Case Study 1: Theresa

Assess and comment on the following:

1) Diet history:
Energy intake: about 230 kcal
Macronutrient Distribution: mostly carbohydrates, no
added fat, and hardly any protein.
Micronutrient Distribution: takes a multivitamin but
from dietary intake lacking iron, vitamin D, calcium, and
probably magnesium, phosphorus, potassium, and vitamin
C.
Fluid Intake: 48 oz (4 cans of diet coke)+4 oz (soup)+8 oz
(tea) = 60oz
2) Anthropometrics:
IBW: 118 lbs
% IBW: (64.5 lbs/118 lbs)*100= 54.6% IBW
Treatment goal weight: 90% IBW = 106 lbs
3) Biochemical Status:
Low: potassium, chloride, and total protein
Normal: sodium, CO2, glucose, BUN, creatinine, calcium,
phosphorus, magnesium, albumin
Values to watch: glucose-if elevates may be an indicator of
refeeding risk. Phosphorus and magnesium- if get to low
can also be an indicator of refeeding syndrome.
*Need to normalize hydration before a real assessment can
be performed on laboratory data*
4) Resting Energy Expenditure: 655+(9.6*29.3kg)+(1.8*156.5 cm)(4.7*34)=
655+281.28+281.7-159.8= 1,058.18 kcal
Her REE is probably 75-80% of total REE since she is in a
hypo metabolic state: 795 kcal - 848 kcal
Answer the following:
1) Additional testing recommended: echocardiogram, chest x-ray,
bedside cardio work-up, complete metabolic panel, DEXA, and
bone scan. The monitoring I would recommend would be cardio
monitoring and the use of fall precautions in her room.
2) I would recommend a full dental history and work up to
understand the type of food she will be able to handle. A
metabolic cart would be useful to have a better understanding of
her current metabolism. A full diet history with food allergies

and food intolerance information will be useful in creating a diet

plan, although check with past physicians and family for any self
reported food allergies.
3) Initial diet prescription: 1000 kcal (34kcal/kg bw)
Recommended rate of refeeding: 30-40kcal/kg bw in an
inpatient setting
Feeding methods: By mouth unless patient starts to purge
often-if this happens may be advisable to add an NG tube.
Supplements: at least 1 Ensure plus a day, may add more
depending on food patient is willing to eat.
Supplements: can stay on centrum multivitamin
4) Breakfast: 8oz whole milk (160 kcal), cup oatmeal (80 kcal)
Lunch: Turkey Sandwich- 2 slices whole wheat bread (160 kcal),
3oz turkey breast ( 135 kcal) . cup steamed broccoli with 1oz
cheese ( 100 kcal)
Dinner: cup lasagna ( 155 kcal), 8 oz fruit juice (60 kcal)
Snack: 1 Ensure Plus (200 kcal)
Total Kcal: 1,050 kcal
5) For inpatient monitoring Theresa should have 1:1 supervision
during any meals and for up to 2 hours after a meal if concerned
about her purging. She should also be monitored for a calorie
count, if concerned that she is not finishing her food so the RD
will have an accurate account of what food she is really in taking,
not just diet prescription.
6) Theresa should be in inpatient hospitalization because her blood
pressure is less then 90/60, she is less then 85% of ideal body
weight, she refuses to eat more then listed in diet history (230
kcal), and she needs supervision during meals, has a history of
purging. Since she only has a part time job she probably does
not have insurance so a social worker should be called to help
Theresa apply for Medicaid during her stay in the hospital before
she is sent to an inpatient hospitalized eating disorder facility.
Theresa needs to be in a hospitalized facility, Medicaid would
help ease the financial burden she may face without aid of
insurance.

