Case Study: Anorexia Nervosa in the Adolescent Male Patient

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CASE STUDY , ANOREXIA NERVOSA IN THE ADOLESCENT MALE PATIENT. By Rachel Reid Dietetic Intern, May 16 2011, Introduction to Patient DM. Anorexia Nervosa, Medical Complications, Nutrition Assessment. Nutrition Diagnosis, OHSU Guidelines Atypical Eating Disorders. Nutrition Interventions Monitoring and, Evaluation.
Outcomes and Summary, Patient DM , Overview of Eating Disorder. 15 yo male in July of 2009, PCP confirmed 20 lb weight loss over 6 mos . Restrictive eating and excessive exercise since. March 2009 , Diagnosed with Anorexia Nervosa , Parents admitted pt to Kaiser Eat Clinic . Since admitted and failed several treatment centers . Readmitted to DCH for the 3rd time on 3 30 2011 . Anorexia Nervosa , An exaggerated desire for thinness DSM IV . Symptoms Include , 1 Refusal to maintain a body weight above.
85 of expected weight , 2 Intense fear of becoming fat with self worth. based on weight or shape , 3 Evidence of an endocrine disorder. amenorrhea for females loss of sexual, potency for males . Prevalence of Anorexia Nervosa, The actual number of individuals affected is unknown . 0 3 of the population has all three symptoms, Anorexia Nervosa .
37 to 1 3 of the population has sub , threshold Anorexia Nervosa missing one. of the symptoms , 3 2 of young women 18 30 y o are. diagnosed with an eating disorder , 10 of patients that are diagnosed with an. eating disorder are males , Numbers taken from International Journal of Eating. Risk Factors, No known etiology however there are risk factors .
Dieting Behavior, Excessive Exercise, Past Abuse. Negative Self Evaluation, High Level Perfectionism. Body Dysmorphic Disorder, Obsessive Compulsive Disorder. 56 risk assigned to, Genetic Predisposition, Anorexia Nervosa Males. Clinical presentation similar if not identical to. Specific Differences in Males , More feminine attitude and behavior .
More closely identify with mothers, Many question gender identity . sexual orientation, Afraid of sex, Homosexuals are over represented. Behavioral Characteristics , Compulsive exercise, Preoccupation with weight lifting or muscle toning. Focus on certain body parts e g thighs stomach . Difficulty eating with others, Preoccupation with food. Disgust with body size or shape, Physical Characteristics Males.
Low body weight 15 or more below expected , Lowered body temperature blood pressure pulse rate. Tingling in hands and feet, Thinning hair or hair loss. Lanugo downy growth of body hair , Heart arrhythmia. Lowered testosterone levels, Emotional Social Characteristics Males. Depression, Social isolation, Strong need to be in control.
Rigid inflexible thinking all or nothing , Gender identity conflict. Perfectionist, Irritability, DM s History of Treatment. Aug 2009 9 22 2009 Oct 2009 7 19 2010 12 6 2010 12 2010 . 9 30 2009 to July 12 14 201 2 4 2011, 2010 10 1 2010 0. Outpatient Inpatient Outpatient Residential Inpatient Residential. Treatment Treatment Treatment Inpatient Treatment Inpatient. Day Treatment Treatment, Kaiser Eat Doernbecher Kaiser Eat Seattle Doernbecher Seattle. Clinic Children s Clinic Center for Children s Center for. Hospital Discovery Hospital Discovery, St Vincent, No Weight Admit Wt No Weight Admit Wt Admit Wt Admit Wt .
Gain Little 44 5 kg gain little N A 50 3 kg 51 2 kg. Success success , D C Wt Rec D C Wt D C Wt D C Wt . 46 5 kg Residential 55 45 kg 51 2 kg 53 18 kg, Center IBW 58 5 kg. Admission to DCH on 3 30 11, Admitted for weight loss and. bradycardia , 5 weight loss in 2 months, Heart Rate 42 bpm. Patient s History, Social History, Parents divorced Joint custody .
Different parenting styles , Very few friends Withdrawn personality . Values physical fitness and health , Failed to make high school BB team October 2008 . Family History, Father s nieces diagnosed with anorexia nervosa . Mom and Dad treated for depression and anxiety , Psychiatric History. Saw a counselor d t social isolation , Per father pt cannot ever relax anxious .
Eating Disorders Are Complicated, Behavioral, Psychological. Physiological, Requires a Multidisciplinary Approach . Psychological Psychologist Social Worker , Medical Physician . Nutritional Dietitian , 3 30 MD s Initial Assessment and. 1 Start with Phase 2 Eating Disorder Protocol, 2 Start with 1800 kcal diet tonight Nutrition consult in the.
