From the Guidelines
A comprehensive SOAP note for a patient with bulimia nervosa should include detailed documentation of their eating disorder symptoms and treatment plan, with a focus on cognitive behavioral therapy (CBT-E) as first-line treatment and consideration of fluoxetine (60-80mg daily) as recommended by the American Psychiatric Association (1). The subjective information should capture the patient's self-reported binge-purge behaviors, including frequency, triggers, compensatory behaviors (vomiting, laxative use, excessive exercise), body image concerns, and any comorbid anxiety or depression. Objective assessment should document vital signs (particularly noting any bradycardia or orthostatic hypotension), weight (avoiding focusing on the number in front of the patient), physical examination findings (checking for Russell's sign on knuckles, dental erosion, parotid gland enlargement, and cardiac abnormalities), and relevant laboratory results (electrolytes, especially potassium, comprehensive metabolic panel, and CBC) as outlined in the APA guidelines (1). Some key points to consider in the assessment include:
- Diagnosis of bulimia nervosa with severity classification based on purging frequency, medical complications, and any psychiatric comorbidities
- Identification of co-occurring health conditions, including co-occurring psychiatric disorders (1)
- Comprehensive review of systems (1)
- Laboratory assessment, including a complete blood count and a comprehensive metabolic panel (1) The plan should outline a multidisciplinary approach including:
- Cognitive behavioral therapy (CBT-E) as first-line treatment (1)
- Consideration of fluoxetine (60-80mg daily) which is FDA-approved for bulimia (1)
- Nutritional counseling with a registered dietitian
- Regular monitoring of electrolytes and weight
- Specific safety planning if medical instability is present Follow-up appointments should be scheduled at appropriate intervals based on illness severity, with clear documentation of warning signs requiring immediate medical attention (1).
From the FDA Drug Label
In the controlled clinical trials of fluoxetine supporting its effectiveness in the treatment of bulimia nervosa, patients were administered fixed daily fluoxetine doses of 20 or 60 mg, or placebo Only the 60–mg dose was statistically significantly superior to placebo in reducing the frequency of binge–eating and vomiting Consequently, the recommended dose is 60 mg/day, administered in the morning.
The recommended dose of fluoxetine for bulimia nervosa is 60 mg/day, administered in the morning 2.
- The dose may be titrated up to this target dose over several days.
- Maintenance/Continuation Treatment: Systematic evaluation of continuing Prozac 60 mg/day for periods of up to 52 weeks in patients with bulimia who have responded while taking Prozac 60 mg/day during an 8–week acute treatment phase has demonstrated a benefit of such maintenance treatment 2.
- Patients should be periodically reassessed to determine the need for maintenance treatment.
From the Research
Bulimia SOAP Note
- A SOAP note for bulimia nervosa typically includes the following components:
- Subjective: Patient's report of symptoms, including frequency of binge eating and purging episodes
- Objective: Physical examination findings, laboratory results, and other objective data
- Assessment: Diagnosis of bulimia nervosa, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
- Plan: Treatment plan, which may include cognitive-behavioral therapy (CBT), medication, or a combination of both 3, 4, 5, 6, 7
Treatment Options
- Cognitive-behavioral therapy (CBT) is a first-line psychotherapeutic treatment for bulimia nervosa, and has been shown to be effective in reducing symptoms of the disorder 3, 4, 5, 7
- Medications, such as fluoxetine, may also be used to treat bulimia nervosa, particularly in patients who have not responded to psychotherapy or have relapsed after treatment 4, 6
- Combination therapy, which includes both CBT and medication, may be more effective than either treatment alone 4
Assessment and Diagnosis
- Diagnosis of bulimia nervosa is based on criteria from the DSM-5, which includes recurrent episodes of binge eating and purging, as well as distress or impairment in social or occupational functioning
- Assessment of bulimia nervosa typically includes a physical examination, laboratory tests, and a psychological evaluation to rule out other conditions and to assess the severity of symptoms 3, 4, 5, 6, 7