Examkin

Question

Difficulty: MediumSomatic Symptom and Eating Disorders

A 19-year-old woman is admitted to the hospital with severe anorexia nervosa, restricting type. She presents with a BMI of 13.2 kg/m^2, a heart rate of 38/min, and a blood pressure of 82/50 mm Hg. The patient reports consuming only small amounts of water and black tea for the past two weeks. The multidisciplinary team is formulating a comprehensive treatment plan to ensure medical stabilization and long-term recovery while minimizing the risk of fatal complications. Arrange the following clinical management steps in the most appropriate sequential order, from immediate admission priorities to long-term management.

  1. 1Perform baseline assessment including serum electrolyte panel and an electrocardiogram.
  2. 2Initiate cautious caloric prescription at 10-20 kcal/kg/day under continuous cardiac telemetry.
  3. 3Monitor metabolic panels closely and replete intracellular electrolytes in response to insulin-mediated shifts.
  4. 4Advance to a steady weight restoration protocol targeting 1-2 kg of gain per week.
  5. 5Implement outpatient cognitive-behavioral therapy for eating disorders (CBT-E) once cognitive function improves.

Answer

The correct sequence is: Baseline labs/ECG -> Cautious caloric initiation -> Repletion of electrolyte shifts -> Steady weight restoration -> Outpatient psychotherapy.
The management of severe anorexia nervosa follows a strict hierarchy of needs: preserving life, restoring physical health, and addressing psychological pathology. Immediate baseline assessment (labs/ECG) must occur before any nutrition is provided to identify pre-existing dangerous derangements. Next, feeding must be initiated very cautiously to avoid triggering a massive insulin surge. Despite cautious feeding, intracellular shifts of phosphorus, potassium, and magnesium often occur, requiring vigilant monitoring and repletion (preventing refeeding syndrome). Once the acute metabolic risk window has passed, the focus transitions to steady, protocol-driven weight restoration. Finally, psychotherapy is implemented, as the severely starved brain lacks the cognitive capacity to engage meaningfully in complex psychological therapies like CBT-E until baseline nutritional status is somewhat restored.

Step-by-Step Solution

1
Identify the immediate threat to life.
The patient's severe malnutrition places her at extreme risk for sudden cardiac death and refeeding syndrome, making baseline labs and ECG the absolute first priority.
Establishing a baseline prevents exacerbating unrecognized hypokalemia or hypophosphatemia when feeding begins.
2
Determine the initial nutritional strategy.
Feeding is initiated very slowly (10-20 kcal/kg/day) rather than aggressively.
Slow introduction of carbohydrates minimizes the initial insulin spike, reducing the severity of intracellular electrolyte shifts.
3
Plan for acute metabolic complications during early refeeding.
The team monitors daily (or twice daily) metabolic panels to replete phosphorus, potassium, and magnesium as they shift into cells.
Despite cautious feeding, refeeding syndrome can still occur; proactive repletion prevents life-threatening arrhythmias.
4
Establish the subacute recovery goal.
The patient is transitioned to a steady weight restoration protocol (1-2 kg/week).
Once the high-risk metabolic window resolves, consistent caloric surplus is required to restore organ function and body mass.
5
Select the appropriate long-term psychiatric intervention.
CBT-E is planned for the outpatient setting.
A severely starved brain lacks cognitive flexibility. Evidence-based psychotherapy is most effective after partial or full weight restoration.

Key Concept

Sequential management of severe anorexia nervosa emphasizes acute medical stabilization and refeeding syndrome prevention before long-term weight restoration and psychotherapy.
Rate this question

Topics

Somatic Symptom and Eating Disorders

More questions from this topic