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Case Study Katiefinal
Case Study Katiefinal
Kathryn Cornwall
Sodexo Dietetic Internship, Philadelphia
March 5th, 2015
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Table of Contents
Abstract.3
Introduction...4
Discussion of the Disease..4
Eating Disorder Statistics
Types of Eating Disorders
Diagnosis: DSM-V and Medical Criteria
Symptoms and Complications
Labs
Medical & Psychological Treatment
Medical Nutrition Therapy for Anorexia20
The Role of the R.D.
Nutrition Assessment
Intervention with the Anorexia Patient
Caloric Needs
Macronutrient Needs & Micronutrient Needs
Goals and Monitoring
Supplementation v. Nutrition Support
Presentation of the Patient.28
Critical Comments.38
Summary39
Terminology..................................................40
Medication Bibliography...................................................41
Appendix42
References..46
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Abstract
Anorexia Nervosa is not just a diagnosis. Its not just a certain type of person. It
can affect both men and women, young and old. It is not just someone who does not eat. It is not
just someone who wants to be thin. Anorexia is a disorder that encompasses the individual it
affects, both inside and out, both mentally and physically. It is often more than just what it
appears on the outside. Anorexia can be a lifelong battle. It can be a daily struggle. The person it
affects needs motivation to battle their eating disorder and a support system behind them in order
to be most successful. A part of the recovery process should include a team of professionals. One
of the most important players in this team can be the dietitian. The role the dietitian plays turns
into more than just medical nutrition therapy; it turns into being an integral part of the patients
support team.
Anorexia is a type of eating disorder in which the person experiences excessive
thoughts of gaining weight or a have a fear of being fat, along with avoidance of food,
restriction of food, and typically a distorted self-image or body-image. All of these factors
combined can cause metabolic changes that can result in life-threatening consequences
medically. Oftentimes, other psychological disorders such as anxiety or depression can also play
a role in an eating disorder. Due to these various co-morbidities, there is not just one- way to
treat an eating disorder. However, there are valuable steps clinically a dietitian should be
following in order to promote the most helpful treatment and best possible outcome for their
patient.
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Introduction
It was initially a challenge making a decision about what direction to take this case study
in. However, after working as a counselor with eating disorder patients for the past five years I
found myself realizing that I have always been on the therapy side of a treatment team and not on
the clinical nutrition end. It made sense to me to take what initially drew me into the world of
nutrition and learn as much as I could about the physiological side of anorexia from the
dietitians standpoint. It takes so much effort, not only on the patients part in the treatment of
this disorder but especially as the dietitian, to overcome the thoughts and behaviors that create
such an unhealthy lifestyle. My goal is to learn as much as I can about the role of the dietitian in
the treatment of anorexia and just how he or she can help in keeping the patient medically stable
but also provide the appropriate nutrition counseling to help the patient succeed in their recovery.
Discussion of Disease
Statistics
The recent statistics on eating disorders in this country are staggering. In the United
States alone, 30 million people, including both men and women, will suffer from an eating
disorder at some point in their lifetime.1 This number is likely much higher since it is estimated
that many of these cases go unreported for a variety of reasons. Eating disorders are not just a
temporary concern; they can affect someone for their entire lifetime, and often intermittently.
They are not just a mental health disorder but can include a complicated medical case especially
in the long term. Eating disorders are complex and have severe health consequences if left
untreated.2 No matter what the eating disorder, binge eating disorder, anorexia nervosa, bulimia
nervosa, or EDNOS, the overall health outcomes can be very scary. Anorexia in particular has
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the highest mortality rate of the psychiatric diagnoses. 3 Oftentimes, anorexic patients cannot see
just how serious their condition is which can be a major contributing factor to just how bad their
physical situation can get medically. 5-20% of anorexia patients will die. 2 Knowing this statistic
alone shows just how imperative not only a mental health intervention is but also that a clinical
nutrition intervention is needed.
