This is the story of an extremely thin girl, very beautiful and intelligent, and on the verge of dying. She did not have other medical problems except being thin, which was a problem of her own making.
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One day at the hospital, a colleague physician said to me:
- Have you seen our new patient? She weighs about 50 pounds...
- How tall? - I asked distractedly.
- Oh, about five foot seven.
That got my attention. At five foot seven inches, a person should weigh at least 119 pounds (the lower limit of normal). The patient described by my colleague was so severely underweight I couldn't imagine how she stayed alive.
It wasn't long until I got to see her. Not out of curiosity, but because she developed an irregular heart beat for which a medical consult was requested.
She was admitted to the SNF (the Skilled Nursing Facility) - a place where chronically ill patients receive nursing care. At the age of 21, she was one of the youngest persons I ever saw in that unit.
When I first entered the room, she was covered almost entirely by a blanket, leaving only her head in sight. She had flowing dark hair and, so I thought, a real beautiful bone-structure to her face. When I say "bone-structure", that's exactly what I mean, since you could see the outline of every bone in her skull. The cheeks were sunken to the point of being non-existent. The cheekbones stood out like enormous ridges, and so did the orbits. The skin overlying the bones was ashen, with an almost cadaverous hue.
I introduced myself and asked about her problem. She gave me a precise, well-jointed report of her symptoms: She had occasional bouts of rapid heart beat, associated with shortness of breath and mild chest pressure - mainly when walking up and down the corridor in the SNF.
During the physical exam, I witnessed the full extent of her condition: There was virtually no flesh around the midsection, hips or thighs. The bones were sticking out huge, with deep craters in between. The whole abdomen was a crater. So was the region where the glutes should have been. As far as the thigh muscles, they were completely absent.
During that initial encounter, we didn't talk about weight issues. She was obviously not inclined to do so, and I was busy planning the medical management of her problems. I put her on cardiac telemetry, and ordered an EKG and routine blood-work.
- For the time being, please stay in bed - I told her. - Until we know what's going on, you shouldn't be walking around.
- But I have to walk after meals - she replied, with a worried look.
I remembered what the nurse had told me before I entered the room: "... she's pacing the corridors to burn off calories."
As a matter of fact, I could understand how that happened: Our young patient was trying to beat each "new low" she ever achieved. Once her weight dropped to a certain level, she had to better that level. There was a certain compulsive drive which compelled her to do so. In fact, I believe this is the case in most patients suffering from anorexia nervosa.
Later, I learned she had been hospitalized multiple times and in multiple clinics, for the same recurrent problem: Anorexia. A few times her weight had gone up to 80-90 pounds, only to dip down each time thereafter. Her family (both father and mother) seemed concerned and supportive, but nevertheless rather rigid. They were very interested in what could be done to fix the problem, but not at all in what caused it. In fact, nobody talked about that.
Our patient's lab work proved to be quite abnormal (as was to be expected). Her potassium was dangerously low and her liver function was elevated (both common side effects of starvation). She was recommended to receive IV nutrition, which she promptly refused (it contained calories). So, all we could give were IV fluids.
This young girl's hospital stay was complicated by a pulmonary embolism (a clot to her lungs), for which she had to be admitted to the ICU. At that point, since she was unconscious, her parents gave their consent for the IV nutrition to be started.
After a few days, the patient's condition improved enough for her to go back to the SNF. She was now conscious again, and wasted no time at regaining control over her diet. It was due to this fact that we finally talked about her weight. During one of my routine visits, she asked me very politely:
- Could you please tell me how many calories I'm getting through the IV solution?
- About 600 - I replied. (We had been cutting down on her IV nutrition, as she was now able to take food by mouth.)
- And what I'm eating here throughout the day adds up to another 600 - she said. - So that's 1,200 total. Isn't that too much...?
- Well, if you keep eating that every day, you can expect your weight to stabilize at about 100 pounds. - I replied. - Do you think that's too much?
There was a momentary silence. Of course, 100 pounds was not too much and logically, she had to admit that. She just had trouble letting go of her previous "achievement", all those pounds she had lost below the 100 mark.
On a moment's impulse, I said to her:
- I think you'd look good if you gained a little weight - I said to her. - I think you'd look beautiful.
It was true: I really believed what I was saying. Perhaps that's why it hit home. She looked at me with surprise, but also with a flicker of contentment.
Shortly thereafter, I moved on to another rotation and quit seeing this patient. I heard she was under psychiatric treatment to try change her distorted body image. Then, she was discharged from the hospital and I lost touch altogether.
Several months later, while walking through the hospital corridors, I was stopped by a slender girl with radiant black eyes. I was surprised to hear her call my name, since I had no idea who this person was. She looked quite vibrant, full of life and vitality.
- I just wanted to say thank you for everything - she said. Only then did I realize who it was.
- Lennie...? - I said incredulously. (She looked normal, if still rather thin. At that time, her weight must have been around 90 pounds.)
- Yes, I'm here for a follow-up.
- Are you fine otherwise?
She nodded light-heartedly:
- Yes, everything is ok.
I told her she looked great, as was the truth, we exchanged another few words and then said goodbye.
That was the last time I saw her. I'd like to think she recovered and never had to drop by the hospital again.
Still, by the medical books, anorexia nervosa is a chronic condition and quite likely to linger on. Acute bouts usually alternate with periods of remission of varying duration. On the whole, however, the likelihood of relapse is high. This being said, I'd still like to think this case was an exception to the rule, and that the story really had a happy ending.
PS. The name Lennie is, of course, fictitious. The story, however, is real.
Useful links: Side effects of rapid weight loss
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