A 16-year-old girl comes to the office due to a 3-week history of constipation and stomachaches, which are getting worse despite over-the-counter laxatives. The patient has no significant medical history and takes no medication. She consumes a vegan diet and exercises 2 hours a day, which she says "is necessary so I don't become any fatter than I am already." Family history is significant for Hashimoto thyroiditis in her mother, as well as scleroderma and obsessive-compulsive disorder in her sister.
Physical examination is significant for a thin, young female with fine hair on her face and body and with dry skin. Temperature is 37.2 C (99 F) , blood pressure is 80/55 mm Hg, pulse is 39/min, and respirations are 14/min. BMI is 16.5 kg/m². Laboratory results are as follows:
Which of the following is the best next step in management of this patient?

Question

A 16-year-old girl comes to the office due to a 3-week history of constipation and stomachaches, which are getting worse despite over-the-counter laxatives. The patient has no significant medical history and takes no medication. She consumes a vegan diet and exercises 2 hours a day, which she says "is necessary so I don't become any fatter than I am already." Family history is significant for Hashimoto thyroiditis in her mother, as well as scleroderma and obsessive-compulsive disorder in her sister.
Physical examination is significant for a thin, young female with fine hair on her face and body and with dry skin. Temperature is 37.2 C (99 F) , blood pressure is 80/55 mm Hg, pulse is 39/min, and respirations are 14/min. BMI is 16.5 kg/m². Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98c5_7e53_853d_6335d42eb5a8_MD0002_00 This patient's significantly low BMI (<18.5 kg/m²), distorted view of her body weight, lanugo hair, bradycardia, hypotension, and hypokalemia are consistent with anorexia nervosa (AN). The mainstay of treatment in medically stable patients is psychotherapy and nutritional rehabilitation. However, when malnutrition is severe, organ compromise (eg, cardiomyopathy, cardiac atrophy, arrhythmia, respiratory failure, seizures) resulting from lack of nutrients or from electrolyte and fluid imbalances can be fatal. In these cases, inpatient hospitalization is required for medical stabilization and careful refeeding. ² Hospitalization of patients with AN is indicated with ≥1 of the following symptoms: Unstable vital signs, BMI <15 kg/m², syncope, electrolyte disturbance, seizures, cardiac failure, or dysrhythmias. This patient's presentation includes abnormal vital signs (hypotension, bradycardia) and electrolyte disturbances (hypokalemia). (Choices A and C) Although nutritional counseling and psychotherapy are the main forms of treatment for AN, this patient is medically unstable and first must be hospitalized due to the risks of complications from organ failure and cardiac compromise. (Choice D) Psychiatric evaluation is important in assessing for comorbid disorders such as depression and anxiety, which are often seen with AN. Hospitalization, however, is a priority in this patient. (Choice E) Although hypothyroidism can lead to constipation, bradycardia, and dry skin, it more often results in weight gain and hypertension rather than the hypotension and very low weight seen in this patient. In addition, thyroid function tests may not be helpful in management of AN as patients can present with euthyroid sick syndrome (ie, low T3 or T4) due to the body's adaption to chronic nutritional depletion. Educational objective: The long-term treatment of anorexia nervosa includes psychotherapy and nutritional rehabilitation. However, a patient with unstable vital signs, BMI <15 kg/m², or serious medical complication of malnutrition (eg, syncope, electrolyte disturbance, seizures, cardiac failure, dysrhythmias) must be hospitalized to prevent mortality from organ failure. ² __________ References: Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/25591200) Identification and management of eating disorders in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/21115584)

A 16-Year-Old Girl Comes to the Office Due to a 3-Week