Transcript Adolescent Medicine QOD Review

Adolescent QOD
(trust me, they have more than
one question a day)
• The mother of an 8-year-old girl is concerned
because she has noticed the recent onset of
yellowish staining on her daughter's underwear.
The mother requests an antibiotic. The girl is
embarrassed, says she feels fine, and states
that no one has ever touched her genital area.
She is at Sexual Maturity Rating 2 of pubertal
development and she has a clear, scant, mucoid
discharge at her introitus, with normal hymenal
tissue. She has no other findings of note on
physical examination.
Of the following, the MOST appropriate next
step is
1.
2.
3.
4.
5.
a course of an oral antibiotic
pelvic ultrasonography
reassurance of both the mother and child
recommendation that the child douche regularly
vaginoscopy
Answer C
•
The increased estrogen concentration that accompanies the onset of puberty results
in thickening of the vaginal epithelium, change in the pH from alkaline to acidic, and
production of a mucoid discharge (leukorrhea). During established menstrual cycles,
the discharge changes in character from mucoid or watery in mid-cycle to a stickier,
scantier discharge as a result of increasing progesterone concentrations in the
second half of the cycle and finally to an increased quantity just before menses.
There are no associated symptoms such as itching or odor. However, parents may
note staining of the underwear when the discharge air dries, raising concerns about a
possible infection, as described for the girl in the vignette. Treatment is reassurance,
education on good hygiene, including wiping from front to back, and wearing of cotton
underwear. The use of sitz baths with room temperature water followed by air drying
may be suggested if the child continues to be bothered by the discharge. With the
development of the labia majora as puberty progresses, leukorrhea becomes less of
an issue. A physiologic discharge may increase in quantity with the wearing of tight
clothing or underwear made from nonabsorbent material. If a wet mount is obtained,
it shows epithelial cells, normal flora, and few, if any, white blood cells.
•
•
Bubble baths and douching should be discouraged, and there is no role for antibiotics
or vaginal creams for leukorrhea. The presence of a foreign body would result in a
foul-smelling, yellow vaginal discharge that may be blood-stained. If a foreign body is
suspected and not clearly visible, vaginoscopy under anesthesia for removal may be
required in a young child. There is no role for a pelvic ultrasonography in this
situation.
American Board of Pediatrics Content Specification(s):Know the management for
a physiologic vaginal discharge (leukorrhea)
Recognize that physiologic leukorrhea in girls may be misinterpreted as a sign of
disease
• You receive a call from the radiologist, who
states that one of your 17-year-old female
patients had radiography to rule out a fracture
on which he noted osteopenia. She was in your
office 1 month ago with complaints of tiredness.
She denied any excessive exercise, body image
concerns, or weight loss. At that time, her body
mass index was 20.2 kg/m², and physical
examination findings were normal. In reviewing
her chart, you note that she achieved menarche
at age 15 years but has had only two light
bleeding episodes since then.
Of the following, the MOST likely cause of
this girl's osteopenia is
1.
2.
3.
4.
5.
decreased overall caloric intake
increased caffeine and soda intake
lack of weightbearing exercise
primary ovarian insufficiency
rickets from vitamin D deficiency
Answer D
•
Osteopenia in a previously healthy female usually is the result of a hypoestrogenic
state. Common causes include malnutrition, as in anorexia nervosa and female
athlete triad (disordered eating, amenorrhea, and osteoporosis), or medicationinduced, as with depot medroxyprogesterone acetate. Primary ovarian insufficiency,
previously referred to as premature ovarian failure, is another cause of a
hypoestrogenic state that may be more common than initially recognized. It
represents a continuum of impaired ovarian function whose cause is uncertain in
most cases. Not all patients have profound estrogen deficiency and, therefore,
symptoms may be variable, as in this patient, with her complaints of tiredness but
otherwise normal examination findings. The girl experienced a relatively late onset of
menarche (median age of menarche in the United States is 12.43 years) and now
has secondary amenorrhea. Patients who have at least 4 months of amenorrhea,
often preceded by a prodrome of irregular menstrual cycles that may be infrequent or
more frequent, warrant measurement of follicle-stimulating hormone to rule out this
condition before being placed on any hormonal medications to regulate their menses
or for contraception.
Imbibing cola and caffeine-containing drinks, lack of weightbearing exercise, and
vitamin D deficiency may affect bone density, but they do not alter menstrual cycles.
The lack of weight loss and a normal body mass index reported for this girl make
decreased caloric intake unlikely.
American Board of Pediatrics Content Specification(s):Know that ovarian failure
is a risk factor for osteoporosis
• A 13-year-old girl who is late for her menstrual
period has a positive result on a urine pregnancy
test in your office. She is a healthy girl who has
a negative past medical history. She wishes to
continue with the pregnancy and feels she is
ready to be a mother. Her 19-year-old sister has
a 1-year-old healthy infant and lives in the same
household. Her mother asks you if the girl is at
higher risk for medical complications because of
her age.
Of the following, the MOST appropriate
response is that
1.
2.
3.
4.
5.
good nutritional care will eliminate risk
good prenatal care will eliminate risk
she has the same risk as her older sister had
she is at increased risk for preterm delivery
there is no increased risk related to her young
age
Answer D
•
The primary concern with outcomes of adolescent pregnancy is among females who
are either unaware that they are pregnant or in complete denial that they could be
pregnant and, therefore, do not access prenatal care. The most frequently cited
medical complications of adolescent pregnancy are similar to those experienced by
adult women and include anemia, pregnancy-induced hypertension, low birthweight,
prematurity, intrauterine growth restriction, and neonatal mortality. The risk for these
outcomes in adolescent mothers is related predominantly to the social, economic,
and behavioral factors that predispose such young women to pregnancy.
