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CASE PRESENTATION A 17-year-old girl was brought to the emergency department by her worried parents. The patient was described by her parents as having symptoms of fatigue, dizziness and syncope over the past few days. She also had no appetite, a weight loss of 11.4 kg over the past four months and a recent uncharacteristic pursuit to exercise. When the patient was further questioned, she complained of cold hands and feet, constipation, dry skin and hair, and headaches. Her social history revealed social withdrawal, depression, and irritability, as well as having difficulty concentrating and making decisions. Her performance at school had also fallen. The physical exam revealed a quiet, young girl who looked her age, was in no distress, but had cool peripheries. Her skin was slightly mottled in appearance, with some anhydrotic eczema of her extremities, and her blood pressure was difficult to auscultate. When obtained, it was lower than her usual values, at 84 systolic and 70 diastolic. Her pulse was 47 bpm, and irregularly irregular. Respiratory and abdominal examinations were normal. The patient however looked very underweight and thin. Her weight and height were 47 kg and 1.7 m, respectively; her calculated body-mass index (BMI) was 16. She also had a moderate loss of muscle mass and edema of her extremities. Further history taking from the patient, while alone, revealed that she had stopped menstruating seven months ago. There were no changes in sleep or any changes in bladder or bowel movements, and nausea and vomiting were denied. Her past medical history was remarkable for a stress fracture of her fibula and multiple admissions to hospital for depression, and she was also once admitted for suicidal ideation. Moreover, the patient denied any current laxative or diuretic use, and when asked about her diet, she stated that it consisted of yogurt and some fruit, with no meal at lunchtime while at school. Daily servings would not exceed a total of 750 kcal/day and her meals never contained any fat. She described herself as "fat…overweight" and her only pastime was exercising. When asked about her weight, she stated, "the more weight I lose, the more I wish to loose." She denied having any problems and explained that she was annoyed that her parents, friends, and teachers were concerned. It seems that the patient has very poor insight into her situation, and continues to perceive herself as healthy. Despite being …

Anorexia Nervosa: The physiological consequences of starvation and the need for primary prevention efforts.