A 19-year-old woman comes to the university health center due to "feeling cold all the time." She wears sweaters despite the warm weather and sleeps with multiple blankets at night. The patient also states that she has had difficulty losing weight and wonders if a thyroid problem could be causing her symptoms. She says, "I go to the gym at least 5 times a week, but I feel like I'm stuck at the same weight. I've even cut bread from my diet because it was making me constipated." Menarche was at age 12, and the patient's last menstrual period was 2 months ago. Family history is significant for Graves disease in her mother and Sjögren syndrome in her maternal grandmother. Temperature is 36.2 C (97.2 F), blood pressure is 80/50 mm Hg, pulse is 38/min, and respirations are 16/min. BMI is 15 kg/m². The patient is alert and cooperative but appears tired. Laboratory results are as follows: Oral electrolyte supplements are administered. Which of the following is the best next step in management?

Question

Quizplus · Accepted Answer

11ec25c8_d751_9f01_bc81_b3368002d355_MD0003_00 Anorexia nervosa is an eating disorder that usually begins in adolescence. It is characterized by distorted body image, determined dieting, and phobic avoidance of many foods, resulting in unsafe weight loss. Risk factors include high-achieving, type-A personalities and participation in activities in which there is pressure to be slender (eg, ballet, running). To lose weight, patients may fast and/or exercise excessively (restricting subtype) or compensate for binge eating with laxatives or vomiting (purging subtype). Many patients also have secondary amenorrhea. Nutritional rehabilitation and psychotherapy (ie, individual, group, family) are the primary interventions for medically stable patients. Indications for hospitalization include signs of dehydration, unstable vital signs, cardiac dysrhythmias, electrolyte disturbances, organ involvement due to malnutrition, or very low weight. This patient is medically unstable and fulfills criteria for hospitalization (pulse < 40/min, blood pressure < 80/60 mm Hg, hypokalemia, hypophosphatemia). Meals should be supervised; some patients may require nasogastric tube feeding. (Choices A and C) These medications are generally used as second-line adjunctive treatments. Olanzapine may aid in weight restoration and can be considered if nutritional counseling and psychotherapy are ineffective. Selective serotonin reuptake inhibitors such as fluoxetine can be helpful if comorbid depression or anxiety symptoms do not resolve with refeeding. Fluoxetine is used as primary treatment for bulimia nervosa (not anorexia nervosa). (Choice B) Patients with anorexia nervosa often have low T3 and/or T4 levels (also known as euthyroid-sick syndrome) due to the body's adaption to chronic nutritional depletion. Thyroid replacement therapy is not indicated as these levels will normalize with adequate weight gain. Replacement therapy is also potentially dangerous in these patients due to the risk for cardiac arrhythmias and osteopenia. (Choices E and F) Psychotherapy and nutritional rehabilitation are the mainstay of treatment for medically stable patients, but this patient requires prompt inpatient stabilization rather than outpatient referral. Educational objective: Indications for hospitalization in patients with anorexia nervosa include unstable vital signs, cardiac dysrhythmias, electrolyte derangements, and severely low body weight. References: Medical complications of anorexia nervosa and their treatments: an update on some critical aspects. (http://www.ncbi.nlm.nih.gov/pubmed/26138740) Medical complications of anorexia nervosa and bulimia. (http://www.ncbi.nlm.nih.gov/pubmed/26169883) Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/25591200)

A 19-Year-Old Woman Comes to the University Health Center Due