With good prenatal care, adolescents have the same outcomes as adult women, but
among those younger than age 15 years, some studies point to a modest increase in
prematurity, low birthweight, and neonatal death, despite good prenatal and
nutritional care. Biologic factors are considered to be the cause of the negative
outcomes and include low prepregnancy weight and height, poor pregnancy weight
gain, and parity.
•
American Board of Pediatrics Content Specification(s):Know that with good
prenatal care and nutrition, the physiologic outcomes for young adolescent mothers
can be significantly improved
Understand that the younger a pregnant teen is, the greater the risk of pregnancy
complications for the teen and the fetus
• As an adjunct to abstinence education, you are
asked about the value of starting a 'virginity
pledge' program in your neighborhood school.
You meet with the school staff to educate them
on the pros and cons.
Of the following, evidence suggests that the
MOST likely outcome of such programs is
that
1.
2.
3.
4.
5.
formal pledges are more effective than informal
pledges
most pledgers abstain from oral sex
pledgers and nonpledgers have similar sexually
transmitted infection rates if sexually active
pledgers are more likely than nonpledgers to
abstain from vaginal intercourse
pledgers are more likely than nonpledgers to use
condoms when they become sexually active
Answer C
•
The virginity pledge movement began in 1993, and initial reports indicated that
adolescents who took such pledges were more likely to delay initiation of sexual
intercourse than those who did not. Later studies suggested that the outlook was not
as positive, noting that 61% of young adults who took pledges reported breaking their
vows. Also, the effect of virginity pledges did not extend to other sexual behaviors.
Pledging adolescents were equally likely to engage in oral sex as those who did not
make pledges. Longitudinal studies examining sexually transmitted infections among
young adults indicated that rates of such infections among pledgers did not differ
from nonpledgers. Pledging adolescents were less likely to use condoms at first
intercourse and less likely to worry about and get tested for sexually transmitted
infections. Studies examining the association between formal and nonformal virginity
pledges and the initiation of genital play, oral sex, and vaginal intercourse found that
adolescents who made private pledges or promises to themselves (nonformal
pledges) to wait to have sexual intercourse until older had reduced likelihoods of
engaging in sexual intercourse and oral sex. These findings suggest that a more
effective approach may be to encourage young people to make personal
commitments to delay the onset of sex and raise their awareness of how early sexual
initiation is associated with risks that may threaten future plans.
American Board of Pediatrics Content Specification(s):Recognize that
adolescents who participate in abstinence-only programs or who take abstinence
pledges are just as likely to participate in sexual activity as those adolescents who do
not participate in such programs
• You are seeing a 16-year-old girl who is new to
your practice. Screening questions reveal that
she began sexual activity 1 year ago, has had
unprotected sex with four partners in the last
year, and occasionally smokes marijuana. Her
physical and gynecologic examination results
are normal today. She opts to use condoms as
her sole birth control method. She asks when
she should return.
Of the following, the MOST appropriate visit
schedule for testing for this girl is
1.
2.
3.
4.
5.
a Papanicolaou test annually
Chlamydia trachomatis screening every 6 months
HIV screening every 6 months
syphilis screening every 6 months
yearly serologic testing for herpes simplex virus
Answer B
•
•
All sexually active females younger than 25 years of age should be screened
for Chlamydia trachomatis at least yearly. Screening every 6 months is recommended
for those in a higher-risk category, usually defined by behavioral factors such as
younger age, the number of sex partners, new or more than one sex partner, partner
at least 2 years older, substance use, lack of condom use, a previous history of
C trachomatis infection, homelessness, in detention, and being paid for sex.
Papanicolaou testing should begin at age 21 years. The Centers for Disease Control
and Prevention recommend routine human immunodeficiency virus testing for all
sexually active adolescents; it should be repeated yearly for higher-risk youth.
Syphilis testing is recommended for pregnant adolescents or when other infections
are diagnosed. There is no current recommendation for routine screening for herpes
simplex virus. Screening for Neisseria gonorrhoeae infection also should be
conducted in sexually active adolescents.
American Board of Pediatrics Content Specification(s):Recognize that higher-risk
adolescents (eg, those with multiple sexual partners or histories of prior sexually
transmitted sexual infections) should be screened for Chlamydia
trachomatis and Neisseria gonorrhoeae every 6 months
• A 16-year-old sexually active girl requests a
contraceptive method. Other than being a light
smoker, she has no findings of note on her past
medical history and physical examination. Her
grandparents are obese and have hypertension
and diabetes. She asks about the dangers of
using oral contraceptives.
Of the following, the MOST likely fatal adverse
effect of combined oral contraceptives for this girl
is due to the development of
1.
2.
3.
4.
5.
breast cancer
cholestatic jaundice
diabetes
hypertension
venous thrombosis
Answer E
•
Available contraceptive options include barrier and hormonal methods. Other than
latex allergy, condoms have no health risks. Adverse effects of combined (estrogen
and progesterone) oral contraceptives (COCs) include the rare but serious adverse
reactions and the more common but not life-threatening effects. The risk of death is
estimated at 1 per 200,000 nonsmoking users younger than age 35 years. Serious
acute adverse effects include those caused by blood clots, which are described in the
mnemonic ACHES: abdominal and chest pain, severe headaches, eye problems
(visual changes), and swelling or aching pain in calves/legs. Myocardial infarction and
strokes involve arterial thrombosis, the risk for which increases substantially over
time among those who smoke. Venous thrombosis, on the other hand, is not affected
by smoking but by prothrombotic genetic defects. Such risks, although rare, can be
minimized by screening for a personal or family history of thrombosis. If positive, the
patient should have protein C, protein S, and antithrombin III concentrations
evaluated. Women who have migraine headaches associated with focal signs should
avoid using COCs.
