When questioned about her decrease in weight, the patient notes that she became concerned that her diet was unhealthy after her health class talked about diabetes and obesity. Around the same time, her father was told by his doctor that he had prediabetes and should lose weight and decrease sugar intake. Her father has lost about 20 lb by decreasing his sugar intake, eating a more plant-based diet, and exercising regularly. Holly started to watch her sugar intake too and joined the gym with her father. She became a vegetarian and is now a vegan, because she is concerned about cruelty to animals. She now exercises at the gym with her father, goes for runs by herself around the school track, and does crunches in her bedroom. She used to think she would be happy at her current weight of 44 kg, but now that she is at this weight, she feels an urge to have a lower weight. She thinks she looks heavy when she looks in the mirror.

Her mother reports that Holly eats a full plate of food at every meal, but the food is very healthful. Holly’s diet recall is as follows: for breakfast, she had a bowl of oatmeal made with water and a spoonful of peanut butter. For lunch, she had an entire plate of greens with lentils, slices of avocado, and a bowl of watermelon. For dinner, she had two plain baked potatoes and salad; she did not eat the roast beef that the family had because she does not eat meat. She declined dessert last night as she does on most nights, although she will eat fruit for dessert.

Holly is questioned confidentially about her social history . She reports a good relationship with her mother, father, and two brothers at home. She feels safe and loved. She enjoys school and all of her activities. She is a competitive violinist and is involved in the student community service organization. She has friends and can name a best friend (Her mother later notes that Holly has been spending less time with her friends and avoids a lot of fun outings that she would have enjoyed when she was younger.). Holly denies all substance abuse. Her mood is “fine,” and she denies any depression or suicidality. There are no firearms in the home.

Holly’s vital sign s show bradycardia to 49 bpm supine and a blood pressure of 102/70. Standing vital signs are 88 bpm and 100/72. She has a normal temperature and oxygen saturation. Her weight is 44 kg, height is 163.5 cm, and BMI is 16.5. On physical exam, Holly is very thin and sallow appearing. She has a flat affect and speaks in a high, quiet voice. She has bitemporal wasting and no parotid enlargement. No dental decay is noted. She has shotty lymphadenopathy in her anterior cervical chain, without thyromegaly. She has no acne, hirsutism, or lanugo. Extremities are cool to palpation with good cap refill. Abdomen is scaphoid with hard stool palpated in the lower left quadrant. Spinous processes are prominent with an abrasion noted over the lumbar spine. Breasts are a small tanner 5, and pubic hair is tanner 4. Neurologic exam is within normal limits. Mental status exam is significant for a flattened affect, but Holly is otherwise lucid and communicative. You suspect that Holly has anorexia nervosa.