Types of Eating Disorders
The Diagnostic and Statistical Manual of Mental Disorders is used in the psychiatric
practice to diagnose the type of eating disorder a person has. Currently, the Fifth Edition has
specific guidelines for anorexia nervosa, bulimia nervosa, binge eating disorder, and other
specified feeding or eating disorders which are grouped into two categories: OSFED and UFED.
OSFED stands for other specified feeding or eating disorder and unspecified feeding or eating
disorder. Previously, EDNOS was the category for eating disorders not other-wise specified.
The DSM-V updated this into the OSFED, UFED category. For psychiatric purposes as well as
insurance purposes, they use this diagnostic manual to develop treatment plans and guidelines for
understanding the specific disorder.
Anorexia nervosa, in the guidelines of the DSM-5, is diagnosed based off the following
traits:
Calorie/Energy restriction
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Bulimia nervosa, in the guidelines of the DSM-5, is diagnosed based off the following
traits which occur on average a least once a week over a three month time period:
Self-worth is based off body image, evaluation of self and body shape
Binge and purge behavior does not exclusively happen during anorexia episodes 5
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Binge eating disorder, in the guidelines of the DSM-5, is diagnosed based off the
following traits:
Feelings of lack of control during binge period or unable to control how much
they are eating
Binge eating when other periods or behaviors of bulimia or anorexia are not
present 5
There are many other possible eating disorders that can be considered when feeding and
eating behaviors are being considered. Pica, rumination disorder, and avoidant/restrictive food
intake disorder are all more symptom-specific based eating disorders but tend to be less common
than the disorders listed above. OSFED diagnoses must be made when a person has eating
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behaviors that are clinically significant issues and have symptoms that cause problems with their
functioning but do not meet the full criteria of other eating disorder criteria. UFED is when
behaviors cause the same problems and impairments but do not meet any of the criteria of other
eating disorders. 5
Diagnosis of AN
Beyond the DSM-V criteria used to diagnose, there are other medical criteria and testing
that is performed to help affirm the diagnosis. There can be multiple tests, exams, questionnaires
used to try to identify the main symptoms and if there are any other medical complications
arising on top of the eating disorder. A physical exam, complete blood counts, bone scans, EKGs
and other tests can all be used to pinpoint the exact symptoms and problems. 6
It is appropriate for the patient to have a standard physical exam. Evaluating their height,
weight, BMI, growth chart plotting when applicable, vital signs, and their overall appearance is
an imperative part of diagnosis. Typically BMIs of <17.5 are considered a clinical indicator.7 If a
patient has not menstruated one or more times, otherwise known as amenorrhea, it should be
considered a sign of AN. However, this is not a mandatory diagnostic criterion due to the fact
that some patients can be male, never had their period in the first place, or are post-menopause.
Laboratory testing can also be very telling about what is happening clinically with the
anorexia patient. The following lab work can be considered in determining the overall picture of
what may be happening with these patients:
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There are many other clinical tests that can be indicated in the AN patient. Depending on
the case and the length of the disorder, it may be medically important to check for signs of longterm malnutrition. Often times in the clinical setting nursing can check for blood in stools and
monitor the input and output of the patient. MRIs, CT scans, and other tests can be used to scan
for ventricular enlargement from malnutrition. Patients with AN for more than 6 months and are
considered underweight should get a DEXA scan or a bone scan to determine if they have any
signs of osteopenia or osteoporosis. Limited estrogen exposure, consistent low body weight, and
long term amenorrhea can all contribute to poor bone density. Many deaths from anorexia are
from the cardiac arrhythmias that occur due to the severe electrolyte imbalances. This makes the
cardiologists role so important to the over treatment of the patient. Nursing can give EKGs and
work with cardiologists to monitor the vital signs of these patients to make the team aware of the
severity of the individual patients heart condition. 7
Physical Symptoms
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The most apparent and obvious physical symptom is weight loss. Reviewing growth
charts, weight trends, prior medical records, and the patients overall weight history is
imperative. There is no longer a set percentage of their ideal body weight required to get an
anorexia diagnosis however, it can be helpful to understand just how malnourished a patient
might be. It is also helpful in determining the weight goals to set for these patients to get them