Case 2: Kevin
1) Look at attached growth charts labeled Kevin.
IBW: 101.6 lbs
% IBW: (115/101.6)*100= 113%
Treatment goal weight: He should at least maintain weight
or gain a minimum of 10lbs within the year since his
growth is starting to stunt, in a year he should be 66,
currently he is 61.5.
Growth and development: Kevin started at 61 and 161 lbs
a year ago, he is currently 61.5 and 115lbs. In a year he
grew half an inch and lost 46 lbs. According to his growth
chart he is supposed to be 64 currently, indicating that he
is beginning to stunt. He needs to maintain or gain weight
so he can start to grow again and hopefully catch up on the
height he lost.
BMI plot: look at attached chart labeled Kevin
Kevins BMI %: a little under 75%, between 50-75%
2) Kevins diagnosis is EDNOS according to DSM IV since he is at
ideal body weight not below, in DSM 5 he would fit the
classification of NEC-AN subclinical.
3) His blood work indicated normal electrolytes, glucose,
Hgb/Hct, cholesterol, and albumin but his pulse and blood
pressure are low. I would recommend a echocardiogram, a
cardiac workup, a liver panel test, a metabolic cart, and a
DEXA or x-ray to see if stunting has effected bone health yet.
4) Kevins exercise is not something I would classify as excessive
but in order to continue he will need to intake more calories to
help him work. His personal trainer can be used as a potential
ally if he can help Kevin eat more with the pretense of a better
workout results. Although if Kevin illustrates a lot of
resistance with increasing food intake then he needs to cut
back or stop his exercise regimen.
5) Kevins diet:
Energy: 845 kcal
Macronutrient distribution: low amount of
carbohydrates-only sources from yogurt, apple and

bread, no added fat, protein seems adequate based

on total calorie intake.
Micronutrients: reportedly taking a multivitamin
with minerals but do not know what type of
multivitamin
6) Without taking exercise into account Kevins resting energy
expenditure should be 1462 kcal although, Kevin is most likely
hypometabolic causing his resting energy expenditure to drop
between 1097-1170 kcal. Since he is not in an inpatient
facility it will be harder to increase Kevins calorie prescription
excessively. I would ideally start Kevins caloric prescription of
1,600 kcal per day. That is about 30 kcal/kg bw.
7) I would use an options meal plan with Kevin, I would work with
him to plan out four different options for each meal around
the same caloric intake and allow him to pick and chose which
one he eats everyday. Creating the meal plans I would
reference the exchange list.
Meal Plan:
Breakfast: 6 fl oz Greek yogurt, C granola, apple
Lunch: Turkey Sandwich-2 slices whole wheat bread, lb
turkey breast, C avocado. 8oz milk, carrot sticks
Dinner: 2 grilled chicken cutlets, baked potato, and salad
with low-fat dressing
Snack: nuts or a protein bar and hand fruit (apple)
8) The topics I would focus on in nutrition education would be
the necessity of a certain amount of calories for growth, the
importance of carbohydrates and fat for growth and muscle
formation.
9) The objectives for nutrition counseling would be to help Kevin
understand that he needs to intake more calories for growth
and to help Kevin expand his food intake to more food and a
higher variety of food. The type of counseling I would use to
approach Kevin and his family will be statistics and evidence
that Kevins restriction of food is inhibiting his growth and
development and can cause him to stop growing. Kevin is in
the pre-contemplation change, he does not understand why
he is seeing an RD so it may be difficult to make Kevin and his
family understands that his diet and recent weight loss is
affecting his development. If statistics did not work I would
try a health approach, since he does want to firm up his body
needs more energy to produce muscle and function, by
approaching his weight this way Kevin may be more

