Swollen Cheeks or Jawline
The most consistent physical sign of an underlying eating disorder in this patient is swollen cheeks or jawline, which represents parotid gland enlargement from recurrent self-induced vomiting. 1, 2
Clinical Presentation: Russell's Sign
The recurrent infections along the dorsal surface of the hand over the MCP joints, with multiple scars and lesions at different healing stages, represent Russell's sign—calluses and trauma caused by repeated contact with the upper incisors during self-induced vomiting. 3 This is a pathognomonic finding for bulimia nervosa and indicates compensatory purging behavior following binge eating episodes. 3
Why Swollen Cheeks/Jawline is the Correct Answer
Parotid gland enlargement (appearing as swollen cheeks or jawline) is a direct sequela of the same purging behavior causing Russell's sign. 1, 2 The mechanism involves:
- Repeated self-induced vomiting stimulates salivary gland hypertrophy, particularly affecting the parotid glands 4, 5
- This creates visible bilateral swelling along the jawline and cheeks 1
- Parotid enlargement is specifically listed as a key physical warning sign for eating disorders in multiple guidelines 1, 2
Why Other Options Are Incorrect
Good dentition and gum health would be inconsistent with eating disorders. Self-induced vomiting causes dental enamel erosion, dental caries, and poor gum health due to repeated acid exposure from gastric contents. 1, 4, 5
Limb casts for recent bone fractures could suggest osteoporosis from prolonged malnutrition and amenorrhea, but this is a long-term complication requiring months to years of illness. 1, 2 The question asks for findings most consistent with the acute presentation of Russell's sign, which indicates active purging behavior.
Thick hair with typical hairlines contradicts eating disorder sequelae. Patients typically present with alopecia, hair thinning, and fine lanugo-like hair growth on the face due to malnutrition. 1, 3
Clinical Significance
This 23-year-old female demonstrates the classic triad of bulimia nervosa:
- Russell's sign (dorsal hand lesions from self-induced vomiting) 3
- Parotid gland enlargement (swollen cheeks/jawline) 1, 2, 4
- Young female demographic (eating disorders are more common in females) 6
Recognition of these dermatologic and oral-facial signs enables early diagnosis and treatment, which is critical given that bulimia nervosa carries a 76.3% lifetime rate of depression and significantly elevated suicide risk. 6
Essential Next Steps
- Perform comprehensive evaluation including vital signs, orthostatic measurements, and BMI calculation 2, 7
- Order complete blood count and comprehensive metabolic panel to assess for hypokalemia and hypochloremic alkalosis from purging 8, 2, 7
- Obtain electrocardiogram to evaluate for QTc prolongation, which predicts sudden cardiac death risk 2, 7
- Assess for dental erosion, xerostomia, and other oral manifestations of chronic vomiting 4, 5
- Screen for comorbid depression, anxiety, and suicidality 2, 6