back into a healthy weight range. Patients with consistent body weight below 85% of their ideal
can begin to suffer from amenorrhea, or missed menstruation, if they are women able to get their
periods to begin with. Its important to monitor the status and ask because complications from
amenorrhea can span into other medical problems in the long term.7
It is important to take notice of the persons skin; which can be very telling about the
patient. Looking for signs of lanugo, the downy layer of hair growth, as well as dry or chapped
skin can also indicate a problem. Yellow skin can indicate jaundice and liver problems associated
with rapid weight loss. Muscle wasting as well as loss of subcutaneous fat can show signs of
malnutrition. Temporal wasting, clavicle wasting, and overall poor skin quality can be a great
indicator of whats really happening medically even if the patient is downplaying their
symptoms. Checking patients extremities for edema can indicate fluid shifts and retention. This
would indicate electrolyte imbalances in the body. Often times patients suffer from hair loss and
can complain of brittle hair as well as nails. Checking a patients mouth for their dentition and
other oral health can show signs of purging. Dental decay, tooth loss, and poor gum quality are
all indicators of possible vomiting or poor nutrition overall. These are all physical signs that the
dietitian can notice while doing their assessment as well as if they are able to perform physical
assessments. 7
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Other symptoms can include edema, dehydration, orthostasis, syncope, generalized
fatigue, and insomnia. Most of these symptoms result from fluid shifts; and electrolyte
imbalances can come and go depending on the current state of the patient. Overall poor nutrition
and poor conditioning can contribute to the fatigue and lack of sleep. Each patient can have
multiple symptoms or just one or two of these complaints. Together many of these medical and
physical complications over time can cause severe, life-threatening situations for these patients.
Combine these patients lack of ability to see the severity of their circumstances with these very
daunting medical problems and the result can be very devastating.
Behavioral Symptoms
The behavorial symptoms of AN can vary greatly between patients but there are a few
common themes we see in this population. Amongst the most relevant is the immense fear of
weight gain. The patient believes there is never enough weight lost despite losing significant
amounts of weight. It becomes very difficult for the patient to grasp the severity of their illness.
They often have rigid thinking and refuse to believe, trust others. This can lead to denial issues,
trust issues within their social and family units, and can result in the patient being introverted.
Patients tend to withdrawal from their normal schedules, habits, family, and friends. They can
also have little tolerance for others or processes. Certain responsibilities can fall to the wayside
and their eating disorders responsibilities become most important. The combination and cycle of
these behaviors can result in suicidal ideations, depression, and extreme anxiety. 7
In the realm of nutrition, the patient typically refuses food or fluids, or both. They can
refuse all food or just restrict to certain foods. Sometimes AN patients have particular healthy
foods and unhealthy foods that they categorize and take diets to extremes. Patients can hide
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foods, pretend to eat, take smaller portions, or avoid even sitting down to eat altogether. Fluids
often become an issue for these types of patients because they either drink too much or too little.
Fluid-loading or filling up on water to keep a full feeling is common. On the opposite end of
the spectrum, some patients will refuse to drink any beverages as a means to avoid feeling full
and avoiding extra calories. Patients have to be evaluated individually to determine their own
eating and drinking behaviors so that the treatment team can address how they will treat them on
a personalized basis.
Another aspect of anorexia, depending on the type, can involve over exercising or an
obsession with burning the amount of calories taken in. Patients ritually need to exercise or go to
the gym. These behaviors can contribute to the person becoming even more malnourished and
can put them in danger of having even more problems with episodes of syncope, becoming
orthostatic, and putting their heart health at risk. There are also AN patients that can develop
addictions to diuretics, diet pills, supplements, or laxatives. It becomes ritualistic similarly to the
exercise addiction. These things can also cause problems with their health, as one can imagine,
with electrolytes and other micronutrients in the body. 7
The mood of these patients can change quickly and become a challenge when trying to
provide treatment. Mood swings and depression are common amongst this population. Its
helpful to be aware that these mood changes are not necessarily directed towards the care
provider and to be flexible in your methods to speaking with these patients. Separating the
person from the disorder is often the first steps to showing the patient you are trying to
understand their disorder.
