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Difficulty: MediumSomatic Symptom and Eating Disorders

A 15-year-old girl is admitted to the inpatient pediatric unit for severe anorexia nervosa, restricting type. She has a body mass index (BMI) of 13.2 kg/m², a heart rate of 42/min, and blood pressure of 88/55 mm Hg. Physical examination shows lanugo, temporal wasting, and acrocyanosis. Arrange the following interventions in the most appropriate clinical sequence for the management of this patient, from initial inpatient evaluation to definitive post-hospitalization care.

  1. 1Obtain a baseline electrocardiogram and assess serum levels of phosphorus, potassium, and magnesium.
  2. 2Initiate closely monitored, gradual nutritional rehabilitation with a low starting caloric intake.
  3. 3Perform daily monitoring of serum electrolytes with prompt repletion as needed.
  4. 4Engage the patient and parents in outpatient family-based therapy (FBT).

Answer

The correct sequence is: (1) Obtain a baseline electrocardiogram and assess electrolytes, (2) Initiate gradual nutritional rehabilitation, (3) Perform daily monitoring of serum electrolytes, and (4) Engage the patient and parents in outpatient family-based therapy (FBT).
The management of severe anorexia nervosa requires a structured, sequential approach prioritizing medical safety. First, baseline electrolytes and an ECG must be obtained to assess for existing derangements and the immediate risk of arrhythmias. Second, gradual nutritional rehabilitation is initiated to slowly reverse the starvation state. Third, because the reintroduction of carbohydrates stimulates insulin release and drives phosphorus, potassium, and magnesium into cells, daily electrolyte monitoring and aggressive repletion are crucial to prevent refeeding syndrome. Finally, once the patient is medically stabilized, the focus shifts to long-term psychiatric recovery, for which family-based therapy (FBT) is the first-line treatment in adolescents.

Step-by-Step Solution

1
Assess initial clinical and metabolic status.
Baseline ECG and comprehensive metabolic parameters are obtained.
Severely malnourished patients are at immediate risk for fatal arrhythmias and baseline electrolyte derangements, which must be identified before any intervention.
2
Begin medical management of starvation.
Gradual caloric reintroduction is initiated.
Starting with a low caloric intake prevents a rapid insulin surge that causes severe intracellular shifts of electrolytes, thereby mitigating the risk of refeeding syndrome.
3
Monitor and manage acute complications of refeeding.
Electrolytes are checked daily and repleted as needed.
Refeeding syndrome typically manifests within the first few days of nutritional rehabilitation; close monitoring prevents clinical deterioration.
4
Plan definitive long-term psychiatric treatment.
Family-based therapy (FBT) is initiated upon discharge.
Once medically stable, FBT is the evidence-based gold standard for adolescents with anorexia nervosa to achieve long-term weight restoration and behavioral change.

Key Concept

Sequential management of severe anorexia nervosa prioritizes acute medical stabilization (baseline assessment followed by careful refeeding and monitoring) before transitioning to longitudinal psychiatric care.
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Topics

Somatic Symptom and Eating Disorders

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