A 16-year-old girl is brought to the emergency department by her parents due to severe fatigue and dizziness. She has lost 15 kg (33 lb) over the last 4 months and restricts her daily intake to under 500 calories. Her temperature is 35.8°C (96.4°F), blood pressure is 85/50 mm Hg, and pulse is 42/min. Her BMI is 14.2 kg/m². Physical examination reveals fine downy body hair and temporal wasting. The patient is admitted to the hospital.
Arrange the following management steps in the most appropriate chronological order from initial acute management to long-term therapy.
- 1Obtain an electrocardiogram and comprehensive metabolic panel
- 2Administer cautious intravenous fluid resuscitation
- 3Initiate supervised, gradual enteral nutritional rehabilitation
- 4Commence cognitive-behavioral therapy for eating disorders
Answer
The correct sequence is to first assess for immediate life threats (electrocardiogram and metabolic panel), then correct hemodynamic instability (intravenous fluids), followed by nutritional recovery (enteral rehabilitation), and finally initiate long-term psychiatric treatment (cognitive-behavioral therapy).
The correct chronological order follows the universal medical principle of prioritizing life-threatening acute medical issues before addressing chronic psychiatric conditions. Diagnostic evaluation (ECG/labs) dictates the immediate resuscitation needs (fluids). Once hemodynamically stable, the physical effects of starvation are treated (gradual feeding). Finally, with improved cognition and stability, the underlying psychiatric cause is addressed (CBT).
Step-by-Step Solution
Key Concept
In severe anorexia nervosa with medical complications, management follows a strict hierarchy: acute medical assessment and stabilization (ABCs, electrolytes, hemodynamics), followed by careful nutritional rehabilitation, and finally formal psychiatric psychotherapy.