Medical Complications
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The most common medical findings seen with AN include cardiac changes such as
murmur, orthostasis by pulse or by blood pressure, hypothermia, bradycardia, edema of
extremities with pitting, and slow capillary fill time. Fluid and electrolytes are going to be vital
in the monitoring of the AN patient as well. Screening patients lab values is very important in
the hospital setting. Oftentimes the symptoms of these abnormalities are overlooked as the
patient gets used to feeling weak and fatigued. In terms of sodium values, hypokalemia can be an
indicator that the patient partakes in behaviors like purging and laxative abuse. Hyponatremia
typically is seen with fluid overload, or patients who drink too much water. Hypoglycemia can
also occur in lower weight AN patients.8 Potassium may be low with overall malnutrition or
purging behaviors. Hyperkalemia may be present with dehydration. Chloride may be low from
purging or water loading behaviors. Bicarbonate will be elevated with vomiting. Phosphate may
be elevated with kidney function problems, excess Vitamin D, or healing stages of bone breaks.
Low phosphate is also present in malnutrition or increased glucose metabolism. Magnesium is
also low with fluid losses and high with dehydration. Hypocalcemia occurs with malnutrition or
use of laxatives. High calcium levels may be showing long-term diuretic use or bone fractures.
Liver function tests, cholesterol, amylase, lipase and hormone levels may also be seen in eating
disorder patients. 9
One of the most serious complications of anorexia medically is the effect starvation has
on your cardiac function. The fatigue associated with AN usually stems from the decreased
cardiac output. The cardiac muscle becomes weakened ultimately resulting in sinus bradycardia,
orthostatic hypotension, and systolic dysfunction. Due to these cardiac issues, its critical a
patient avoids caffeine and exercise. The body becomes used to the decrease in metabolic
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function and seems to adjust to the insufficient energy intake. These decreased metabolic
functions can also cause patients to experience hypothermia.
Table 1. Criterion of Cardiac Complications
Hypothermia
overnight
Bradycardia
Hypotension
Hg
Pulse increase of >35 BPM or BP decrease
Orthostasis
>10mm Hg
Re-feeding syndrome is a complication that occurs when the cardiovascular system fails
following high caloric intake in patients who are already compromised due to starvation and the
complications surrounding starvation metabolically become unstable. Re-feeding occurs when a
shift of phosphate from extracellular space to intercellular space causes phosphate to be
incorrectly incorporated into new tissues. This process in turn causes phosphate depletion in the
body systems resulting in little available ATP, poor cardiac stroke volume, and increased
demands on the cardiac muscle. By feeding a patient slowly, this should prevent re-feeding
syndrome from occurring but strict lab work monitoring is key. Sometimes a medical doctor will
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recommend a supplement to help with the increased phosphate needs during the initial week of
re-feeding. 8
The Academy of Nutrition and Dietetics recommends the following calorie progression in
those patients who are at risk for re-feeding syndrome:
Day One: 10 kcal/kg/day and 5 kcal/kg/day for those with BMI <14
Source:
http://www.oncoline.nl/index.php?
pagina=/richtlijn/item/pagina.php&id=36015&richtlijn_id=880
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Renal impairment is another serious concern with these patients. Despite patients having
normal creatinine levels, having low BMI and body weight put them at risk for poor renal
function. AN patients should receive urinalysis tests frequently to monitor electrolyte levels as
well to help determine renal function.
Eating disorder patients commonly can experience the following:
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30meq/L
diuretic abuse
tendencies
Gastrointestinal issues are very common in AN patients and is often one of the main
complaints of patients in recovery. Medications are often prescribed in the clinical setting to
help elevate some of these problems. However, GI problems can persist long after initial
refeeding and recovery depending on the individual. These things can elevate with weight
restoration and higher BMI. 8
Common GI Complications
Slowed GI motility
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Constipation
Bloating
Early satiety 8
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Family-based treatment or the Maudsley approach is an ideal way to treat eating
disorders in the adolescent population. This approach involves the support of the parents or
caregivers with an emphasis on weight restoration while the patient cannot be expected to do any
cognitive work while experiencing the effects of starvation. This method does not work for all
situations especially those here family abuse is present or the patients parents have their own
mental struggles. Traditional treatments focus on insight, motivation, and psychotherapy and
tend to be the typically treatment in the adult population. 16 There are many ways that the
traditional method can be installed and depends on what is available to the patient in your region.