understanding if he feels that you are helping him reach his

fitness/health goal.
10)
I would involve Kevins parents in some of the counseling
sessions since he is only 14.5 years old his mother probably
does all of the grocery shopping for the house and is
responsible for the food available for him to eat. I would
include them in the diet planning and health goals, although I
would make sure that they understand the importance of
preventing Kevin from losing any more weight. If his parents
illustrate resistance in believing Kevin needs to gain or
maintain weight I will try to get over that barrier and teach
them the importance of calorie intake and growth in an
adolescent. If they still illustrate resistance I will include them
in less sessions if they illustrate resistance during counseling.
11) I would allow Kevin to go to camp if he does not lose any
more weight before his time to leave for camp. I would
involve the camp staff to make sure that he is eating his food
and talk to the kitchen staff to ensure that Kevin is not asking
for any special foods that would contribute to calorie
restriction. If his parents are illustrating a resistance to
nutrition counseling this may be a nice way for Kevin to
separate from that, he may also eat more or differently so he
does not feel different or left out with the other campers.
12)
Psychotherapy is warranted at this time to assess Kevin
and his parents. Their relationship may play a major role in
his eating disorder. Psychotherapy may also be useful to
assess Kevins self esteem and views on himself and to
discover why he feels that way. Therapy may help him work
through confidence issues that may also be contributing to his
food restriction. I think Kevin may benefit from CBT to
understand how eating makes him feel but I think a more
helpful therapy will be regular therapy to work on his illusions
about his weight and to help him build self confidence. The
type of therapy that may be useful to Kevin is Interpersonal
Therapy (IPT) this type of therapy takes is structured from CBT
and traditional therapy. This may be the most use full form
for Kevin to help him gain more self-worth and confidence and
change his eating behaviors. Kevin is very regimented in
eating and exercise so by addressing certain behaviors he
may become more willing to make changes.
13)
To complete the assessment of Kevin I would want to know
Kevins family history of height and weight. This would help to

know the height that Kevin would most likely grow to if he can
get his growth back on track. Any food allergies will also be
helpful to complete Kevins assessment. His medical history
would also be necessary so the RD will be able to see his full
weight pattern. I would also want more tests to complete my
assessment of Kevin. I would want to test his thyroid
efficiency to rule out low T3 syndrome. I would request a
basic serum electrolyte assay, BUN, erythrocyte
sedimentation rate, complete blood count including
differential aspartate aminotransferase, alanine amino
transferase, and alkaline phosphatase. A urinalysis (specific
gravity) test, and assess the levels of estrogen and serum
testosterone in Kevin to get a better understanding of where
he stands medically and health wise.
14) Short term objectives will be to stop his weight loss, help
Kevin start to gain weight to hopefully kick start his growth,
increase calorie intake to at least 1600 kcal a day, and expand
Kevins diet. Long term goals will be to catch Kevin up to the
height he is supposed to be, increase Kevins calorie intake to
2000 kcal a day, and get Kevin up to a weight of up to 135 lbs
(ideal body weight for a 16yr old by at 66) since he is
currently 14.5 years old. Kevin may need to be at a higher
weight then goal because he is beginning to stunt so more
weight may be needed to start his growth again. Kevins goal
weight is always changing since he is still growing.

Case Study 3: Sara

1) Sara has bulimia nervosa according to DSM IV and DSM 5. Sara
has been binging and purging for over three months and her
frequency has increased to 1-2 times a day, 4-5 times a week.
This is a self-report so she may be binging and purging more or
less frequently then reported.
2) Look at attached growth chart.
Saras height holds at the 25th percentile yet her weight has
changed a lot over the past year. She started between the 50th
and 25th percentile and then dropped down to close to the 10th
percentile-this was a large weight drop in a short period. She
then rapidly gained weight and was over the 50th percentile,
currently she lost a little weight and sits at the 50th percentile for
her age.
3) IBW: 117.3 lbs
% IBW: 103%
Saras treatment goal weight should be to maintain her weight
and normalize her eating and then maybe revisit a weight loss
plan. Although if her eating normalizes her metabolism will
return to normal which may lead to a normalization in weight.
4) Current BMI: 21.8 BMI %: 55% ( between 75th and 50th
percentile)
See attached BMI chart
5) Assessing Saras non-fasting blood work I would be concerned
with her high cholesterol, which can signal production of fat in
the body to compensate for her erratic eating habits. Her CO2
levels are also high which indicate that she is purging frequently.
Her potassium is also low which may indicate that she is
malnourished-I would want to check other electrolyte levels to
see if she is in danger for any deficiencies or other complications.
6) Saras measured energy expenditure is 1120 kcal/day. This
amount is only 80% of the predicted energy expenditure for Sara.
The predicted energy expenditure is 1,400 kcal (1400*.8=1120).
I would address this issue in my treatment plan by explaining to
Sara that by restricting and then binging and purging she is
causing her body to conserve energy. I would explain that this
state is not permanent she can fix it and raise her metabolism by
eating consistently and the right amount of food for her age,
weight, and height. I will explain to Sara that she will not lose
any weight with her metabolism as decreased as it currently is

