Colleen

Abbott
Case Study: Anorexia Nervosa
Subjective
1. Physical appearance: Thin but not cachectic. Muscular legs and very thin upper arms, but no
prominent jutting of the bones. No evidence of inducing vomiting/scars on fingers.
2. Diet History
a. Feeding History: Patient from the _______ and ate a traditional Latin diet. The patient
grew-up being taught to respect the meal time. Per mom, patient disliked fast food as a
young child and reported likes her meals. In December, over Christmas break, mom
noticed patient reducing intake at meal times and no longer eating dessert. At Spring
break patient had eliminated certain foods, for example peanut butter. At second
follow-up, Mom reports becoming gluten-free and soy-free and questions how this
influenced the patients eating habits.
b. Method of feeding: Prior to admission patient ate meals in the cafeteria at her boarding
school.
c. Oral/ Enteral Intake: Mom reports doctor prescribing Ensure TID. Patient manipulated
Dad to reduce to one Ensure per day. Oral intake had reduced prior to admission.
d. Vitamins/ Mineral Supplements: calcium, Vitamin D, and a multi-vitamin. Per mom,
patient received vitamin shot at the endocrinologist over spring break (unsure of exact
shot, suspect vitamin B12).
e. Food Allergies: No Known Allergies
PES
1. Nutrition-related diagnosis: Oral food/ beverage intake inadequate (NI-2.1) related to restrictive
eating as evidence by 16% weight loss x 4 months.
a. This PES is highly nutritional significant
b. History of diagnosis: This is the patients first time having a nutritional diagnosis.
2. Diet Order: 4/11: 1500 kcal/day: 500 kcal/meal x 3. Enteral nutrition support via NG tube:
Nutren 1.5 @ 60 ml/hr; advance by 20 ml q 4 hours as tolerated to reach goal of 100 ml/hr x8
hours overnight. 4/13: 1800 kcal/day: 600 kcal/meal x 3; advance by 300 kcal/ day until reach
goal of 2400 kcal/day. Enteral nutrition support via NG tube: Nutren 1.5 @ 100 ml/hr x8 hours
overnight; goal provides 20 ml/kg/day, 30 kcal/kg/day, 1.2 g protein/kg/day. 4/15: 2400
kcal/day: 700 kcal/meal x 3 + 300 kcal snack. Enteral nutrition support via NG tube: Nutren 1.5
@ 100 ml/hr x 8 hours overnight; goal provides 20 ml/kg/day, 30 kcal/kg/day, 1.2 g
protein/kg/day.
3. Age: 00 year old
4. Weight: 40.5 kg
a. Percentile: <3rd ; 1%ile
b. Z-score: -2.34

5. Height: 158 cm
a. Percentile: 10-25th; 23%ile
6. BMI: 16.22
a. Percentile: <3rd; 2%ile
b. Z-score: -2.14
7. IBW: 50 kg
a. Percent IBW: 82%
8. Patient plotted on growth chart: see attached
a. Growth chart is appropriate for the age and sex of the patient.
b. Patient has been rapidly losing weight prior to admission.
9. Estimated Requirements
a. 61 kcal/kg/day
b. 1.6 g/kg/day
c. 1916 ml
d. Energy and protein requirements were determined by using the DRI based on age,
multiplying by an activity factor of 1.5 for weight gain, multiplied by ideal body weight
and divided by current body weight. Fluid requirements were determined by the
Holiday-Segar Method.
10. Nutrition Related Medications: PhosNaK due to re-feeding risk, and an MVI for decreased po
intake over an extended period of time. There is no consensus regarding prophylactic
administration of phosphorous supplementation during the first weeks of nutritional
rehabilitation or whether to supplement phosphorus only when levels drop.1
11. Pertinent Labs
a.

4/15
4/13
4/11
4/10
Na
142
142
143
144
K
4.0
3.9
3.9
3.8
Cl
107
106
106
104
CO2
28
22
27
28
Glucose
88
71
73
97
BUN
18
13
15
16
Cr
0.7
0.7
0.8
0.8
Ca
8.8
8.9
8.7
9.4
Phos
3.9
4.2
4.5
3.7
Mg
2.3
2.4
2.3
2.4
Albumin



4.5

b. Altered labs that indicate re-feeding syndrome include: hypophosphatemia (< 3.0
mg/dL), hypomagnesemia (< 1.7 mg/dL), and hypokalemia (< 3.5 mg/dL). These lab
values can be normal at admission and the electrolytes can drop once feeding occurs.
The theory behind re-feeding syndrome is the electrolytes shift from extracellular to
intracellular spaces with re-feeding, stimulated by insulin secretion in response to

reintroduction of carbohydrate.1 These intracellular shifts result in the drop in serum