Pills containing lower doses of estrogen combined with the newer generation of
progestogens cause no significant changes in blood pressure, carbohydrate and lipid
metabolism, gallbladder disease, or cholestatic jaundice. In those predisposed to
gallbladder disease, the development of stones may be accelerated with the newer
lower-dose pills. COCs protect against benign breast conditions, but the risk of breast
cancer with use of these agents is unclear. Because studies have conflicting results,
there is no recommendation to withhold COCs in women who have family histories of
breast cancer. The link between COCs and hepatocellular adenoma is clear, but the
incidence is low.
•
Minor estrogenic adverse effects of COCs include nausea, dizziness, irritability,
weight gain, and bloating; progestogenic adverse effects include acne, hirsutism,
weight gain, loss of libido, and depression. Such effects can appear in up to 50% of
women but generally disappear within a few months of pill use. Menstrual cycles
become lighter and shorter with COC use, and intermenstrual bleeding may occur.
The transdermal patch and the ring are newer delivery forms of combined hormonal
contraception. The patch can cause local skin reactions at the application site. In
addition, users are more likely to have breast tenderness, vaginal spotting, and
dysmenorrhea in the first two cycles than users of COCs. Ring users have infrequent
hormone-related adverse effects. Fewer than 6% of users complain of vaginitis and
vaginal discomfort.
Progesterone-only methods of contraception include the mini-pill, depot
medroxyprogesterone acetate (DMPA) injections, an implantable device, and the
levonorgestrel intrauterine system. Menstrual irregularity, weight gain, depression,
and breast tenderness are the more commonly noted adverse effects of these
contraceptive methods. DMPA is more likely to cause decreased bone density, which
reverses upon discontinuation of this method.
American Board of Pediatrics Content Specification(s):Know the complications of
the various forms of contraception for adolescents
• A 16-year-old boy presents to the emergency
department with headache, dizziness, and chest
pain. He is agitated and has occasional ticlike
movements. On physical examination, his
temperature is 37.5°C, heart rate is 120
beats/min, respiratory rate is 20 breaths/min,
and blood pressure is 130/86 mm Hg. His pupils
are mildly dilated and briskly reactive. Other
findings on the remainder of his examination are
within normal parameters.
Of the following, the MOST likely
explanation for this boy's symptoms is abuse
of
1. alcohol
2. cocaine
3. dextromethorphan
4. LSD
5. marijuana
Answer B
•
•
•
The patient described in the vignette is exhibiting signs of stimulant intoxication.
Cocaine is a commonly abused stimulant among adolescents. Alcohol and marijuana
are sedatives, and the absence of hallucinations makes dextromethorphan or lysergic
acid diethylamide (LSD) ingestion unlikely.
Signs and symptoms of acute cocaine overdose include tachycardia, hypertension,
hyperthermia, agitation, headache, and restlessness. Cocaine ingestion should be
considered in any adolescent who presents with altered mental status, new-onset
seizures, chest pain, dysrhythmias, myocardial ischemia or infarction, shortness of
breath, intracranial hemorrhage, epistaxis, or myoglobinuria. Three phases are
identified in severe toxicity, with progression through the phases occurring over
minutes to approximately 1 hour, depending on the dose and route of exposure.
Cocaine overdose may resemble serotonin syndrome, neuroleptic malignant
syndrome, thyroid storm, and other hyperadrenergic states.
Signs and symptoms in chronic cocaine users often depend on the route of exposure.
Risk for dependence also is related to route of exposure, with intravenous users and
those who smoke cocaine at higher risk because of the rapid onset of psychological
effects.
American Board of Pediatrics Content Specification(s):Know the major
physiologic consequences (somatic consequences) attributable to cocaine or the
method of cocaine administration
Know the major behavioral consequences of cocaine use/abuse, including whether
there is a known potential for physiologic addiction
Know the signs and symptoms of acute cocaine overdose
• A 17-year-old boy asks you for help with quitting
cigarette use. He started smoking at age 14
years and now smokes between four and six
cigarettes a day. He was able to quit for 2
months in the past year but resumed smoking
after an argument with his girlfriend.
Of the following, the medical literature
indicates that MOST youth
1.
2.
3.
4.
5.
can quit smoking on their own
do not wish to quit smoking
double their cessation rates with counseling
find scare tactics very effective
increase their cessation rates with medication
use
Answer C
•
Most adolescents are light smokers who do not smoke daily and often smoke less
than 10 cigarettes a day. However, they are at risk for developing smoking-related
diseases and have trouble quitting. Therefore, every adolescent should be asked
about tobacco use, while remembering to respect their privacy and maintain
confidentiality.
Most smoking youth wish to quit and try to do so on their own, but those who enroll in
a cessation program are twice as likely to be successful. The new United States
Public Health Service clinical practice guidelines strongly recommend that clinicians
use effective counseling methods and medications to help their patients quit the use
of tobacco products. However, evidence of the effectiveness of these methods in
youth is not as strong as in adults.
