Andra Prum, DO, FAAFP & Leslie Parsons, DO, FAPA Assistant
Medical Directors Florida State University, University Health
Services Slide 2 Slide 3 Objectives To describe the case of a
severely anorexic college student in crisis. To discuss the factors
surrounding the initial plan of care for an acutely ill anorexic
patient in crisis using the bio-psycho-social model of care
management. To identify resources in the geographic southeast
United States for acute care inpatient management of the college
student with severe disordered eating. Slide 4 History of Present
Illness CC: Wellness Check up. No concerns HPI: 19 y/o female
patient who is here for an eating disorder issue. The pt. notes she
was initially told she needed to lose weight to improve her skills
in softball two years ago which drove her to poor eating habits and
excessive working out. Slide 5 History of Present Illness Referred
by the recreation center on campus Eats only 2 meals/day No red
meat Doesnt like how she looks but is afraid to gain weight
Exercising 1 - 2 hours a day twice weekly to get rid of skin fold
on abdomen Recent binging, self-induced vomiting, calorie
restriction, skipping meals Worry about school and parents hounding
her about her health Slide 6 History of Present Illness (cont.) She
was identified by a trainer at the gym who contacted our Health
Promotions Director of the situation who subsequently initiated an
intervention. Pt. was then seen by Leslie Parsons, DO, Director of
Psychiatry, and was diagnosed with severe anorexia (BMI 15.4). Pt.
was then referred to our FSU medical clinic for lab work and
evaluation today. Slide 7 History of Present Illness (cont. ) Pt.
notes she has been experiencing dizziness, occasional syncopal
episodes, fatigue, diffuse abdominal discomfort, and h/o bulimia.
Notes losing 120 lbs in past 2 years. Has been seen by a
Hematologist due to chronic low white blood cell count. Pt. denies
dyspnea, chest pain, cough or wheeze, palpitations, irregular heart
beats, extremity swelling, nausea / vomiting, backache, joint or
skeletal pain/swelling at this time. Denies suicidal ideation or
homicidal ideation. Slide 8 Past History Medical History: Iron
deficiency anemia B12 deficiency Passed out twice, once after
working out and smoking marijuana Bone marrow test related to
persistent anemia Was told that she was on the verge of needing a
blood transfusion approximately 9 months prior Allergies:
Penicillin, pollen Meds: Pt. denies Surgical History: Surgical
repair of arm fracture/ dislocation in 2003. Slide 9 Past
Psychiatric History Never before seen a psychiatrist Never before
been in counseling or psychotherapy Never before been hospitalized
for psychiatric reasons Never before been in an eating disorders
program Slide 10 Family History Mother described as a worrier with
a history of an eating disorder Another family member had
postpartum depression Two family members reportedly died suddenly
out of nowhere while otherwise healthy Cancer runs in the family
Aunt with drug addiction Sister with heart murmur Slide 11 Social
History Father retired marine Younger sister was focus of familys
attention due to various rebellious behaviors Told by high school
softball coach that if she wanted to start, she would need to lose
weight (she weighed 225 pounds at the time) Concerned about grades
due to wanting to become a physician Not currently sexually active
Drinks Caffeinated tea daily Slide 12 Substance Abuse History
Denied using any alcohol or illicit drugs since coming to FSU
Acknowledged drinking a lot and smoking marijuana beginning at the
age of 16. Denied any history of blackouts but stated that she
drank to intoxication and/or vomiting Slide 13 Physical Examination
VITALS: LMP: 9/2011 (6 months ago) T: 96.8 P: 48 R: 12 BP: 86/64
Ht: 70 inches Wt: 107 BMI: 15.4 Overall Appearance: Alert,
