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Difficulty: HardSomatic Symptom and Eating Disorders

A 2828-year-old man is brought to the emergency department by his partner due to worsening lethargy and near-syncope. Over the past year, he has severely restricted his dietary intake and exercises intensely for 33 hours daily, expressing a profound fear of gaining weight. Physical examination reveals temporal wasting and lanugo over his trunk. Temperature is 35.2∘C35.2^\circ\text{C} (95.4∘F95.4^\circ\text{F}), blood pressure is 82/50 mm Hg82/50 \text{ mm Hg}, pulse is 38/min38\text{/min}, and respirations are 12/min12\text{/min}. His body mass index is 12.4 kg/m212.4 \text{ kg/m}^2. Electrocardiogram reveals sinus bradycardia with a prolonged QTc interval. Initial laboratory studies show:

Laboratory testResult
Potassium2.7 mEq/L2.7 \text{ mEq/L}
Magnesium1.2 mEq/L1.2 \text{ mEq/L}
Phosphorus1.8 mg/dL1.8 \text{ mg/dL}

Arrange the following clinical management steps in the most appropriate chronological sequence for this patient.

  1. 1Admit to an inpatient medical telemetry unit
  2. 2Administer intravenous electrolyte replacement
  3. 3Initiate gradual enteral caloric rehabilitation
  4. 4Transfer to an inpatient psychiatric eating disorder unit
  5. 5Commence outpatient cognitive-behavioral therapy

Answer

The correct sequence is: Admit to an inpatient medical telemetry unit → Administer intravenous electrolyte replacement → Initiate gradual enteral caloric rehabilitation → Transfer to an inpatient psychiatric eating disorder unit → Commence outpatient cognitive-behavioral therapy.
Patients with severe anorexia nervosa presenting with profound malnutrition, vital sign instability, and electrolyte abnormalities require a sequential step-up to step-down approach. The first priority is preventing sudden cardiac death. The presence of severe bradycardia, hypotension, and QTc prolongation mandates immediate admission to a medical unit with continuous cardiac telemetry. Second, profound electrolyte deficits (hypokalemia, hypomagnesemia, hypophosphatemia) must be aggressively corrected. If caloric rehabilitation is initiated before correcting these deficits, the resulting insulin surge will drive remaining electrolytes intracellularly, triggering fatal refeeding syndrome. Third, once electrolytes are being supplemented, gradual enteral caloric rehabilitation is initiated with strict monitoring. Fourth, when the patient becomes medically stable (normal vital signs, stable electrolytes on oral supplementation), they are transferred to an inpatient psychiatric unit specialized in eating disorders to continue supervised weight restoration and begin intensive behavioral therapy. Finally, upon achieving a safe weight and demonstrating sufficient behavioral control, the patient is discharged to initiate outpatient cognitive-behavioral therapy.

Step-by-Step Solution

1
Assess the patient's medical stability and triage setting.
The patient has severe bradycardia (38/min38\text{/min}), hypotension (82/50 mm Hg82/50 \text{ mm Hg}), prolonged QTc, BMI <15 kg/m2< 15 \text{ kg/m}^2, and profound electrolyte derangements.
These critical findings indicate impending cardiovascular collapse. The patient requires immediate inpatient medical admission with cardiac telemetry, rather than direct psychiatric admission.
2
Determine the priority of interventions upon medical admission.
Intravenous electrolyte replacement must precede or accompany the very initiation of nutritional rehabilitation.
The patient already has hypophosphatemia, hypomagnesemia, and hypokalemia. Introducing calories (especially carbohydrates) without correcting these will precipitate refeeding syndrome, causing severe intracellular shifts of phosphorus and potassium, potentially leading to fatal arrhythmias.
3
Plan the long-term treatment pathway once medical stability is achieved.
Transfer to a psychiatric eating disorder unit, followed by outpatient psychotherapy.
Medical floors stabilize acute physiology but do not adequately treat the underlying eating disorder. Once hemodynamically and metabolically stable, intensive inpatient psychiatric care is required for weight restoration protocols, eventually transitioning to outpatient cognitive-behavioral therapy to prevent relapse.

Key Concept

Management of severe anorexia nervosa requires immediate medical stabilization (telemetry, electrolyte correction) to prevent refeeding syndrome and arrhythmias, followed by gradual nutritional rehabilitation, and subsequently transitioning to psychiatric step-down care.
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Topics

Somatic Symptom and Eating Disorders

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