One approach in primary care settings is the 5As model for brief face-to-face
intervention (ask, advise, assess, assist, arrange). Patients who appear unwilling to
quit may respond to brief interventions that are based on principles of motivational
interviewing, a form of directive, patient-centered counseling. Studies indicate that,
compared with usual care (brief advice, self-help pamphlets, reading materials, or a
referral), the use of counseling doubles long-term abstinence rates, although absolute
success rates still are low (abstinence rates increase from 6.7% to 11.6% [95%
confidence interval, 7.5-17.5]). There is no clear evidence to recommend a particular
counseling technique. A recent meta-analysis of studies that employed cognitive
behavioral strategies (self-monitoring and coping skills), social influence strategies
(addressing social influences that serve to promote or maintain smoking), and
motivational strategies (techniques to clarify desire for change and reduce
ambivalence toward change) did find significant effects.
•
Two methods are deemed ineffective or inappropriate for youth. One is a sensory
deprivation environment method, which requires that youth be placed in an
environment that deprives them of sensory stimulation (eg, a dark room) to help them
clarify any conflicting feelings they have about tobacco use. The second relies solely
on "scare tactics" (eg, showing pictures of diseased lungs, presenting people who
have been disfigured by a tobacco-related disease) to change tobacco behavior by
evoking fear of the possible consequences of tobacco use.
Seven medications (five nicotine and two non-nicotine) reliably increase long-term
smoking abstinence rates in adults: nicotine gum, inhaler, lozenge, nasal spray, and
patch; bupropion SR; and varenicline. Although studies indicate that these
medications are safe for use in adolescents, long-term cessation rates do not differ
from placebo in available studies. Results of research on the use of varenicline in
adolescents are awaited.
American Board of Pediatrics Content Specification(s):Know the role that
pharmacologic and non-pharmacologic treatment may play in tobacco cessation
• An 18-year-old boy, who has a past medical history of
poor school performance, behavior problems, and one
episode of visual hallucinations, is brought to the
emergency department because of incoherent speech
and agitation. On physical examination, you note that the
adolescent is staring into space and has occasional
garbled speech. His heart rate is 125 beats/min,
temperature is 37.0°C, and blood pressure is 125/82 mm
Hg. His pupils are 5 mm bilaterally. His skin is flushed
and sweaty, he has no needle track marks, and his
abdomen is slightly distended. His reflexes are
hyperactive, but there are no focal neurologic findings.
The rest of his examination findings are unremarkable.
Of the following, the MOST likely cause of
this boy's findings is
1.
2.
3.
4.
5.
anticholinergic intoxication
depression with psychotic features
early-onset schizophrenia
marijuana use
phencyclidine (PCP) use
Answer E
•
The boy described in the vignette is exhibiting signs of the use of the dissociative
drug phencyclidine (PCP), including blank staring, incoherent speech, tachycardia,
sweating, and muscle rigidity. Characteristic symptoms at higher doses are
nystagmus, which may be vertical, rotary, or horizontal; hallucinations; seizures;
coma; and death. The effects of high doses of PCP may mimic schizophrenia, with
disordered speech, delusions, hallucinations, disordered thinking, and catatonia. PCP
sometimes is considered a hallucinogen because it has some of the same effects,
altering a person's perceptions, sensations, thinking, self-awareness, and emotions.
However, PCP does not fit easily into any one drug category because it also can
relieve pain or act as a stimulant.
Anticholinergic drugs may cause hallucination and tachycardia but typically are
associated with elevations in body temperature, dryness of the skin, and mydriasis,
features not exhibited by the boy in the vignette. Marijuana may cause tachycardia,
redness of the eyes, and acute anxiety but not the other features noted for the boy in
the vignette.
•
Street drugs may unmask a latent mental condition. However, underlying depression
with psychosis or schizophrenia should not result in the physical symptoms noted for
this boy. To make a diagnosis of depression or schizophrenia, it is important to
determine that the symptoms preceded the onset of the substance or medication use,
that they persist for 1 month after cessation of acute withdrawal or severe
intoxication, that they are substantially in excess of what would be expected given the
type or amount of substance used or the duration of use, or that other evidence
suggests the existence of an independent non-substance-induced psychotic disorder
(eg, a history of recurrent non-substance-related episodes). Of note, the
hallucinations seen with these conditions, compared with those seen with substance
use, are more likely auditory than visual. Finally, a positive family history of either
disorder is helpful in making the diagnosis.
American Board of Pediatrics Content Specification(s):Distinguish between
schizophrenia and hallucinogenic drug use
A game warden accompanies his wife, new
baby, and 13-year-old stepson to the
infant’s 2-week health supervision visit. He
explains that he must store the gun he is
required to carry for his job at home, but
he is concerned about the risks of having
a gun in the home.
Of the following, the BEST advice to give
this father is to
1.
2.
3.
4.
5.
enroll his stepson in a formal firearm safety course
show the stepson how to handle the gun appropriately
store the gun locked and loaded in a high, secret
cabinet
store the gun locked and unloaded with ammunition
locked and stored separately
store the gun unloaded in a locked gun safe with the
ammunition stored adjacently
Question 10 Answer D
•
Firearm injuries are common in the United States, which has the highest rate of gun
injuries among developed nations. In 2004, the Centers for Disease Control and Prevention
recorded 2,852 firearm-related deaths in children as well as 13,846 nonfatal gun-related injuries.
In 2007, there were 12.5 firearm deaths per 100,000 children in the United States. Males 15 to 19
years of age are eight times more likely to die of firearm-related injuries than females and African
American male youth sustained the highest rates of firearm related deaths (combined homicide,
suicide, and accidental deaths) at 70 per 100,000 adolescents in 2007.
•
A 2005 study in the Journal of the American Medical Association documented that safe storage of
both long guns and handguns reduced the risk of suicide and accidental injury due to firearms.