but if she starts to eat more consistently her metabolism will rise
and she will be burning the correct amount of calories for her
age. I would assure that she will not experience a large weight
gain by eating more food because her body needs the energy to
start functioning properly again (i.e-raise metabolism). I would
tell her that when her metabolism is normalized and she is
consistently eating we can address a weight loss plan if she still
feels like she needs to lose weight.
7) Binge/Purge Day:
School day:
Breakfast: 0 kcal
Lunch: 225 kcal
Afternoon Binge: 2050 kcal, retained 1025 kcal
Dinner: 400 kcal
Evening Binge: 700 kcal, retained 350 kcal
Total intake: 3375 kcal (including binges)
Total retained: 2000 kcal after purging
Weekend:
Breakfast: 0 kcal
Lunch: 160 kcal
Dinner/Evening Binge: 2400 kcal, retained 1200 kcal
Late Evening Binge: 1800 kcal, retained 900 kcal
Total intake: 4360 kcal (including binges)
Total retained: 2260 kcal after purging
Non-Binge Day:
Breakfast: 0 kcal
Lunch: 160 kcal
Dinner: 400 kcal
Evening: 60 kcal
Total intake: 620 kcal
Average kcal intake: (2000+2260+620)/3= 1,627 kcal
Kcal range: 1600-2000
8) Short term calorie prescription goal: 1600-1800 kcal per
day. This would be a short term goal since according to her diet
history of binge day and non-binge day eating Saras average
intake is 1,627 kcal.
Long term calorie prescription goal: 1800-2000 kcal per day.
Long term her calorie prescription should go up to 2000 kcal
because even though national recommendation for a 17 year old
female who is sedentary is 1800 kcal Sara may need extra

calories to help stabilize her metabolism so I would place her

upper calorie prescription at 2000 kcal per day.
9) I would work with Sara to give her an option meal plan. I would
work with her to plan different options for each meal so she is
comfortable with different food in case she cannot complete her
meal plan she will have a backup plan so she will not feel out of
control and binge. Giving Sara a few options may help her stay
on track.
Weekday meal plan:
Breakfast: Coffee with Greek yogurt (130 kcal) and an
apple (60 kcal) or 2 hard-boiled eggs (150 kcal) or cup
oatmeal (80 kcal) and a banana (60 kcal).
Lunch: Salad with 5oz grilled chicken (250 kcal) dressing
(80 kcal) and a fruit (60 kcal) or a turkey sandwich (WW bread
and 3oz turkey and 1 oz cheese) (340 kcal) with carrots (25 kcal)
After School: Protein bar (200 kcal) or Greek yogurt (130
kcal) or a protein shake (200 kcal) *Important to have something
satisfying because this is her normal binge time*
Dinner: with 8oz milk (100 kcal); 4 oz Grilled Chicken (180
kcal) with a salad (30 kcal) and dressing (80kcal) and C rice
(160 kcal) or a 6 oz baked potato (160 kcal) with C broccoli
(25 kcal) and 1 oz cheese (75 kcal) and 4 oz meat
(chicken/turkey/pork) (180 kcal) or a lean cuisine (350 kcal) with
C rice/starch (80 kcal) and salad/vegetable (25 kcal)
Evening Snack: with 8 oz milk (100 kcal); Greek yogurt
(130 kcal) or fruit (60 kcal)
Total kcal: 1,660 kcal
*calories calculated by carbohydrate exchange list*
10)
Yes, I would definitely include Saras parents in the
nutritional care process. Since Saras parents are separated it
may be necessary to speak to them individually but it is
important to get her parents on the same page so there is less
change in Saras eating-consistency is key for Sara. I would
involve the parents in meal planning since they probably do most
of the grocery shopping, but they should also be aware of what
Sara should be eating and foods that may trigger binges so they
can avoid buying those foods. It is also important for her parents
to understand what may trigger a binge for Sara to help change
that behavior. For instance when Sara binges in the evening
maybe her mom should implement a no food outside the kitchen
rule and if Sara wants a snack her mom should sit with her or
serve her a proper amount. Another helpful thing would be if
Saras parents did not keep large bags or boxes of food in the
house-maybe place cereal or cookies in serving size bags so Sara