emaciated, cachectic appearing pale female NAD Skin: sullen,
appearance pale HEENT: oropharynx clear, dry lips, gingivitis Neck:
Neck supple, without masses or thyroidomegaly Chest: lungs clear to
auscultation, chest wall non-tender Heart: Bradycardic, 2/6 syst
murmur appreciated. Abdomen: scaphoid, + mild diffuse tenderness no
rebound no guarding with skin sag on abdomen due to severe cachexia
Spine/Extrem: diffuse muscle atrophy noted upper and lower
extremities, no edema. Neuro: Grossly normal neurologic exam Slide
14 Physical Examination/ Mental Status Psych: alert, oriented,
cognitive function intact, cooperative with exam, poor eye contact,
poor eye contact, speech diminished output, volume, mood depressed,
judgment and insight poor, no auditory or visual hallucinations,
speech clear, thought content without suicidal ideation. Slide 15
Diagnostic Testing Laboratory testing: CBC with differential
Comprehensive metabolic panel Nutrition Panel: Magnesium,
Phosphate, Calcium, B12 level, Folate Thyroid Panel EKG DEXA, if
associated with Female Athletic Triad: Disordered eating Amenorrhea
Osteoporosis Slide 16 Diagnostic Testing L= Low, H=High CBC: WBC:
1.6 k/mm3 (L), Hg: 7.5 g/dl(L), Hct: 22% (L), MCV: 97 FL
Comprehensive Metabolic panel: Glu: 85 mg/dl, BUN: 27mg/dl(H),
Cr:1.03 mg/dl(H), K: 5.2 mmol/L (H), Ca: 8.8mg/dl (L), Pro: 5.7
g/dl(L), Alb: 4.0, AST: 228 U/L(H), ALT: 282 U/L (H) Slide 17
Diagnostic Testing L= Low, H=High Nutrition panel: Mg: 2.1mg/dl,
PO4: 3.3 mg/dl, Folic Acid: 17.5 ng/ml B12: >1500 PG/ml Thyroid:
TSH: 3.14 mlU/L, Free T4: 0.62 ng/dl Urine Drug screen: neg. EKG:
Sinus Bradycardia Rate 37, otherwise WNL DEXA: ordered. Urine preg:
negative Slide 18 Assessment Anorexia Nervosa Symptomatic
Bradycardia Prerenal azotemia- Dehydration Anemia- Normocytic
Leukopenia (chronic) Slide 19 Acute Management Plan Our patient was
sent to the local emergency room via ambulance for symptomatic
bradycardia, dehydration, severe neutropenia and anorexia nervosa
for further diagnostic testing and treatment. Dr. Parsons contacted
patients family (as agreed to by patient) and they will be driving
to town to meet patient in hospital. Slide 20 Management Based on
findings, we determined that the patient needed inpatient medical
stabilization Patient was admitted to local hospital where she was
given IV fluids, cardiac and lab work monitoring Slide 21
Management We encouraged the patients mother to try to find an
inpatient eating disorders treatment program that could address
patients poor medical condition as well as provide the needed
intensive psychotherapy. Pressure continued to be placed by the
attending physician to discharge as the patient was considered
medically stable. We tried to have another local hospital with a
psychiatric inpatient unit admit patient temporarily while waiting
for transfer to an eating disorders program. Inpatient psychiatric
unit stated that the patient was too unstable medically to be on
their unit. Slide 22 Management Slide 23 Patient continued to eat a
minimal number of calories during her hospital stay She was
admitted on a Baker Act and had a police officer with her 1:1,
hence, she was unable to purge Patients mother was also with her
most of the time Patients mother and I called several different
inpatient eating disorder programs with various levels of
reciprocal communication Slide 24 Management Ultimately, patient
was discharged home to her mothers care with the plan to admit her
to an inpatient eating disorders program as soon as possible
Patients mother called to let me know that she had been admitted We
assisted patient in getting a medical withdrawal from her classes
We have not heard from the patient or her mother since then Slide
25 Definition: Anorexia Nervosa DSM IV criteria for Anorexia:
Refusal to maintain body weight at or above a minimally normal
weight for age and height (