No matter what the treatment method, food is ultimately going to be the medicine for these
individuals battling anorexia.
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involved in the patients specific case. The knowledge of the nutritional aspect of anorexia will
provide the RD with the facts needed to provide the entire treatment team with a fitting treatment
plan. The RD can supply the treatment team with data from their nutrition assessments that may
be priority in keeping the patient medically stable. For instance, often times just seeing what a
patient is consuming in the hospital does not show what potential micronutrient deficiencies are
present. A proper food history obtained by the RD can predict what problems may need to be
addressed sooner than some lab work that does not always show imminent problems right away.
The RD also provides the role in treatment regarding the creation of normalized eating patterns
as well as understanding the life stages of growth with nutrition. All of these things combined
helps with RD hopefully promote weight gain, which tends to lead to better outcomes in this
population. 9
Nutrition Assessment
Assessing, monitoring, and evaluating the patient becomes even more challenging in
cases of anorexia. Obtaining a history and physical assessment is key to identifying the main
nutritional issues. Often this may need to be gathered from not only the patient but the patients
family as well. Depending on the type and co-morbidities surrounding the anorexia, the patient
may or may not be forth-coming to all of the symptoms they may be displaying. The age of the
patient will play a role as well. Be mindful that sometimes patients have been used to keeping
their disorder a secret and are capable of lying in regards to symptom use. Its imperative to use
what they report, what the family reports, and what their lab work may be indicating before
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making a final decision in their care. Keep in mind that there are serious consequences including
death in cases of co-morbidities that may increase suicidal ideation so any indicators of mental
distress need to be referred out to another specialty.
Beyond the RDs typical assessment tools used in the hospital setting, there are a few
questions to ensure you look into before completing an assessment on AN patients. The
following are assessment questions to touch on and information to obtain from patient or obtain
from history and physical:
Recent weight changes versus usual body weight? (Past 6 months, past year?)
Dietary intake or history (Whats a normal day for you?, Whats a typical
breakfast, lunch, dinner?)
Last menstruation/dates?
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There are questionnaires and surveys that can be used to assess presence and severity of
anorexia. Typically, if in an interdisciplinary team setting, a psychologist or psychiatrist may be
the one using these psychological tests. The RD would have to be trained or have psychologybased education in order to distribute these tests accurately. The following are commonly used in
assessment:
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uncomfortable and taxing for their patient. Making appropriate and reachable goals will assist in
this process.
The objectives of intervention on an anorexia patient, in regards to the dietitian:
Promote weight gain based off growth rates, age, and normal patterns
Monitor diet histories and food journals; look for any other potential issues such
as laxatives, diet pills, etc.
Honoring the presence of the illness; knowing there will be food rejection but
making normalized eating patterns a goal
Strive for the patient to gain self-esteem; create a new normal and avoid
preoccupations with food, weight, numbers, calories, etc.
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Make nutrition education, therapy, and planning a part of the treatment teams
main concern 7
Caloric Needs
Typically the dietitian will use all of their information available; and based off of
the growth rate, age, IBW, UBW, and all other pertinent weight data will determine the best goal
weight for the patient. It can be useful to set small goals for the patient as it can be overwhelming
to use the final weight goal in the counseling setting. Estimating caloric needs for AN patients
has been set by the APA, or the American Psychiatric Association, use the following guidelines
unless otherwise set by your facility:
Promote weekly weight gain; 1-2lbs or 2-4lbs per week are normal goals
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aware of common medical problems associated with restriction of certain macronutrients will be
helpful in your treatment of the patient.