Thus, parents who own guns should be advised of the need to safely store guns. Unfortunately,
some parents may not wish to discuss their gun ownership with their child’s physician and since
most firearms are owned and stored by men, mothers may not know if there is a gun in the home
and how it is stored.
•
Children also may be at increased risk for firearm injury if there are accessible guns in the homes
of their playmates or child care provider. Therefore, parents should also be advised to ask child
care providers and others who may care for their child about accessible guns in their homes and it
may be advisable to discuss firearm injury prevention with all families regardless of gun
ownership.
•
Ideally, safe storage of firearms involves placement of unloaded and locked firearms and
ammunition in separate storage areas with separate locks since a loaded firearm or easy
availability of ammunition which is stored near the firearm increases the risk that an unsupervised
child will be injured. There is no evidence that firearm education is an effective way to prevent
firearm injury.
A 14-year-old girl presents to the office for a
routine health supervision visit. Her mother, who
had her menarche at age 13 years, asks if she
should be concerned that her daughter has not
started menstruating yet. Chart review confirms
that the adolescent began breast development
at age 10½ years. She has been tracking along
the 5th to 10th percentile for height and weight
since entering puberty. Her father’s growth spurt
occurred around age 16 years. The girl is at
Sexual Maturity Rating (SMR) 4 for breast
development and SMR 5 for pubic hair
development and has normal external genitalia.
The remainder of her physical examination
findings are normal.
Of the following, the MOST appropriate next
step is
1. follow-up evaluations every 6 months for 1 year
2. hand and wrist radiograph for bone age
3. luteinizing hormone and follicle-stimulating hormon
assessment
4. pelvic ultrasonography
5. thyroid function testing
Question 11 Answer A
•
•
Progression through the development of secondary sexual characteristics
has been divided into stages, referred to as the Sexual Maturity Rating
(SMR) scale (previously, Tanner stages). Although the events are the same,
the timing of onset and rate of progression through the stages may differ
between individuals in each sex. Stage 1 is prepubertal. The average length
of time from stage 2 to 5 in females is 4 years but can range from 1.5 to 8
years. For males, the duration is 3 years but can range from 2 to 5 years.
The average interval between breast development (thelarche, the first
clearly visible sign of pubertal development in most females) and menarche
is approximately 2 years, but the range is 0.5 to 5.75 years. Increase in
growth velocity is the first sign of puberty. Pubic hair development usually
starts later than breast development but reaches SMR 5 earlier.
Most females menstruate in SMR 4. The girl in the vignette is progressing
through pubertal stages normally. Because she is now 3.5 years from the
start of thelarche and younger than age 16 years, observation for further
development, with follow-up evaluations every 6 months for 1 year, is a safe
and prudent course. If she remains asymptomatic and has no menstruation
by age 16 years, an endocrine evaluation is appropriate and should include
assessment of bone age, measurement of luteinizing and follicle-stimulating
hormones, thyroid testing, and pelvic ultrasonography, among other tests.
You are seeing a 13-year-old girl, in whom you diagnosed
anorexia nervosa approximately 18 months ago, for a
follow-up visit. She had started to restrict her food intake
about 6 months before her first visit. There was no
history of binging or purging. She had become
progressively more isolated from her friends and was
very anxious and irritable. Currently, her mother states
that she is doing well at school and has one friend. She
is eating everything but still in small quantities. She has
not had menarche yet but is otherwise asymptomatic.
Her mother had her menarche at age 12½ years. On
physical examination, the girl has normal vital signs, a
body mass index of 17.4, and no focal findings. When
her father comes in after your examination, he is very
upset that she is not “cured after all this time” and that
they still have to supervise her meals and eating habits.
You discuss the usual course of this illness and
prognosis with him.
Of the following, the factor MOST likely to be
associated with a poor prognosis for this girl is
1.
2.
3.
4.
5.
absence of binging and purging
comorbid psychiatric illness
early onset of illness (<14 years)
good family support
short duration of illness
Question 12 Answer B
•
•
Although one of the diagnostic criteria for anorexia nervosa (AN) is
amenorrhea, the onset of AN may predate the onset of puberty or may
occur in the early pubertal stages, interrupting further development and
resulting in primary rather than secondary amenorrhea, which is the case
for the girl described in the vignette. Prognostic factors for eating disorders
have not been reliably identified. Overall, it is estimated that about 50% of
patients do well, about 30% do not do so well, and about 20% do poorly.
The mortality rate of 5% to 10% is the highest among psychiatric disorders,
with death resulting from either suicide or medical complications.
Most longitudinal studies indicate that the onset of AN before adulthood,
especially before age 14 years, along with early, intensive treatment is
associated with a good prognosis. Other factors that are good
prognosticators are good family support and a shorter duration of illness,
suggesting that the behaviors have not become entrenched and the
parents, with guidance, should be able to aid in recovery. Thus, early
recognition and intensive treatment improve the prognosis. Factors
associated with a less positive prognosis include the presence of binging
and purging, longer duration of illness before treatment, poor family
relations, and comorbid psychiatric illnesses.
You are sharing the results of laboratory
testing with the mother of a set of fraternal
twins aged 16 years and at Sexual
Maturity Rating 5. The girl has a
hemoglobin (Hgb) of 12.2 g/dL (122 g/L),
with a mean corpuscular volume (MCV) of
85 fL. The boy’s Hgb is 13.1 g/dL (131
g/L), with an MCV of 80 fL. They both are
active adolescents and, other than
occasional complaints of tiredness, are
asymptomatic.
Of the following, the MOST appropriate
interpretation of the evaluation is that
1.
2.
3.
4.
