A 15-year-old girl is brought to the office after falling in the shower. Her mother was outside of the bathroom when she heard a thud, and went in and found her daughter trying to get back up. The patient insists, "I just slipped. It's no big deal. I am fine." She reports that she had no loss of consciousness, tongue biting, incontinence, or confusion. Her parents are concerned that she lost her balance because she is thin and eats poorly. They also note that she seems depressed and has not been interested in seeing any friends. The patient admits, "I have been a little down since my boyfriend broke up with me, but I don't blame him because I am so fat." She takes no medications, has no allergies, and does not use tobacco, alcohol, or illicit drugs. Temperature is 35.6 C (96 F) , blood pressure is 100/60 mm Hg sitting and 80/48 mm Hg standing, pulse is 50/min, and respirations are 14/min. BMI is 16 kg/m². Examination shows an alert and cooperative girl with dry mucous membranes and emaciation. Calluses are present over the knuckles. The abdomen is soft, nontender, and nondistended. Urine hCG is negative. Laboratory results are as follows:
The patient is admitted to the hospital. Thiamine is administered prior to initiation of a supervised diet. On the third day of hospitalization, the patient develops progressive dyspnea and orthopnea. Temperature is 35.6 C (96 F) , blood pressure is 100/60 mm Hg sitting and standing, pulse is 78/min, and respirations are 24/min. Examination reveals an anxious girl with bibasilar crackles, dullness to percussion of the lung bases, and pretibial pitting edema. Laboratory results are as follows:
Which of the following therapies should be administered immediately?

Question

A 15-year-old girl is brought to the office after falling in the shower. Her mother was outside of the bathroom when she heard a thud, and went in and found her daughter trying to get back up. The patient insists, "I just slipped. It's no big deal. I am fine." She reports that she had no loss of consciousness, tongue biting, incontinence, or confusion. Her parents are concerned that she lost her balance because she is thin and eats poorly. They also note that she seems depressed and has not been interested in seeing any friends. The patient admits, "I have been a little down since my boyfriend broke up with me, but I don't blame him because I am so fat." She takes no medications, has no allergies, and does not use tobacco, alcohol, or illicit drugs. Temperature is 35.6 C (96 F) , blood pressure is 100/60 mm Hg sitting and 80/48 mm Hg standing, pulse is 50/min, and respirations are 14/min. BMI is 16 kg/m². Examination shows an alert and cooperative girl with dry mucous membranes and emaciation. Calluses are present over the knuckles. The abdomen is soft, nontender, and nondistended. Urine hCG is negative. Laboratory results are as follows:

The patient is admitted to the hospital. Thiamine is administered prior to initiation of a supervised diet. On the third day of hospitalization, the patient develops progressive dyspnea and orthopnea. Temperature is 35.6 C (96 F) , blood pressure is 100/60 mm Hg sitting and standing, pulse is 78/min, and respirations are 24/min. Examination reveals an anxious girl with bibasilar crackles, dullness to percussion of the lung bases, and pretibial pitting edema. Laboratory results are as follows:

Which of the following therapies should be administered immediately?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c048_31e6_8f63_01d99ffc9caf_MD0005_00 Refeeding syndrome is a potentially fatal complication in underweight patients with chronic poor oral intake. The constellation of consequences results from sudden fluid and electrolyte shifts during the first 2 weeks of enteral or intravenous nutrition. When patients begin to ingest carbohydrates, the resultant insulin release stimulates cellular uptake of phosphate, which is required to make ATP needed for metabolism. Because phosphate stores are low in starvation, phosphate can be depleted quickly, resulting in life-threatening hypophosphatemia. Potassium, magnesium, and thiamine are also rapidly depleted. Congestive heart failure can develop from a weak, atrophic heart that cannot handle fluid and electrolyte shifts. Inadequate ATP and thiamine contribute to tissue hypoxia, resulting in myocardial dysfunction. Hypokalemia and hypomagnesemia predispose to arrhythmias. Therefore, on refeeding, patients may develop pulmonary and peripheral edema, as seen in this patient. A "normal" heart rate (60-100/min) in formerly bradycardic patients can be an ominous sign of cardiac compromise. Management of refeeding syndrome begins with empiric thiamine repletion and correction of electrolyte abnormalities, especially hypophosphatemia, prior to starting feeds. Caloric intake must be increased gradually with vigilant electrolyte monitoring. Oral phosphate therapy is preferred over the intravenous route as the latter can lead to life-threatening hyperphosphatemia (eg, hypocalcemia, acute renal injury, arrhythmias). (Choice A) Additional dextrose without correcting electrolyte derangements would likely exacerbate refeeding syndrome. (Choice B) Digoxin is sometimes used in the treatment of heart failure and systolic dysfunction. However, it should be avoided in patients with anorexia as low body weight, hypokalemia, and hypomagnesemia increase the risk for digoxin toxicity and subsequent mortality. (Choice C) Administering fluid boluses to a volume-overloaded patient with a frail heart is dangerous and can exacerbate pulmonary edema. (Choice D) Furosemide is used for diuresis but would further deplete this patient's electrolytes. Educational objective: Refeeding syndrome is a life-threatening complication of nutritional rehabilitation in anorexia nervosa. Congestive heart failure can develop from a weak, atrophic heart that cannot handle fluid and electrolyte shifts. Phosphate, potassium, magnesium, and thiamine should be replaced; electrolytes should be monitored closely while caloric intake is increased incrementally. References: A systematic review of approaches to refeeding in patients with anorexia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/26661289) Refeeding hypophosphatemia in adolescents with anorexia nervosa: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23459608)

A 15-Year-Old Girl Is Brought to the Office After Falling