Adolescent learning problem: concentration and diet pills

The presenting complaint is difficulty concentrating at school, and the case is constructed so that taking it at face value is the wrong move. A sixteen-year-old who is thin and frail in appearance and who asks for diet pills has handed you two findings that reframe the first one, and the strongest papers say so explicitly: impaired concentration is a recognised consequence of malnutrition, so the complaint may be the downstream effect of the thing the examination just found rather than an independent problem. Connecting the three observations into one hypothesis, instead of working through them as a list of separate concerns, is the single move that most distinguishes answers to this case. It is also the reading that organises the rest of the paper, since a single hypothesis gives the screening tools something to confirm or exclude.

The setting is not scenery either. A **family nurse practitioner in a rural health clinic** is precisely the clinician least likely to have adolescent medicine, an eating disorder programme or child and adolescent psychiatry within reach, and the fourth question asks for referrals. Write the plan for the clinic you were given: name the referral you want, acknowledge the access problem honestly, and say what you would do in the meantime — telehealth, a dietitian at distance, primary care medical monitoring while a specialist appointment is pending. A referral list that assumes a tertiary centre down the corridor reads as though the first sentence of the case went unread, and that first sentence was put there deliberately. Naming the constraint is not an excuse for a thinner plan; it is the part of the answer that shows you understood which clinician you were being asked to be.

For initial areas of concern, work in two directions. First, take the eating disorder hypothesis seriously: restrictive intake, distorted body image, the medical sequelae that matter acutely — bradycardia, orthostatic changes, hypothermia, electrolyte disturbance — plus amenorrhoea, effects on growth and peak bone mass, and elevated risk of self-harm. Second, keep the differential the concentration complaint alone would generate, because closing it too early is its own error: attention deficit disorder, depression, insufficient sleep, substance use, thyroid disease and anaemia all present this way. The request for diet pills deserves a line of its own, since over-the-counter stimulant preparations are a route to misuse as well as a marker of preoccupation with weight. Say explicitly which of these you are keeping open and why, because a differential that is listed and then never mentioned again has not really been held at all.

The screening question wants named instruments with what a result means. The SCOFF is five questions with two or more positive answers indicating further assessment; the EAT-26 is longer and self-administered; a depression screen adapted for adolescents and a substance use screen such as CRAFFT cover the differential. Distinguish these from surveillance data — the youth risk behaviour system cited in the brief describes populations and does not screen an individual, and saying so shows you read the reference rather than reused it. Objective screening belongs here too: vital signs with orthostatics, and weight and height plotted on a growth chart as percentiles, because adult body mass index categories are not valid for a sixteen-year-old. Percentiles also give you something to track at follow-up, where a single body mass index figure gives you a number that means very little on its own.

Question three says **one** health promotion strategy, so develop one rather than listing four, and keep it a health promotion strategy rather than a treatment. The plan of care in question four names six components and each should appear under its own heading: pharmacological and non-pharmacological interventions, labs, follow-up, teaching, and referrals. The honest pharmacological answer is that no medication treats the core features of restrictive eating disorder, which makes the over-the-counter half largely a counselling task — diet pills, laxatives and diuretics are what you are advising against. Labs should be justified rather than listed, an electrocardiogram belongs in the plan for bradycardia and QT interval, and the criteria that would make this an admission rather than an appointment should be stated. Stating the admission criteria is the safety net the whole plan rests on, and it is the element most often missing from otherwise competent answers.