Table 3. Macronutrient Associated Concerns 11
Glucose Metabolism: hypoglycemia is
medical attention
disease state
Micronutrient needs are likely not met in the anorexic population. Sometimes these
micronutrient deficiencies are challenging to assess because of their blood concentrations versus
whole-status may be varied. However, it is imperative to be able to identify the common
deficiencies since in general they are more at risk than the regular population. Common
deficiencies are listed below, and are usually treated by use of a multivitamin or dietary
supplement in this population:
Zinc
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Copper
Vitamin C
Riboflavin
Vitamin B6
Thiamin 11
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Supplementation versus Nutrition Support
There are some cases where patients are going to need caloric help beyond the beginning
of normalized eating patterns. There are also settings where it is just as important to initiate some
form of nutrition support in the patient. Many times in a hospital setting eating disorders get
overlooked as a serious medical concern for a combination of reasons. 13 It is important for the
RD to be aware that these types of patients often fall through the cracks in the hospital setting. It
is imperative to be familiar with the signs and symptoms of eating disorders so that it is easier to
spot these patients in the hospital or clinical setting.
If a patients capable of weight restoration without nutrition support then that should be
the ideal situation. Gradual caloric increase orally is best. Some patients struggle with the
amount of food needed to meet their goal caloric needs. In these cases, added nutritional
supplements, like Ensure Plus, for example, are typically used. However, some patients need
more than just the added calories from a nutrition supplement but need nutrition support in order
to gain weight. Patients who refuse to eat sometimes are offered nasogastric tube feedings to help
supplement their intakes. TPN is typically not indicated, as gastrointestinal function is likely
intact with these patients. Preserving gut function will be beneficial to the patient in the long run
even though they may suffer from gastrointestinal discomfort with the re-feeding process. TPN
therefore is usually a last resort. The ultimate goal is restoring normalized eating patterns so
prolonging this makes recovery oftentimes longer and more difficult. With that being said, there
are cases where anorexia patients with gastrointestinal co-morbidities have needed total
parenteral nutrition or TPN in order to meet their needs. 14 Use caution before initiating TPN
with anorexia patients and trust your clinical judgment in these situations.
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Highest
Weight/When?: 127#
in May of 2014
Age: 25
BMI: 14.7
Lowest
Weight/When?: 92# in
November 2014
Allergies/Food
Allergies: NKFA;
noted seasonal
allergies
IBW: 137#
Family Hx of ED?: No
family hx of EDs
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throughout her adult life but is on medication. Pt has had no hospital admissions at this point but
has lab work on admission with low BUN. Pts BMI is 14.7, and is 95# upon admission. Pt
presents with 32# undesirable weight loss since May 2014. Pt noted alert and pleasant during
initial assessment. Pt reported high motivation for recovery. Pt reports doing well initially after
last admission, where she left at within 90% of her IBW. However, things have gone down hill
since a bad relationship over the past spring/summer.
Current Diagnosis: AN, depression
Social History: Pt does not smoke, drinks wine socially without reported alcohol abuse, no
noted drug abuse. Pt states being in a difficult relationship over the summer and has been
struggling since. There is some question into whether the man she was in the relationship with
was harassing her or if she was struggling with letting go of the relationship. At this time she is
in a new relationship for approximately 2-3 months. Pt reports she recently shared with her new
boyfriend about her AN. He is open to participating in her recovery process. Pt states he is going
to be doing family therapy with her instead of her parents since she no longer lives at home. Pt
lives with a cousin at this point and has no notable problems with her.
Family History: Reports no notable family hx with illness, no family with eating disorders. Pt
states she has an okay relationship with parents.
Medications at Home: Zoloft, Multivitamin
Medications at Renfrew: Zoloft 100mg 1x/day, Zyrtec PRN, MVI daily, Tums/Calcium daily,
Colace PRN
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Average reported calorie intake? ~500 kcals per day; pt reports trying not to count
calories but is aware
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Living Situation Currently/Plans for Discharge? Lives with cousin in an apartment, plans
on living with cousin after discharge
Previous admissions from anorexia? Inpatient treatment at Renfrew in February 2014,
day treatment post inpatient. Reports check ups regarding medical status at PCP
regularly. Seeds of Hope treatment in 2014 as well.