is not tempted by a large quantity that may trigger a binge.

Saras parents may need to be more involved in Saras eating
and helping her plan a menu to avoid triggers and binging.
Helping Sara overcome her disorder will mean that her parents
may have to change some of the eating habits they have but
they can be great allies in Saras recovery and should be
involved in Saras nutrition care process.
11)
I would want Sara to record what she eats, where she eats
her meals, if she considers the food good/bad and a
meal/snack/binge, if she binge and purged, and where she
binged and purged. I would not want to overstep my boundary
into her therapy sessions so I will focus on the food she is eating
and try to understand binge trigger foods and help her find a way
to substitute those foods and change what she is eating to help
her minimize her binging and purging. In counseling sessions I
will focus on the certain foods (ex. Popcorn, peanut butter,
cookies, or chips) that Sara perceives as bad or binge foods and
work with her to find other foods that will keep her full and help
her not want to binge. By Sara recording what she is eating and
what she classifies that food as I will be able to learn if certain,
quantity of food, or how the food is presented that triggers a
binge. If I notice a pattern like Sara tends to binge after school
when she is alone I may speak with her therapist before
recommending to Sara to join a club or sport, or hang out with
friends to change that behavior and prevent binging and purging.
In CBT therapy a patient records their food intake and their
feelings before during and after eating to help vocalize what
triggers a binge/purge episode. I will use that method of
recording food intake to notice food triggers instead of emotional
triggers that are looked at in CBT. It is important that I speak to
the therapist that Sara decides on so we can establish a
relationship and help Sara, also so we do not overstep our
boundaries. The RD should not be conducting therapy sessions
and the therapist should not be giving nutritional advice.
12)
I am concerned that Saras parents separation and her
brother being away at school are harder on Sara then she
realizes. She may be a little depressed; she has reported feeling
blue even before she started to feel uncomfortable about her
weight. She is at a critical time in her life; she is preparing for
college and the future and she may feel pressure to have a plan
or goal and this may cause her to feel guilty or depressed by not
having a direction. I am concerned that Sara is feeling alone and
I believe therapy will help her work through the troubles and
fears she may be experiencing because of all the changes going

on in her life. I would share her diet history with her

psychotherapist and Saras binge behavior so they are aware of
when Sara is prone to binges during the day and can learn what
emotions are behind it. I will also point out that Sara will purge
in public, like at the restaurant with her friends, this behavior
illustrates that Sara is comfortable with the disease in certain
conditions, the therapist may want to address why she feels ok
purging in a restaurant but not in school. Is it because in school
she is afraid to get caught or was it a single stall bathroom at the
restaurant so she had privacy. These are things that need to be
talked about in Saras therapy sessions.

Case Study 4: Kathy

1) Look at attached NCHS growth charts for Kathy
A) Her height percentile has stayed relatively the same
over the past three years, she started off slightly about the 75th
percentile for height for her age, no she is between the 50th and
75th percentile for height for age but since she experienced
menarche stunting is not a high concern since that usually
signifies the end of growth for a female. Her weight changes are
concerning. At first Kathys weight was above the 75th percentile
for her age between 13 and 14 years of age her weight dropped
and she was then slightly under the 75th percentile but in the last
year she went from 65-70th percentile to under the 25th
percentile. This is a large change, Kathy is not growing that
much anymore so she should not have been gaining weight but
her weight could have stayed constant because it if it did it
would have been close to the 50th percentile for her weight for
age, which is considered ideal body weight.
B) IBW: 121.3 lbs
% IBW: (102/121.3)*100= 84% IBW
Treatment goal weight: 115-120 lbs. Kathy needs to
gain weight to start her menstrual cycle again; she is not
currently in an inpatient facility so weight gain may be slower.
Kathy is still an adolescent which makes her weight a moving

