory muscle fatigue from malnutrition, or exercise-induced symptoms from compulsive exercise. 2, 3

• Screen for co-occurring psychiatric conditions including depression, anxiety, obsessive-compulsive disorder, and suicidality, as these are common comorbidities requiring concurrent treatment. 1
• Evaluate menstrual history, as amenorrhea indicates hypothalamic-pituitary-gonadal axis suppression from malnutrition. 1
• Assess for gastrointestinal symptoms (constipation, abdominal pain), endocrine symptoms (cold intolerance, fatigue), and neurological symptoms (dizziness, syncope). 1

Critical Differential Considerations

Rule out other medical conditions mimicking eating disorders - while eating disorder complications are most likely, consider Addison's disease (primary adrenal failure) in adolescents presenting with weight loss, hypotension, and electrolyte abnormalities, as missing this diagnosis has devastating consequences. 4

• Consider exercise-induced bronchoconstriction if shortness of breath occurs specifically with compulsive exercise, though perform spirometry and pulmonary examination to exclude underlying pulmonary pathology. 1
• Evaluate for food-dependent exercise-induced anaphylaxis if shortness of breath occurs with exercise after eating, particularly with wheat-containing foods. 1

Psychosocial Evaluation

Assess family dynamics and support systems - evaluate parents' understanding of the illness and their approach to treatment, as parental denial or disagreement about treatment can exacerbate the condition. 1

• Determine level of functioning at home, school, and with peers to establish baseline psychosocial impairment. 1
• Screen for history of physical or sexual abuse and assess current suicidality. 1
• Evaluate patient's insight into illness severity and willingness to accept treatment. 1

Common Pitfalls to Avoid

Do not assume normal laboratory results exclude serious illness - more than half of adolescents with eating disorders have normal test results despite being medically unstable and requiring aggressive intervention. 1

• Do not delay ECG while waiting for other test results - cardiac complications are the leading cause of death in eating disorders and require immediate identification. 1, 2
• Do not overlook patients who don't meet full DSM-5 criteria - over half of adolescents with eating disorders have atypical presentations but experience identical medical complications requiring the same aggressive treatment. 1
• Do not attribute all symptoms to the eating disorder without considering alternative diagnoses like Addison's disease, which can present identically. 4