Fear foods? Anxiety around most foods except vegetables; biggest fears are
starches/carbohydrates, dairy, and will not eat red meat
Food rituals? None reported
Do you weigh yourself? Reports she weighs herself daily in the morning on MondayFriday, not on weekends
Calorie Needs: (Adult REE using Mifflin St. Jeor x 1.3-1.5) 1209 x 1.3-1.5= 1571-1814 kcals +
anabolic needs (+500-1000)= 2571-2814 kcals
Protein Needs: (1.8g x kg) 43kg x 1.8= 77 gm protein/day
Fluid Needs: (kg x 35mL) 43kg x 35= 1505 mL or 50 oz or 6 cups water/day
PES: Inadequate oral intake related to disordered eating as evidenced by BMI 14.7, ~500
kcals/day, and 32# weight loss over 6 months.
Nutrition Prescription: Meal Plan A (1500-1800 kcals) with an automatic increased to Meal Plan
B (1800-2100 kcals) after 2 days post admission; 360 kcal supplement for weight loss daily or
restriction of current meal plan (1 can Ensure Plus for >50% of meals, 2 cans of Ensure Plus for
<50% of meals)
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Intervention: Initiate standard meal plan progression with additional calories/supplements;
provide supportive meal environments with support level dining for at least 3 days meal
completion
Nutrition Goals:
12/2/14
12/3/14
12/5/14
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goal weight was met within 90-95% IBW
See Appendix for Weight Trend Documents Over 1st Month, Pictures 1, 2, 3*
11/28
12/2
12/5
12/9
12/17
66
70
75
74
6L
10
13
13
.74
.67
.67
.71
138
140
141
141
4.1
4.2
4.2
99
103
104
103
(Reference Range)
Glucose
65-99mg/dL
BUN
7-25 mg/dL
Creatinine
.50-1.10 mg/dL
Sodium
135-146 mmol/L
Potassium
3.5-5.3 mmol/L
Chloride
98-110 mmol/L
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Carbon Dioxide
25
26
27
30
10.2
9.8
10
10.1
2.3
2.3
3.7
3.7
4.0
4.8 H
5.4 H
19-30 mmol/L
Calcium
8.6-10.2 mg/dL
Magnesium
1.5-2.5 mg/dL
Phosphate/Phosphoru
s
2.5-4.5 mg/dL
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gaining the weight is not a problem for her, it is maintaining once she is in her home
environment.
Estimated Needs: Pt likely in a hyper metabolic state at this point in treatment, now 47.6
kg, will require increased needs to meet weight goals.
47.6 kg x 35 kcals=1666 x 1.8 = ~3000 + (500-1000 for anabolic state) = ~3500-4000
kcals; Meal Plan C+ 2 snacks + 2 supplements = ~ 3500 kcals
Nutrition Prescription: Will continue Meal Plan C (2100-2400 kcals) + 2 snacks per day
of her choice from options available (~350-400 kcals each) + 2 Ensure Plus (350 kcals
each)
Updated PES Statement: Increased energy expenditure related to history of anorexia
nervosa as evidenced by hyper metabolic state and increased calorie needs to gain
weight.
Intervention:
Continue increased meal plan to promote 2-4# weight gain per week
Patient will follow new weighing schedule 3x per week instead of daily
Goals:
Continue 2-4# per week gain towards weight goal of + or 10% of IBW
Attending exercise program at Renfrew to normalize habits
Accepting of 3x per week weights instead of daily weights with decreased anxiety
Monitor and Evaluate:
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Critical Comments
Residential treatment is very different from the clinical hospital setting in regards to your
role as a registered dietitian. The RD sees their patients and gets to know them more in depth due
to the increased length of stay and increased number of sessions. The are looking at the patients
status daily and can make adjustments to their meal plans more frequently since they are
observing them day to day. Their sessions consist more of nutritional counseling than a brief
check in and education you would be getting in the hospital. This allows for more individualized
care with the patient. In the clinical setting of a hospital one may only see the patient a few times
and it may not be the main objective for the anorexia patient to meet weight gains so much as to
be stabilized. The other major challenge I had was that in inpatient treatment like Renfrew, the
nursing staff and CRNP oversee lab work and abnormalities. The RD in this setting has little say
in medications and recommendations in regards to supplements as theyre as pre-established
protocols for this population. All of these things made it a bit more difficult for me to apply my
clinical knowledge from being in the hospital setting to this case study.