3 Adolescent Medicine Consult, 4 Child Psychology Consult. 5 Check Labs per protocol daily AM phos , 6 Boost overnight for Bradycarida. ED Protocol At Doernbecher, ED patients put on a protocol 4 Phases . Phase 2 Most admits , Activity Bed Rest, Wheelchair school. Meals Meals in bed, Meals are pts medicine must be on time no.
substitutions, Complete meal in 30 minutes, Sitters Sitter at all times parents can not act as sitter. Medical Management, Most serious complications exhibited by DM . 1 Growth stunting of organs Kidneys, 2 Cardiac Issues. 3 Refeeding Syndrome, DM s Renal Function, 12 2010 Renal Ultrasound Small Kidneys. High Creatinine levels 3 30 3 31 4 4 4 5 4 7, Creatinine clearance 88 9 L 1 28 1 30 1 26 1 47 1 24.
3 30 3 31 4 4 4 5 4 7, High BUN levels 18 21 23 22 21. Pt referred to a Kaiser Nephrologist after d c, Reduced renal function reported in severe energy restriction . growth stunting, electrolyte imbalances hypokalaemic nephropathy . rhabdomyolysis excessive exercise 2009 case report . DM s Cardiac Complication, 80 Anorexic patients have cardiac complications . 3 30 3 31 4 1 4 2 4 3 4 4 4 5 4 6 4 7, HR 42 45 43 43 49 71 72 68 68.
Low 35 33 35 35 35 39 34 43 41, Sinus Bradycardia Under 50 bpm. Caused by a malnourished weak heart, Other Possible Complications . Arrhythmia, Orthostatic Change in blood pressure . DM s Risk for Refeeding Syndrome, Refeeding Syndrome Severe potentially fatal . electrolyte and fluid shifts associated with, metabolic abnormalities in malnourished patients .
Phosphorous , 3 30 3 31 4 1 4 2 4 3 4 4 4 5 4 6 4 7. 3 6 4 1 3 9 3 5 3 3 2 9 3 5 3 1 2 6, Can result in cardiac complications or arrest . Refeeding Syndrome Cont , Fasting State Catabolism. Processes Glycogenolysis , Gluconeogenesis Lypolysis. Energy Protein and Fat Ketones , Several intracellular minerals become.
severely depleted , However serum concentrations of these. minerals may remain normal , Refeeding Syndrome Cont . Fed State Synthesis, Processes Synthesis of glycogen fat and protein . Requires minerals phos mg and cofactors , Insulin stimulates absorption of K Mg Phos into cell . Water is drawn into cell by osmosis , Decreases serum levels of K Mg and Phos further .
Result Clinical features of Refeeding Syndrome , Hospital vs . Residential Outpatient Goals, Residential Outpatient. Hospital Treatment Goals , Treatment Goals , Weight gain. Stabilization of vital, signs Identify and address. psychosocial factors , Meeting goal calorie, requirements Extensive Counseling .
Discharge , Teaches patient how to, healthfully approach food. and eating, Nutrition Assessment, Thin cachectic appearing 17 y o male. Temporal Wasting, Cyanosis of hands, Dry skin and some bruising on vertebrae per MD. Anthropometrics , Height 165 1 cm 5 5 8th ile, Weight 48 4 kg 106 lbs 11 2 oz 3rd ile. Ideal Body Weight at 50th ile 58 kg 83 IBW . Weight for Age 2 06 ile, BMI 17 6 kg m 2, BMI for Age 6 23 ile.
Growth Chart BMI 15 17, Nutrition Assessment, Patient Says . He feels mentally stronger , Feels like a million bucks physically . Low heart rate just a speed bump in healing process . Following meal exchanges breakfast a little smaller . Does not think he exercises excessively occasional dumb. bells walk b ball , Nutrition Assessment, Father Says . Still very anxious, Can t sleep at night, Consistently not meeting his exchange list goals. Excessively exercising hears him running in place lifting. weights in room etc , Believes he is OCD about his food .
Nutritional Assessment Intake, Pt I have a new healthy relationship with food . 24 Hour Recall Indicated intake of 1050 kcals . Breakfast Oatmeal, Snack Maybe handful of pretzels. Lunch Turkey Sandwich, Dinner 1 c veggies 3 oz chicken breast 1 c rice. Food Preferences , Whole foods beans rice vegetables meat . Dislikes fried processed fatty foods , Soy milk instead of regular milk.