5.
both adolescents have iron deficiency anemia
both adolescents need folic acid supplements
the boy is anemic and needs iron medication
the girl is anemic and needs iron medication
the results are normal in both adolescents
Question 13 Answer C
•
•
The hemoglobin (Hgb) value increases in males during pubertal progression
because of increasing androgen concentrations. In contrast, the value in
females stays steady because of the combination of lower androgen
concentrations and menstrual losses. It is important to correlate laboratory
values for adolescents with their Sexual Maturity Rating (SMR). In white
males, the mean Hgb is 13.2 g/dL (132 g/L) at SMR 1, rising to 15.4 g/dL
(154 g/L) (range of 14.0 to 17.0 g/dL [140 to 170 g/L]) at SMR5. The median
hematocrit (Hct) at SMR1 is 41% (36% to 45%) rising to 46% (41% to 50%)
at SMR 5. The mean MCV rises from 82.8 to 88.2 fL at SMR 5. The Hgb is
slightly lower in African American males who have a mean of 14.6 g/dL (146
g/L) at SMR5. In white females at SMR5, the mean Hgb is 13.4 g/dL (134
g/L) (range, 11.9 to 15.1 g/dL [119 to 151 g/L]), mean Hct is 39.6% (range,
0.36% to 0.45%), and mean MCV is 89.6 fL (range, 82 to 99 fL).
The Hgb and MCV values for the girl described in the vignette fall within the
acceptable range, but her brother’s values are in the anemic range. During
adolescence, the need for iron in both sexes is increased because of rapid
growth and increased blood volume and muscle mass. Further, iron
deficiency anemia is common in both sexes because of poor nutritional
habits and in girls due to menstrual losses. Active adolescents who have
borderline values may benefit from iron supplements, but this boy needs
therapeutic doses of iron to treat his anemia.
You are seeing a 15-year-old sexually active girl
who complains of vague lower abdominal pain
and a vaginal discharge. She has no systemic
symptoms but has experienced intermittent
dysuria over the past week. She believes that
she needs only a prescription for a yeast
infection because she was treated for this a few
weeks ago but the discharge did not resolve
completely.
Of the following, the MOST appropriate next
step is to
1. obtain a vaginal swab for a wet mount
evaluation only
2. perform a speculum & bimanual examination
3. perform an external genital inspection only
4. provide an antifungal prescription
5. send a urine specimen for culture only
Question 14 Answer B
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Newer techniques and changes in recommendations have made screening of the asymptomatic
adolescent for sexually transmitted infections noninvasive and easy. The age for a routine first
Papanicolaou test (Pap smear for cervical cancer screening) has been raised to 21 years to
prevent unnecessary and possibly harmful evaluations and treatments to the cervix in younger
patients. Nucleic acid amplification tests (NAATs) to screen for Neisseria gonorrhoeae and
Chlamydia trachomatis infections can be completed with urine samples or vaginal swabs. Thus,
given these recommendations, there is no need to perform a routine pelvic examination in an
asymptomatic sexually active female. However, these changes should not be interpreted as a
reason not to perform a pelvic examination in a symptomatic adolescent because many conditions
could be missed without such an examination.
The adolescent described in the vignette is sexually active and has dysuria, a vaginal discharge,
and abdominal pain. As a result, a speculum and bimanual examination is the most appropriate
next step in her evaluation. The presence of dysuria raises the possibility of urethritis from a
sexually transmitted infection as well as a urinary tract infection. Therefore, in addition to a urine
culture, her external genitalia should be inspected carefully to identify lesions that could result in
external dysuria (pain when urine flows over an external lesion such as an ulcer), the presence of a
vaginal discharge, and discharge from the urethra that may be visible with or without milking the
urethra. A vaginal discharge may result from either vaginitis or cervicitis and, therefore, requires
more than inspection of the external genitalia and a blind swab of the vagina for wet mount
evaluation or NAAT testing. Inspection for the nature of the discharge, the presence of a foreign
body, possible cervical ulcers, discharge from the cervical os, and friability help with immediate
identification of a cause for the presenting complaint. In addition, the presence of abdominal pain in
this girl warrants a bimanual examination to rule out pelvic inflammatory disease (PID). Other
reasons to consider a complete pelvic examination include menstrual disorders such as delayed
onset of menarche, lack of or excessive bleeding, or severe menstrual cramps as well as
unexplained pelvic pain, pregnancy-related complaints, or suspected abuse. For adolescents who
are not sexually active, a rectoabdominal examination can substitute for a vaginal bimanual
examination.
Prescription of medications without an evaluation generally should be avoided. A yeast infection
would not be a cause of lower abdominal pain for this girl, and possible PID would be missed
without a speculum and bimanual examination.
A 14-year-old girl, who has experienced irregular bleeding
since menarche at age 11 years, presents with painless
menstrual bleeding of 14 days’ duration. She is using 8
to 10 super-pads per day. She says she was told that her
period could be irregular in the first few years, but she is
feeling tired and is upset with the number of days of
bleeding. The only finding of note on physical
examination is mild pallor. Her heart rate is 82 beats/min
and blood pressure is 120/80 mm Hg, with no postural
changes. Laboratory tests show a hemoglobin of 9.4
g/dL (94 g/L) with a normal platelet count, prothrombin
time, partial thromboplastin time, and von Willebrand
panel.
Of the following, the MOST appropriate
treatment for this girl is
1.
2.
3.
4.
