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A8N 70667812600PO BOX63 Pel1rithNSW 2751

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NO. 55? P.l

~ SYDNEN WESTArea Health 'Service

Oept. Of Adolescent Medicinewestmead "aspitalWESTMEAD NSW 2145 .

Telephone (02) 9845 6788Fax (02)9893 9062

12lt1December 2005.<=.

Mr. Krsmanovic

Re: Marko t<rsmanovie ' -, "

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OearMr- KrsmanovicMarko has lost 100gms over the last 1 days making hiS weight 76.2this moming. His urine on testing this moming was dilute, indicating the possibility thathe may have consumed more water prior to his weigh, and therefore the weight loss of

_ _. _ 1oOgms may be an underestimated amount.over the last 4 weekSsir'lcetJeing tl'ansferred1rom.!he High Dependency ward back toA4b, Marko haS gained a total of 3.3 kg over S weeks. MOre"importantly heJlj1S.beenmedically stabilised, his heart rate is 65, and blood pressure 120/85 are both within . -~~ --

normal timitS~Marko has been closely obSelVEldand supervised while in hospital and the team agreethat at this time the severity of his illness and the rigidity of his thinking (all part of \tieillness of an eating disorder) are entrenched. The effectiveness of the inpatient

, programme has been lessened largely due to the MarKO'Sresistance to comply with therecommendations. He still finds it difficult to eat his meals unless observed andsupervised, and despite recommendations his activity levels have increased theexpenditure of energy. Despite being asked to remail'l on bedrest. Marko is

noncomp1iant with this request.Last week he was on 6 dietary supplements (ensures) per day and hiS regular meals.While on leave he admitted to having only 2 ensures per day, and omitting the other

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each day. We are not able to comment on his other oral intake, however given hisresistance on the ward to eating a recommended amount of calories, we remainconcemed that the intake over the weekend may have not been enough to sustain aweight gain. The team is naturally concerned that this approach to his meals hasremained unchanged since his first admission to the ward.The inpatient programme dOe$ not have any coerciVe powers over any individual overthe age of 16 who is not currently medically compromised. While Marko assures us hewill be able to cope ,at home on his own; he cannot explain why ~ has thos far madepoor gains on significant amounts of supplements on the ward. He remains confident

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providing health $ervlces to the communites of Auburn • aaull<ham Hills • 61acktownL..I .... I......u~ • P~rramatta• Hawkesbury· Penrith • Blue Mountains • Greater Utl1gow

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that he has changed and that he does not need the assistance of a psychOlOgist or

individua\ therapy once he is discharged-At this stage Dr LampropOIOuS and the treating team believe that further inpatient stay isof little value If,(hen Marko is unable to engage with it well. Also it appears that he isdespondent about being away from hiS home environment and this is in itself not helpful.

Our recommendations for Marko are as folloWS:

1. supervision ElfMeals 6 meals per day as done on the inpatient unit.... 2. Weekly reView by GP with documentation of weight, pulse, blood pressure. Regular

ECG recordings also..... 3. Dietician follow-UP to check Marko'S dietary IntaKe, further education on appropriateeating, and support during this recovery phase. This can be accessed through areferral by the GP, and subSidised by Medicare for a limited number of sessions.

4. Individual pSychotherapy for MarkO ( which Marko feels he does not want at present)5. Family Therapy to explore the impact of Marko'S illness on the family, and deal with

coping strategies for difficult situations. This aspect of the treatment is centlCll to

Marko'S recovery in the long run6. FolloW up in the cliniC here with Dr Clarke/Dr Lampropoulos in 2 weeks

. WE recognise that thiS is a long and protracted illness and recovery is sloW and_ mUltliaCtofiall¥-detefrnined. In particular it will be important to recognise that Marko's

progress is a reflection of aAy-Change in his cognttlons. The cognitive aspect of hiSillness needs to be addreSSed with indiVidual therapy. " .,."- .'-. -- . -n • -

While this recovery is in progresS, the treating team here are alsO keen to supportMarko, by reviewing him regularly, and ensuring that he is medically stable as hestruggles with the illness. It doeS indeed mean that Marko may need brief admissions inthe coming future for nutritional rehabilitation, as research has demonstrated that thedegree of starvation does interfere with insight, judgement, and the capacity to struggle

with the "'ness in a healthy way. .

We are happy to discUSS any concerns with you again.

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Yours Sincere1y

Dr Simon ClarkeConsultant PaediatriCian

Dr Lila Stephens" .

FeUow

Dr L. ChauguleRegistrar

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(;\'~c!. 2.@05_ 15: 23- ADOLESCENT UNIT NO. 55? •

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.Department of Adole$cl!nt Medicine(02) 98456788

Dietleian to be advised by the GP

SYDNEY - WESTERN SUBURBS(AI~pointments for ~m suburbs are made through Westmead)

westmead-_.. ~-1st floor, 149 Hawk~sbury Rd, Westmead 2145~_~ Telephone: ,02'98063299 " ' · ,.'". l4OC1f:f9iIDif325U h ~ ~......:.L.:..,__,)S'"'-·-~' .-,~---- .' : . ,<

Leichardt " .. ~_","'''':;''c;·''~..c..· -'-'

COASIT, 67 Norton Street, leichardt 2040BankstownSuite 3,80 Kitctlener Parade, Bankstown 2200Penrith .Community Health Centre, Soper PI, Penrith 2750Also counselling at Wood riff cottage on Mon & Tues evenings.

~ Woodriff Cottage: 56 Woodriff Street, penrit\12750HUNTER REG'ON ,-{ ..

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~ RELATIONSHIPS AUSTRALIA (NATK>MAL QFFICE) .Toll~free Telephone Number: 1300 364 277By phoning this free number :Your cail wiUautomatically be directed to the nearestRelationships Australia office in your area.EMAlL: Contqct the National Administration OfficeNational Director: Ms Mary Mertin-Ryan15 Napier Close., Peakin ACT 2600

~ PO BoX 313, curtin ACT 2605 .~ Telephone: 0262854486

. Facsimile: 0262854722Emaiv.;;oftice@.relationShjP;:oo~

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