From the Guidelines
The patient's presentation suggests a potential eating disorder, and according to the American Psychiatric Association practice guideline for the treatment of patients with eating disorders 1, a comprehensive evaluation is necessary to confirm the diagnosis and guide management. The key findings supporting this concern include the patient's history of being a picky eater, recent fatigue, and the discrepancy in pubertal development, with delayed breast development (Tanner stage 1) despite advanced pubic hair development (Tanner stage 4).
- The initial evaluation should include:
- Weighing the patient and quantifying eating and weight control behaviors, as recommended by the APA 1
- Identifying co-occurring health conditions, including co-occurring psychiatric disorders 1
- A comprehensive review of systems 1
- Assessment of vital signs, including temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure; height, weight, and BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents); and physical appearance, including signs of malnutrition or purging behaviors 1
- Laboratory assessment should include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests, as recommended by the APA 1
- The APA recommends (1C) that the initial psychiatric evaluation of a patient with a possible eating disorder include a comprehensive review of systems and identification of co-occurring health conditions 1. Given the patient's presentation and the APA guidelines, a thorough evaluation for an eating disorder is warranted, and management should be guided by the results of this evaluation, with consideration of the patient's overall health and well-being 1.
From the Research
Patient Presentation
The patient is a 14-year-old girl presenting with fatigue, which has led to her going to bed earlier than usual. She has a history of being a picky eater but consistently consumes three meals a day. Her blood pressure and pulse are within normal ranges, and her physical examination is largely unremarkable except for her breast development being at Tanner stage 1 and pubic hair development at Tanner stage 4.
Differential Diagnosis of Fatigue
Fatigue can be caused by various factors, including lifestyle issues, physical conditions, mental disorders, and treatment side effects 2, 3, 4. The differential diagnosis should consider secondary causes such as medications, anemia, and pregnancy, as well as life-threatening conditions like cancer. However, laboratory tests are only useful in a small percentage of cases, and repeat testing is generally not indicated if initial results are normal 2.
Evaluation and Management of Fatigue
The evaluation of fatigue should involve a comprehensive history and physical examination, focusing on identifying common secondary causes and life-threatening problems 3, 4. Treatment should include a structured plan for regular physical activity, such as walking, and may involve the use of caffeine, modafinil, or selective serotonin reuptake inhibitors in certain cases 2. Cognitive behavior therapy may also be beneficial for patients with chronic fatigue 2, 3.
Potential Underlying Conditions
Given the patient's age and presentation, potential underlying conditions that could be contributing to her fatigue include hypothyroidism, although this would typically be associated with other symptoms such as cold intolerance, weight gain, and dry skin 5. The patient's fatigue could also be related to her dietary habits or other lifestyle factors.
Key Considerations
- Fatigue is a multidimensional construct that can be measured using validated clinical measures 6.
- A comprehensive history and physical examination are essential in evaluating fatigue 3, 4.
- Treatment should be tailored to the individual patient and may involve a combination of lifestyle modifications, medications, and therapies 2, 3.