target, her ideal body weight at 16 (which is a year away) is 122

lbs. Eventually her treatment goal weight will be this but
regulating her body hormones is first priority.
2) Kathys current diagnosis is Anorexia Nervosa with a binge/purge
subtype. Since she experienced amenorrhea and is less than
85% ideal body weight she would fit this classification in DSM IV
which indicates she also fits this classification in DSM 5.
3) Kathys blood work indicated elevated cholesterol which is
common in people with anorexia nervosa since the body is
starved it starts producing more fat, elevating cholesterol so it
can still function-this level usually decreases after weight is
gained. Kathy also presented with borderline low blood glucose
this can indicate that she is at risk for refeeding syndrome; this
level should be monitored daily. I would recommend the
following tests to understand how nutrient deficient Kathy is and
if she is at risk for refeeding syndrome depending on certain
electrolyte levels (phosphorus, magnesium); serum electrolytes,
BUN, complete blood count-to address Kathys cold intolerance,
and erythrocyte sedimentation rate. I would request these to
better understand how Kathys body is functioning. I would also
request blood chemistry studies on serum calcium, magnesium,
phosphorus, and ferritin to check for specific deficiencies in these
nutrients because they are vital to bone health, refeeding
syndrome, and achieving menarche, respectively.
4) Kathys pulse and blood pressure are low which is typical in
anorexics but still concerning. I would request a full cardiac work
up, liver function test, and a full dental exam. I would also
request Kathys dental history since she reports purging her
teeth and gums may be damaged.
5) The psychological issues that may have played a role in Kathys
illness are feelings of inadequacy and not being good enough.
She may feel guilt and shame from when her pediatrician told
her to watch her weight; she took this warning very seriously
becoming more rigid with her diet and exercise over time. The
conversation with the pediatrician may have made Kathy feel
ashamed in inadequate. Another event may have been her
parents divorce and her fathers remarriage. All of this
happened in a crucial time of her adolescence. Kathy may be
feeling like her father replaced her which makes her feel
unworthy. She may use eating and looks as a way to gain what
she perceives as self-worth although, she does not illustrate
confidence in her body since she still tries to hide herself behind

her clothes. I think Kathy would benefit from Interpersonal

Based Therapy, although The Maudsley Approach is
recommended for younger Anorexia Nervosa patients Kathys
home life does not seem stable enough to give her parents that
much control over her eating habits, also The Maudsley Approach
really needs two parental units to oversee eating. IBT may work
best for Kathy since it uses traditional psychotherapy and
Cognitive Behavior Therapy. This combination can address
Kathys self-esteem feelings while finding the connection
between her emotions and eating habits and helping Kathy
change some of the behaviors that may be harming her.
6) Calorie Prescription: 1290-1720 kcal
I arrived at this based off the APA guideline of in taking 30-40
kcal/kg bw. I would start Kathy on the lower end of the calorie
prescription because by using the Harris-Benedict Equation
Kathys resting energy expenditure should be 1326 kcal per day
but Kathy is hypometabolic so her resting energy expenditure
can be as low as 995-1061 kcal per day. I would adjust the
calorie prescription based on Kathys weight status and
adherence to the diet plan she and I will create together. Ideally
I would increase her calorie prescription by 100 kcal every 1-2
weeks. With Kathy I would use the exchange system to plan
meals so she can learn different food options that hold similar
caloric value.