Nutritional Assessment Initial Labs, Labs 3 30 11 3 31 11. Na 138 138, BUN and Cr Renal Function, CO2 32 H 30 H Electrolytes Appear Stable. BUN 18 21 H , Monitor Phosphorous, Cr 1 28 H 1 30 H CO2 Metabolic Alkalosis Renal. Calcium 9 3 9 1 Function , Phos 3 6 4 1, Nutrition Assessment Hydration. Evaluate hydration status based on urine , Specific Gravity measures the concentration of all.
chemical particles in the urine , 3 30 3 31 4 1 4 2 4 3 4 4 4 5 4 6. SG 1 01 1 01 1 02 1 02 1 01 1 01 1 01, 0 0 5 0 0 0 0. Normal Range 1 005 1 030, Under 1 005 overhydrated. Over 1 030 underhydrated, Nutrition Assessment Estimated. Energy Requirements , Catch up growth RDA X desirable weight using BMI .
50th ile IBW , 45 kcal kg x 58 kg IBW 2600 kcal, Protein Requirements . RDA x Desirable Weight, 1 0 g kg x 58 kg 58 g PRO, Fluid Requirements . 48 4 kg 20 x 20 1500 2050 ml minimum, Nutrition Diagnosis. PES Statement , Inadequate oral intake related to, restricting calories as evidenced by. inappropriate weight loss 83 of IBW , and 24 hour recall indicating intake of.
1050 kcals , OHSU Nutrition Guidelines , Atypical Eating Disorders. 1 Achieve calorie and protein goals orally, with general diet . 2 Boost Plus if refuses food , 3 If unable to achieve give by tube . 250 mls Boost Plus overnight for bradycardia not added to. OHSU Nutrition Guidelines, 4 Patient to select 5 foods they don t want to. receive May not select food groups fats fried, DM s 5 Foods .
2 French Fries, 3 Hamburgers, 4 Chicken Strips, 5 Cookies. OHSU Nutrition Guidelines, 5 RD selects daily menus for patient . Menus should be balanced and provide 3, servings per day of dairy . DM Soy Milk or Yogurt, Menu Example, Nutrition Interventions for DM. Goal Optimal Nutrition, 1 Set up meal plan with 1200 kcals per day .
Increase intake by 200 300 kcal day to, 2 Recommend checking Vitamin D. 3 Initiate Calorie Count Manager Check , 4 Meds TUMS MVI Zinc. Monitor and Evaluate, RD Monitors Everyday , 1 Attain adequate intake of goal calories daily. Calorie count completed daily by RSA , Increase calories by 300 kcal day. 2 Weight Gain, AM weights taken daily, Indicator Increase by 100 200 g day.
3 Monitor Refeeding Syndrome, Daily phosphorous labs will be drawn. Indicator Phos WNL, Monitor and Evaluate, Day 3 1500 kcal 480 ml per shift 48 oz per d . Pt eats 100 of meals feeling full , Needed Boost overnight for HR of 33 . Phos WNL Vit D and Zinc WNL, Testosterone 46 L, Changed goal kcals to 3200 kcal. Day 4 5 Weekend 1800 2100 kcal, Pt eats 100 meals feeling full .
No Boost overnight, Phos WNL, Monitor and Evaluate. Day 6 2400 kcal, Pt continues to eat 100 meals feeling full . Phos trending down 2 9 rec replete with, NutraPhos . Day 1 Day Day Day Day Day 6 Day 7, Na 138 138 133 L 134. K 3 8 4 2 3 7 3 9, Co2 32 H 30 28 25, BUN 18 H 21 23 H 22 H .
Cr 1 28 1 3 1 26 1 47, H H H H , Mg 2 3 2 0, Monitor and Evaluate. Day 7 2600 kcal, Continues to eat 100 of meals , Received Boost overnight for low HR . Discussed possible 3 rd snack not, Moved bedtime snack to 9 30 pm . Day 8 2900 kcal, Continues to eat 100 , Requested to move snack time to 3 15 . and dinner at 6 15pm, Monitor and Evaluate, Day 9 1st Day on Goal Calories 3200 kcal .
Continues to eat 100 of his meals did, not receive Boost overnight . Willing to meet with parents to develop a, plan to meet nutrition goals at home . Discharge Meeting , Daily Weights, 3 30 3 31 4 1 4 2 4 3 4 4 4 5 4 6 4 7. 48 8 48 4 47 9 47 6 47 5 47 87 48 2 48 4 48 9, kg kg kg kg kg kg kg kg kg. 1800 1200 1500 1800 2100 2400 2600 2900 3200, kcal kcal kcal kcal kcal kcal kcal kcal kcal.
D C at 100 gm from admit, Why do you think this happened . Catabolic state Anabolic state, Anorexics have a low RMR so weight gain. should be easy right , During refeeding RMR increases. Patient DM: Overview of Eating Disorder 15 yo male in July of 2009. PCP confirmed 20 lb weight loss over 6 mos. Restrictive eating and excessive exercise since March 2009. Diagnosed with Anorexia Nervosa.

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