It was also taxing for me that I was not able to take on the role of the RD more in CHs
case study, as I was not at Renfrew on a daily basis. The fact that they do not have an established
electronic medical record also made it complicated when I was at Renfrew, as I had to track
down a paper chart and decipher handwriting. The staff at Renfrew was extremely helpful in
helping me with what questions I did have since I was not able to be there daily. I was able to
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check in multiple times over the three months CH was there. Overall, I feel like I had an eyeopening experience getting to work on my case study at Renfrew because it showed me just how
different the role of the RD could be from setting to setting.
Summary
As CH was not in the hospital setting I have been completing my dietetic internship at, it
was challenging to continue gathering information on her complete treatment course. However,
after speaking with nursing, nutrition, and other clinical areas at Renfrew this past February, CH
continued to gain weight and meet her weight goals during her second stay in treatment. CH
attended family therapy with her boyfriend and was compliant with attending groups as
scheduled for her. CH was the type of patient that was a people-pleaser so her challenge was
not completing the program but just how to implement recovery into her daily life. CH
discharged after reaching her goal weight and was planning on continuing treatment in the day
treatment setting. She attended the exercise program as well as cooking groups and the grocery
store outing with her team members. In total she was at Renfrew for about three months. CH
was planning on attempting to go back to complete her Masters Degree which she was never able
to finish with her AN being a distraction. She also was hoping to take more serious steps in her
relationship with her boyfriend upon leaving Renfrew.
It is often challenging for young adults to make recovery work with an ever changing
lifestyle as they enter the working world, begin families, and are trying to make relationships
last. For CH, my hope is that she can make recovery work for her with or without a boyfriend or
her family, as they may not be supportive forever. CH is lucky that her AN started later in life
Cornwall 39
and was not a long seeded disease state; I hope that she has a lifetime of memories of health prior
to the recent AN that she will be able to modify her behaviors to better her life in the long term.
Terminology
AN-anorexia nervosa
Azotemia- high levels of nitrogen containing compounds in the blood; elevated BUN/Creatinine
levels
Bradycardia- resting heart rate under 60 beats per minute in adult populations
Glomerular Filtration Rate- a lab test that checks how well the kidneys are functioning by
assessing how much blood will pass through each glomerulus each minute
Ghrelin-hormone that triggers hunger
Leptin-hormone that reduces hunger
Orthostatic hypotension-low blood pressure that can occur from sitting/laying to standing with
symptoms of light-headedness or dizziness; sometimes fainting can occur in severe cases
Tachycardia-faster than normal heart rate while at rest; adult heart rates are typically 60-100
beats per minute
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Medication Bibliography
Medication
Zoloft
Generic Name
Setraline
Indications
Anti-depressant
or selective
serotonin
reuptake inhibitor
(SSRI)
Contraindications
Food
Interactions
Avoid alcohol
Can cause
weight changes;
must monitor
for weight loss
Hyponatremia
Impaired renal
function
Colace
Docusate
Stool softener
N/A
N/A
Tums
Calcium
Carbonate
Prevention or
treatment of
calcium
deficiency
N/A
N/A
*Other medical
treatments may be
indicated-Example:
reducing stomach
acid
Zyrtec
N/A
Cetirizine
hydrochloride
Generic
Multivitamin
Antihistamine
Supplementing
vitamins/minerals
lacking in the
Impaired liver
or renal
function
Use caution
with sedatives
Avoid over
supplementatio
Avoid alcohol
Take separately
from calcium
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diet
Appendix
Picture 1.
Picture 2.
supplement
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Picture 3.
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Picture 4.
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Picture 5.
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