Meal Plan:
Breakfast: 6 oz Greek yogurt ( 130kcal), C granola (80
kcal), 8oz fruit juice (60 kcal)
Lunch: Large tossed salad (50 kcal), 18 almonds ( 135
kcal), 2 oz cheese (90 kcal), 3 Tbsp non-fat dressing (80 kcal),
carrots (25 kcal), 1/3 C hummus (180 kcal), 8 fl oz fruit juice (60
kcal)
Dinner: C steamed vegetables (25 kcal), C lentils
(125 kcal), C brown rice (80 kcal), 8 oz milk (100 kcal)
Snack: peach (60 kcal)
Total Kcal: 1,280 kcal

7) I would show Kathy her growth chart and explain through the
plotting that her current weight is to low which is why she has
experience amenorrhea. Her body is shutting down systems to
preserve energy and nutrients because she is starving herself. I
will explain to Kathy that she needs to eat more food to become
healthy because she is hurting herself by not eating. I will try to
make Kathy understand that she is hurting herself and it could
impact what her goals are for her future. If showing Kathy her
growth chart does not stir a response with Kathy I could try to
explain that she needs to intake more calories so she can form
muscle and get rid of her flabby areas.
8) I would ask Kathys mother to schedule her medical and therapy
appointments while they are in my office so I know that Kathy
will be seeing her doctors and so I can establish a relationship
with her therapist and physician because it is vital that we are all
on the same page to help Kathy. I would request that the
physician weigh Kathy once a week on the same scale so there is
more consistency because each scale is calibrated differently. I
would also like to discuss Kathy with the physician and the
therapist once a week to understand where Kathy stands
medically and what areas they are focusing on in therapy so we
can give her help to the best of our ability, working as a team.
9) Kathy started to exercise after a year of dieting when she was
told to maintain weight. She focused on areas where she felt she
was fat. From her history it does not seem like Kathy is a
compulsive exerciser but working out may have Kathy focusing
on the negatives she sees in her body. She is starting to pick out
certain areas in her body that seem fat rather than looking at her
fully and comprehending that she is not fat and does not have
trouble areas. Exercise may also be contributing to her
continued weight loss. During treatment I would request that
Kathy stop or reduce exercise. I will have to find out her normal
exercise routine before I make specific recommendations about
altering it or stopping it. Exercise may benefit her when she
starts to intake more nutrients so he body can start making
muscle.

New information:
1) First I would make sure that her reported weight is accurate
because 7 pounds is a lot to lose in 2 weeks. If it is accurate, I
would talk to Kathy and her mom and say that it is crucial that
Kathy not lose any more weight or she will have to go into an

inpatient facility because she will require higher supervision

because of potential medical and overall health complications.
I would also make Kathys mom call the therapist in my office
so I know for a fact that an appointment it set up soon. I will
also try to conference her father in the session, depending on
his relationship with his ex-wife, so he understands what diet
Kathy and I are planning and what goes on in our sessions
together. I will make sure her physician is in agreement with
my suggestion for inpatient hospitalized care if weight loss
continues. If by the week after this is addressed Kathy loses
more weight I will refer her to an inpatient facility unless there
is a conflict with her insurance then I would suggest a day
facility. According to Table 8 Kathy should be in inpatient
hospitalization just based off of her % of ideal body weight.
2) At this point I would want another medical work up; blood
pressure, pulse, blood work (full blood count, cholesterol, and
blood glucose), serum electrolyte levels, BUN, and urinalysis.
I would also want another cardio work up (electrocardiogram)
and another liver function test.
3) Short term treatment goals for Kathy would be to stop weight
loss immediately. This is the most important and vital goal in
treatment because of her recent weight loss Kathy is just
under the 10th percentile for her weight-for-age. I would also
work with mom and have her record what Kathy is eating
because since Kathy is not gaining or maintaining weight she
is most likely not adhering to the meal plans we are creating.
Another short term goal will be to get Kathy to intake the
calorie prescription discussed when she first started nutrition
therapy.
4) Long term treatment goals for Kathy will be a weight gain of
1-2 pounds a week with an increase in calorie intake by 100
calories every 1-2 weeks. These goals are contingent to
Kathy achieving the short term goals set for her. Although if
her weight does not stabilize within a week she will be
referred to an inpatient treatment center because her weight
is getting dangerously low and she will need to be monitored
regularly.