5.
a course of iron therapy and an iron-rich diet
a daily dose of oral progesterone pills
combined oral contraceptive pills
gynecologic referral for a dilatation and curettage
tracking with a menstrual calendar and follow-up
appointment in 3 months
Question 15 Answer C
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Painless profuse bleeding of endometrial origin from physiologic anovulation is referred to as
dysfunctional uterine bleeding (DUB). There is no systemic or local pathology, as determined by
the history and physical examination, and the condition should resolve in 2 years postmenarche,
when most menstrual cycles become ovulatory. The girl described in the vignette has concerns
about heavy and prolonged menses. Normal flow can last up to 7 days, with the use of up to
seven menstrual pads in a day. The likelihood that she has a bleeding disorder is low because she
is now 3 years postmenarche and her hemoglobin value is only mildly decreased. In addition, the
findings on screening for bleeding disorders are normal. Most bleeding disorders are
characterized by heavy bleeding in the first or second menstrual cycles, with the quantity of blood
loss creating significant anemia with much lower hemoglobin values. Because there is no
ovulation or production of progesterone with DUB, the endometrial lining builds up from
unopposed action of estrogen on the tissue, and when the lining is subsequently shed, the
bleeding can be prolonged and heavier than usual.
Therapy for DUB depends on the severity of bleeding. If the hemoglobin is in the normal range,
the patient should keep a careful menstrual record, have frequent follow-up evaluations, and be
advised to eat an appropriate iron-rich diet or take iron supplements. Because the hemoglobin for
the girl in the vignette has dropped below 10 mg/dL (100 g/L), she has persistent bleeding and is
mildly symptomatic, further bleeding should be prevented, which can be accomplished with
combined hormonal contraception to regulate the cycles and make the menstrual flow briefer and
lighter. Consideration should be given to hospitalizing her to ascertain that the bleeding is
controlled and the hemoglobin concentration is stabilized. Hospitalization should be considered if
the patient is anemic and unable to tolerate or comply with outpatient therapy. Hospitalization is
indicated if the patient is hemodynamically unstable, is symptomatic (eg, syncope or
lightheadedness with change in posture), or has a hemoglobin value low enough to require a
transfusion. If there is any reason to not use estrogen, progesterone-only pills may be tried.
Surgical intervention is almost never needed for DUB. In fact, if the patient has bled down to the
basal layer of the endometrium, curettage may cause permanent amenorrhea and Asherman
syndrome (scarring within the uterine cavity). If DUB does not resolve in 2 years, the patient
should be evaluated for possible other conditions, such as polycystic ovarian syndrome.
During the annual health supervision visit for an
11-year-old boy, his mother advises you that
over the last year he has had considerable
pubertal development, with rapid linear growth
and both testicular and penile enlargement. On
physical examination, you note that his height is
above the 95th percentile for his age and
confirm that his testicular volume is 12 mL (3.5
cm in length) bilaterally. A bone age radiograph
demonstrates skeletal maturity of 14 years.
Of the following, his upper-to-lower segment
ratio would be expected to be CLOSEST to
1.
2.
3.
4.
5.
0.9
1.1
1.3
1.5
1.7
Question 16 Answer A
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The upper-to-lower (U:L) segment ratio is an important part of the physical examination
that can be used to detect subtle abnormalities of growth and development. The distance
from the pubic symphysis to the floor (in a standing patient) is measured to obtain the lower
segment value; this is subtracted from the patient’s height to obtain the upper segment
value. The U:L ratio is then calculated using the two values. In infants, the legs are
relatively shorter than the rest of the body, resulting in a typical U:L ratio of 1.7. As children
grow, the U:L ratio decreases to approximately 1.0 at 10 years of age. In pubertal children
or those who have completed puberty, the U:L ratio is typically between 0.85 and 0.95. The
boy described in the vignette has experienced mildly precocious puberty, as evidenced by
his relatively tall stature and advanced bone age. Accordingly, his U:L ratio should be
reflective of a pubertal or postpubertal male (U:L=0.9).
•
Children who experience early puberty often have relative tall stature during puberty.
However, they also complete their growth prematurely and have a somewhat lower peak
adult height than expected (because of the rapid fusion of their growth plates and shorter
legs). Conversely, children who experience later puberty may have relative short stature in
youth but an adult height that is slightly above expectations (because of the slow but
constant prepubertal growth of long bones without rapid maturation of the growth plate).
Because the timing of puberty affects both linear growth rate and skeletal maturity, children
who have precocious puberty may have slightly higher (but still within the reference range)
U:L ratios, and children who have delayed puberty have slightly lower U:L ratios. More
extreme examples of changes in the U:L segment ratios are observed in syndromes
characterized by abnormal growth patterns. For example, Marfan syndrome is
characterized by very long legs and, therefore, a very low U:L ratio; patients who have
hypochondroplasia have shorter limbs and, therefore, have elevated U:L ratios.
You are seeing a 16-year-old girl for the first time who
complains of amenorrhea. The mother’s menarche was
at age 12 years. The girl developed pubic hair at age 11
years and breast buds at age 12 years. She has no other
symptoms. The mother reports that the girl eats well and
has been active all her life. Physical examination reveals
a height of 57 in, weight of 89 lb, body mass index of
19.3, breast tissue at Sexual Maturity Rating (SMR) 2,
and pubic hair at SMR 4. A urine pregnancy test shows
negative results. Laboratory results include: luteinizing
hormone of 10 mIU/mL (normal adult female, 2 to 95
mIU/mL), follicle-stimulating hormone of 42 mIU/mL
(normal adult female, 1 to 30 mIU/mL), and prolactin of
27 ng/mL (normal, 5 to 23 ng/mL).
Of the following, the MOST likely cause of this
girl’s primary amenorrhea is:
1.
2.
3.
4.
