Is a physical exam necessary before initiating outpatient eating disorder treatment in patients with a history of eating disorders?

Physical Examination is Mandatory Before Outpatient Eating Disorder Treatment

Yes, you must perform a physical examination before initiating outpatient eating disorder treatment—the American Psychiatric Association explicitly recommends that the initial physical examination include assessment of vital signs, and this is a foundational component of the comprehensive evaluation required for all patients with eating disorders. 1, 2

Required Components of the Physical Examination

Vital Signs Assessment

• Measure temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure at the initial evaluation. 2 These measurements detect cardiovascular instability from malnutrition or purging behaviors, which can cause life-threatening complications including sudden cardiac death. 2
• Document height, weight, and BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents). 2 Weight and BMI trends are critical for determining medical stability and treatment planning. 3

Physical Signs of Malnutrition and Purging

• Assess for physical signs of malnutrition or purging behaviors, specifically Russell's sign (calluses on knuckles from self-induced vomiting), parotid gland enlargement, and dental erosion. 2 These findings provide objective evidence of purging behaviors that patients may minimize or deny. 4
• Examine for skin changes, bradycardia, and gastrointestinal disturbances that indicate eating disorder pathology. 5

Essential Laboratory and Diagnostic Testing

Initial Laboratory Workup

• Obtain a complete blood count to detect anemia, leukopenia, and other hematologic abnormalities. 2 Approximately 60% of anorexia nervosa patients show normal laboratory values despite severe malnutrition, so normal results do not exclude serious illness. 2
• Order a comprehensive metabolic panel including electrolytes (sodium, potassium, chloride, bicarbonate), liver enzymes, and renal function tests (BUN, creatinine) to identify hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, and hepatic or renal dysfunction. 2

Cardiac Evaluation

• Perform an electrocardiogram in all patients with restrictive eating disorders, severe purging behaviors, or those taking QTc-prolonging medications. 2 Up to one-third of deaths in anorexia nervosa are cardiac-related, with sudden cardiac death being a frequent cause of mortality. 2
• Monitor QTc intervals in patients with restrictive eating or severe purging, as they require ongoing cardiac monitoring due to risk of sudden cardiac death. 2

Clinical Rationale for Physical Examination

Medical Complications Require Detection

• Eating disorders cause serious medical complications affecting every body system, with both acute and chronic consequences. 6 Prolonged starvation results in cardiac muscle atrophy, sinus bradycardia, and QTc interval prolongation. 2
• Low weight, low body mass index, and rapid weight loss are the most important independent predictors of QTc interval prolongation in anorexia nervosa. 2

Comprehensive Review of Systems

• The American Psychiatric Association recommends that the initial psychiatric evaluation include a comprehensive review of systems. 1 This identifies co-occurring health conditions and medical instability that would require higher levels of care. 1, 2

Critical Pitfalls to Avoid

• Do not rely solely on patient self-report or assume medical stability based on appearance alone—patients may minimize symptoms, and physical findings like bradycardia or orthostatic hypotension may be the only indicators of severe malnutrition. 4, 3
• Do not skip the physical examination because the patient appears "not that sick"—early intervention decreases the risk of long-term pathology and disability, and subtle physical findings may be the only early warning signs. 3
• Do not proceed with outpatient treatment if the physical examination reveals medical instability—patients with severe complications must be medically stabilized in an acute care hospital setting before transfer to outpatient eating disorder treatment. 2

Integration Into Multidisciplinary Care

• The physical examination findings guide the coordinated multidisciplinary treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise. 2, 7 The psychiatrist or primary clinician coordinates treatment using medical examination results to determine appropriate level of care. 7
• Physical examination findings determine whether outpatient treatment is safe or whether escalation to higher levels of care (partial hospitalization, residential, or inpatient) is required based on health status, weight patterns, and test abnormalities. 3