Examkin

Question

Difficulty: MediumSomatic Symptom and Eating Disorders

A 17-year-old male is evaluated in the emergency department after experiencing a syncopal episode during cross-country track practice. He reports strictly limiting his food intake over the past 8 months to 'optimize his race times' and has subsequently lost 18 kg (40 lb). Temperature is 35.8°C (96.4°F), blood pressure is 80/50 mmHg, pulse is 38/min, and BMI is 13.5 kg/m². Physical examination reveals temporal wasting, lanugo on his back, and cold, cyanotic extremities. An electrocardiogram reveals marked sinus bradycardia with a prolonged QTc interval. Laboratory studies demonstrate significant hypokalemia, hypomagnesemia, and hypophosphatemia. Arrange the following interventions in the most appropriate chronological order for the comprehensive management of this patient, from the most immediate acute intervention to long-term follow-up.

  1. 1Admit to an inpatient medical unit with continuous cardiac telemetry
  2. 2Administer intravenous repletion of potassium, magnesium, and phosphate
  3. 3Initiate a carefully titrated, low-calorie nutritional rehabilitation protocol
  4. 4Commence family-based therapy (FBT) and comprehensive psychiatric evaluation
  5. 5Transition to a specialized intensive outpatient eating disorder program

Answer

The correct chronological sequence prioritizes immediate medical survival and hemodynamic stability, followed by metabolic correction, safe refeeding, psychotherapy, and finally, outpatient step-down care.
The correct sequence reflects the hierarchy of clinical urgency in severe anorexia nervosa. Immediate survival depends on recognizing the need for a medical (not psychiatric) inpatient level of care due to profound hemodynamic instability (bradycardia, hypotension, syncope). Once admitted and placed on telemetry, the most imminent threat to life is a fatal arrhythmia secondary to QTc prolongation and intracellular electrolyte depletion; therefore, intravenous repletion of potassium, magnesium, and phosphate is prioritized. Starvation is then addressed via a low-calorie, gradually advancing nutritional protocol to prevent refeeding syndrome. Only after the brain receives adequate nutrition and the patient achieves medical stability can psychotherapy (such as Family-Based Therapy, the gold standard for adolescents) be meaningfully implemented. Finally, the patient is transitioned to a step-down intensive outpatient program to ensure continued weight gain and prevent relapse.

Step-by-Step Solution

1
Assess hemodynamic and medical stability.
Patient is admitted to a medical inpatient unit with telemetry.
A BMI < 15 kg/m², severe bradycardia, hypotension, and QTc prolongation are absolute indications for medical hospitalization with continuous cardiac monitoring.
2
Correct life-threatening metabolic and electrolyte derangements.
Intravenous potassium, magnesium, and phosphate are administered.
Hypokalemia and hypophosphatemia, combined with a prolonged QTc, pose an imminent risk for torsades de pointes and must be addressed prior to or concurrently with feeding.
3
Reverse the starvation state safely.
A titrated, low-calorie enteral nutritional rehabilitation protocol is initiated.
Providing calories too rapidly in a severely malnourished state precipitates refeeding syndrome; thus, strictly controlled caloric advancement is required.
4
Address the underlying psychiatric pathology.
Family-based therapy (FBT) is commenced.
Psychotherapy is the cornerstone of long-term eating disorder treatment but is ineffective when a patient is acutely starving and cognitively impaired from malnutrition.
5
Coordinate long-term recovery and maintenance.
The patient is discharged to an intensive outpatient program.
Maintenance of weight restoration and prevention of relapse require continuous, structured psychiatric and nutritional support outside the hospital.

Key Concept

The management of severe anorexia nervosa requires a strict hierarchy of interventions: acute medical stabilization (inpatient telemetry), metabolic correction (electrolyte repletion), physiological restoration (titrated refeeding), and finally psychological rehabilitation (family-based therapy and outpatient step-down care).
Rate this question

Topics

Somatic Symptom and Eating Disorders

More questions from this topic