values making these nutritionally significant labs. This patient did not appear to develop
re-feeding syndrome, however, the patient did receive PhosNaK upon admission. The
patient had low serum calcium but albumin was normal. The patient also had high
magnesium.
Assessment
1. Nutrition Risk Level: High
a. This patient is at a high nutrition risk due to the 16% weight loss over 4 months
consistent with severe protein-calorie malnutrition
2. Pertinent Lab Values: 4/10: Albumin: 4.5 WNL, no pre-albumin or C-reactive protein labs
available. Phosphorous, magnesium, and potassium are pertinent lab values for re-feeding
syndrome.
a. Albumin and pre-albumin are used to assess energy and protein synthesis in the liver.
Levels are typically normal due to adequate protein intake in the context of extreme
restriction of carbohydrates and fat, or to dehydration.2 Phosphorous, magnesium, and
potassium can drop once feeding is introduced causing cardiac and neuromuscular
dysfunction.1 Nutrition is related to these labs because it is suspected when
carbohydrates are consumed an insulin surge leads to the electrolyte shift.
3. IV Fluids: N/A
4. Growth
a. Rate of weight change: Prior to admission 16% weight loss x 4 months. After admission
patient has gained 3 kg, averaging 500 grams per day.
b. Not appropriate for growth for the patient to have significant weight loss. The amount
of weight gain is very high; the goal is for 250-300 grams per day.
c. The patient is 00 years old and should be continuing to grow. Weight gain needs to
continue after patient is discharged however; weight gain per day should not be so high.
5. Diet order prior to admission
a. Macro and micronutrient needs not met prior to admission as evidence by the severe
weight loss and restrictive of all foods.
b. Fluid needs not meet prior to admission as evidence by the severe weight loss and
restrictive of all foods.
c. Doctor in the Dominican Republic recommended Ensure TID and patient negotiated
with her parents for Ensure once a day. Ensure is appropriate for the patient considering
her po intake was restrictive at the time.
d. Considering the patient negotiated for Ensure once a day and the parents allowed it, the
supplements contributed minimal to the overall intake due to her increased needs.
e. The patients nutrition needs were not being met prior to admission which is made clear
by the severe weight loss.
6. Diet order

a. Patient receiving adequate macro and micronutrients with po intake, enteral nutrition,
and MVI, PhosNaK intake.
b. Patient receiving adequate fluid.
c. Patient receiving appropriate supplements based on po intake. Boost is provided is the
patient does not consume 100% of meals.
d. Patient has been receiving enteral nutrition support via NG tube: Nutren 1.5 @ 100
ml/hr x 8 hours overnight; which provides 20 ml/kg/day, 30 kcal/kg/day, 1.2 g
protein/kg/day contributing to po intake.
e. The enteral and po intake administration method is appropriate. The patient has the
opportunity to eat 100% of meals. Any meals not finished the calories are met with a
second po intake opportunity with Boost. If the patient is unable to drink the
supplement then the patient is given the difference of the calories in the tube feeding.
f. The patient is receiving an adequate diet based on the patients needs.
7. Accuracy of data available is very likely since the patient is diagnosed with anorexia nervosa the
calorie intake and weights can be considered accurate.
Plan/ Goals
1. Oral Nutrition: 2400 kcal/day: 700 kcal/meal + 300 kcal snack
2. Enteral Nutrition: Nutren 1.5 @ 100 ml/hr x 8 hours overnight, providing 20 ml/kg/day, 30
kcal/kg/day, 1.2 g protein/kg/day
3. Parententeral Nutrition: N/A
4. Labs/ Studies: Requested measuring vitamin D and lab value was not measured.
Magnesium, phosphorous, and potassium were measured, magnesium has been running
high and phosphorous, and potassium was normal. The calcium measured was low,
however, albumin was normal.
5. Growth: Patient has gained 3 kg, averaging 500 grams per day. The goal is for the patient to
gain 250-300 grams per day.
6. Additional Information Needed: N/A
7. Follow-Up: The first follow-up was two days after admission and the second follow-up was
two days after the first follow-up due to the anticipated discharge. Discussed with mom the
history of when the eating disorder began at the first follow-up. At the second follow-up
provided mom with the discharge meal plan and explained how to estimate exchanges. The
mother was provided with contact information of the RD and online resources for calorie
counting. The patient is not to participate in meal planning; her only role is to eat what she
is given. The patient completed a supervised lunch this day. The third follow-up was one
day after the second follow-up since the patient was not discharged and a new weight was
measured.
8. Justify your plan/ goals: The long-term plan is for the patient to be successful with weight
gain and learn how to manage her eating disorder. Currently, the patients mother is
determining who will supervise the patient once discharged: someone at school or will the
mother move to the states to monitor the patient.


References
1. Golden NH, Keane-Miller C, Sainani KL, Kapphahn CJ. Higher caloric intake in hospitalized adolescents
with anorexia nervosa is associated with reduced length of stay and no increased rate of refeeding
syndrome. J Adolesc Health. 2013; 53: 573-578.
2. American Academy of Pediatrics. Pediatric Nutrition Handbook. United States of American; 2003.
3. Le Grange D, Accurso EC, Lock J, Agras S, Bryson SW. Early weight gain predicts outcome in two
treatments for adolescent anorexia nervosa. Int J Eat Disord. 2014; 47(2): 124-129.