A 23 year old female is brought to your office by her mother for psychological evaluation. Her mother reports that the patient prepares food for the entire family but she does not eat much. Even if she eats, she vomits out with self-induced vomiting. This behavior has gotten worse over the last 3 years. She is very goal oriented in her social life. She thinks she is overweight and spends 3-4 hours a day doing all kinds of physical exercises to ‘burn the extra calories in buttocks’. She thinks something bad will happen soon unless she changes how she looks. She is fearful of fat. She has been seeing her psychologist for the last 6 months but it does not seem to help much. She reports cold intolerance, muscle weakness, loss of stamina, constipation, abdominal pain, and feeling down. She has irregular menses with some months going with no periods. She feels depressed but ‘not enough to see a doctor’. Vital signs: Height: 5 feet 1 inch, Weight: 74 pounds, Temperature = 95 F, BP = 85/65 mm Hg, Pulse = 48/minute General: looks fatigued, stressful Mental status: oriented to place, person and time Head: Parotid gland hypertrophy Oral: Dental decay, white patches on tongue Lungs: clear to auscultation Heart: normal S1,S2, sinus bradycardia with occasional irregular beats Abdomen: non-tender Musculoskeletal: ⅗ strength, decreased range of motion in extremities Extremities: Peripheral edema in the ankles, scars and calluses on the back of the hand Nervous system: hyporeflexia Skin: Petechiae, sallow complexion, dry, scaly skin Hair: presence of downy body hair on trunk and extremities Diagnostic tests: Hemoglobin 10.1 g/dl Blood film: Echinocytes and acanthocytes. Sodium 129 mEq/L Potassium 3.1 mEq/L FSH 3 mIU/ml LH 4 mIU/ml TSH 7 microU/mL BUN 22 mg/dL LDL 423 mg/dl ECG: sinus bradycardia, QTc 542 ms You discussed your impression of your observations and diagnostic tests to the patient and her mother. But the patient does not take you seriously. What is the most likely diagnosis in this patient?
