Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Bulimia
BULIMIA
An eating disorder that consists of recurrent episodes of binge eating and subsequent purging or laxative abuse. Most patients are within a normal weight range but can have frequent fluctuations of weight of 10 lb or more resulting from alternating binges and fasts.
I. Etiology
A. A complex condition involving biologic, psychological, and social issues
B. Predisposing factors
1. Overweight female
2. Overconcerned with weight
3. A perfectionist
4. Difficulty communicating sadness, anger, or fear
5. Low self-esteem
6. Difficulty resolving conflict
II. Incidence
A. Occurs primarily in late adolescence or early adulthood
B. Primarily in females (90%–95% of cases)
C. An estimated 19% of college females and 5% of college males use purging as a method of weight control; however, not all cases of selfreported overeating and occasional purging are true bulimia. A significant number of cases may be overdiagnosed on the basis of the simple criteria of binge eating and subsequent purging. According to Schotte and Stunkard, the prevalence of bulimia in a sampling of 994 university women was no greater than 1.3%.
III. Indications of bulimic behavior
A. Recurrent episodes of rapid consumption of high-calorie foods
B. Binge eating done secretly, usually terminated by external factors (e.g., abdominal pain, sleep, visitor)
C. Abdominal pain after binge eating
D. Purging by vomiting after binge eating; alternating binge eating and fasting
E. Reasonably normal weight range with periodic fluctuations of about 10 lb
F. Preoccupation with weight
G. Attempts at weight loss through rigid dieting, vomiting, laxative or diuretic use; episodes of fasting
H. Fear of losing control and not being able to stop eating
I. Depression following binge eating
J. Awareness of abnormal eating pattern
K. Poor impulse control, also exhibited in other behavioral aberrations, such as substance abuse, self-mutilation, sexual promiscuity, lying, and stealing
L. Excessive exercising
M. Erosion of tooth enamel
N. Possible amenorrhea
O. Electrolyte imbalance
P. Attempts to maintain weight within a specific range for activities, such as wrestling, dancing, figure skating, modeling
IV. Subjective data
A. Sores in mouth
B. Dental caries
C. Heartburn
D. Chest pains
E. Bloody diarrhea (with laxative abuse)
F. Bruising
G. Muscle cramps
H. Fainting
I. Menstrual irregularities
V. Objective data
A. Weight: Normal or overweight
B. Parotid gland hypertrophy
C. Dental caries and enamel erosion (from contact with stomach acid)
D. Pyorrhea
E. Calluses and abrasions on dorsum of hands (from contact with teeth from self-induced vomiting)
F. Abdominal distention
G. Muscular weakness
H. Intermittent edema
I. History positive for indications of bulimia
J. Laboratory abnormalities
1. Elevated serum bicarbonate (metabolic alkalosis secondary to vomiting)
2. Hypokalemia, hypochloremia, hyponatremia
3. Metabolic acidosis (with laxative use)
4. Hypocalcemia or hypercalcemia
VI. Assessment
A. A diagnosis of bulimia may be made if the following are present:
1. Binge eating with a sense of loss of control
2. Binge eating with compensatory behavior of the purging type
(self-induced vomiting, laxative abuse, diuretic abuse) or nonpurging type (excessive exercise, fasting, or strict diets) a minimum of two times per week for 3 months
3. Dissatisfaction with body shape and weight
B. Identify type
1. Purging type: Engages in self-induced vomiting or use of laxatives, diuretics, or enemas
2. Nonpurging type: Inappropriate compensatory behaviors, such as fasting or excessive exercise
VII. Plan
A. An interdisciplinary approach should be used, incorporating medical management, nutritional counseling, and mental health.
B. Medical management
1. Visits should be scheduled on an individual basis according to the severity of the symptoms and physical findings. Initially they should be at least every 2 weeks until the patient is medically stable.
2. Include
a. Physical examination with particular attention to anticipated physical findings in bulimic patients
b. Weight
c. Laboratory tests: On an individual basis, depending on physical status
d. Counseling: Include psychosocial issues as well as medical and nutritional. It is not reasonable for the primary health care provider to separate these issues and address medical management alone because it is a multifaceted problem, and generally the medical management “pulls it all together” for the patient.
C. Nutrition: Refer to nutritionist.
D. Mental health
1. Psychiatrist
a. Individual counseling
b. Medication (antidepressants), if indicated
2. Psychologist
a. Family therapy
b. Individual therapy to
(1) Resolve underlying psychological issues
(2) Restore normal nutrition
(3) Increase self-esteem
(4) Help development of self-control
E. Behavior modification
F. Drug therapy
1. Antidepressants
a. SSRIs: Fluoxetine is the only FDA-approved medication for bulimia
b. Avoid TCAs, MAOIs, and bupropion
2. Anticonvulsants (phenytoin): Research has shown that binge eaters often have an EEG abnormality; anticonvulsants can sometimes control binge eating.
G. For the occasional “binger and purger” whose physical examination and laboratory tests (CBC, electrolytes, urinalysis) are within normal limits, office management can be attempted for a short time. The duration of office treatment must be individualized for each patient.
1. Counseling should concentrate on following issues:
a. Body image
b. Normal weight for height
c. Nutrition
d. Dental concerns
e. Excessive exercising
f. Self-control
g. Self-esteem
2. Have child keep careful record of intake and of any episodes of binging and purging.
3. Recheck weekly.
a. Obtain weight.
b. Review dietary history.
c. Provide counseling.
4. Refer if episodes continue or if depression or despair is present.
VIII. Follow-up: Contact after referral for support and encouragement.
IX. Complications
A. Esophagitis
B. Esophageal tears
C. Gastric dilatation
D. Hypokalemia with resultant cardiac arrhythmias
E. Depression
X. Consultation/referral
A. Any child with complications
B. No response to treatment (e.g., continuing binge eating, purging, laxative abuse)
C. For pharmacologic therapy
National Association of Anorexia Nervosa and Associated Disorders, Inc. (ANAD). Address: Box 7, Highland Park, IL, 60035. Telephone: Toll-free hotline: 847-831-3438. Website: http://www.anad.org
The Massachusetts Eating Disorder Association (MEDA). Telephone: 617-558-1881. Website: http://www.medainc.org
National Eating Disorders Association. Telephone: 800-931-2237. Website: http://www.
NationalEatingDisorders.org
Schotte, D.E., & Stunkard, A. J. (1987). Bulimia vs bulimic behaviors on a college campus.
JAMA, 258(9), 1213–1215.
The Academy for Eating Disorders. Telephone: 703-556-9222. Website: http://www.aedweb.org The American Anorexia Bulimia Association. Address: 165 W. 46th St., Suite 1108, New
York, NY, 10036. Telephone: 212-575-6200. Website: http://www.aabainc.org