5.
congenital adrenal hyperplasia
excessive exercise
imperforate hymen
prolactinoma
Turner syndrome
Question 17 Answer E
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The absence of menses or amenorrhea often is broadly classified as primary (no menarche by
age 16 years) or secondary (lack of menses for 3 to 6 months, once initiated). Other than genital
tract obstruction, the causes for primary and secondary amenorrhea may overlap. For example, a
girl may begin sexual activity before the onset of her first period, and pregnancy could be the
cause of primary amenorrhea. The source of amenorrhea might be better assessed by
considering causes in different compartments: the outflow tract, the ovaries, or the hypothalamicpituitary axis. Imperforate hymen or the Mayer-Rokitansky-Küster-Hauser syndrome may be the
cause in the genital tract outlet. In the ovaries, the cause may be chromosomally related, as in
Turner syndrome, or nonchromosomal, as with damage to the ovaries such as after radiation or
chemotherapy. These entities produce hypergonadotropic hypogonadism in which the folliclestimulating hormone (FSH) concentration is high. The cause of polycystic ovarian syndrome
(PCOS), the most common endocrinopathy seen in adolescent females, is unknown but is
believed to be related to insulin action. Finally, the source may lie in the hypothalamic-pituitary
area (resulting in hypogonadotropic hypogonadism with normal or low FSH), often due to stress,
weight loss, excessive exercise, or more rarely, a space-occupying or destructive pituitary lesion.
If the patient has evidence of androgen excess (eg, hirsutism, acne, clitoromegaly) and
amenorrhea, adrenal causes should be sought, in addition to evaluation for PCOS.
The short stature combined with minimal breast development and amenorrhea described for the
girl in the vignette suggests the possibility of Turner syndrome. Her FSH value is high, indicating
ovarian failure. Late-onset congenital adrenal hyperplasia (21-hydroxlase deficiency) causes signs
of androgen excess. Excessive exercise with failure to ingest sufficient calories may cause
stunting of growth and interruption of puberty, but it would not result in ovarian failure. Females
who have imperforate hymens complete pubertal growth and secondary sexual development
normally. They present with monthly lower abdominal pain and may have an enlarged uterus that
is palpable above the pubic symphysis. Examination of the external genitalia should reveal a blue
bulging membrane (Item C218). Prolactinomas are often micro- rather than macroadenomas and,
therefore, produce no symptoms or signs of increased intracranial pressure. With a tumor, the
prolactin concentration is usually greater than 100 ng/mL. Affected patients occasionally present
with delayed puberty or secondary amenorrhea with or without galactorrhea
A 17-year-old girl is brought to the emergency department
by her parents because of vomiting. She has no fever,
headache, abdominal pain, or diarrhea. She says that
over the past 3 years she has periods of time when she
vomits and then she is fine for a while. She denies
inducing the vomiting. Her periods are regular, and her
last one was 2 weeks ago. On physical examination, you
note normal vital signs, a body mass index of 28.5, a
small subconjunctival hemorrhage on the right eye, and
slight enlargement of her parotid glands bilaterally.
Laboratory results reveal a normal complete blood count
and erythrocyte sedimentation rate, amylase of 75 U/L,
and lipase of 1 U/L. Her pregnancy test is negative, and
a urinalysis has a specific gravity of 1.030 with trace
protein and ketones.
Of the following, the MOST likely
explanation for these findings is
1.
2.
3.
4.
5.
acute pancreatitis
bulimia nervosa
cyclic vomiting
diabetic ketoacidosis
ectopic pregnancy
Question 18 Answer B
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•
•
•
•
•
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The girl described in the vignette has a history of recurrent vomiting, subconjunctival hemorrhage, and parotid
gland enlargement, which strongly suggests the diagnosis of bulimia nervosa. Affected patients often have a net
caloric gain despite vomiting because of the amount of calories consumed during their recurrent binge episodes.
Therefore, they may be overweight and have normal menses. Patients who have been inducing vomiting for a long
period of time may be able to have emesis with limited, if any, stimulation, even occasionally by gently jumping up
and down.
The criteria for diagnosis of bulimia nervosa are:
·Recurrent episodes of binge eating that are characterized by eating an amount of food in a period of time that is
clearly larger than most people would eat during a similar time period and in similar circumstances coupled with a
sense of lack of control over eating during the episode.
Use of inappropriate behaviors to prevent weight gain, such as self-induced vomiting; misuse of laxatives,
diuretics, enemas, or other medications; fasting; or excessive exercise.
The binge eating and inappropriate behaviors occur twice or more each week for a period of 3 months.
Self-image is inappropriately influenced by body shape and weight.
Two types of bulimia nervosa exist. In the purging type, the person regularly engages in self-induced vomiting or
misuse of laxatives, diuretics, or enemas. In the nonpurging type, the person uses other inappropriate
compensatory behaviors, such as fasting or excessive exercise, but does not regularly engage in self-induced
vomiting or the misuse of laxatives, diuretics, or enemas.
The lack of abdominal pain with normal amylase and lipase values rules out pancreatitis for this girl. Cyclic
vomiting is a syndrome of recurrent stereotypic spells of vomiting in between which the patient is completely well.
Frequently associated symptoms include fatigue, pallor, anorexia, and nausea. Cyclic vomiting is more common in
younger children, who tend to outgrow it in their preteen or early teen years, but they often subsequently develop
migraine headaches. There is a strong family history of migraine. The occasional adolescent who has this
syndrome experiences intense episodes of vomiting that may occur with menses; parotid enlargement is not a
typical feature. The lack of glucose on the urinalysis for this girl rules out diabetic ketoacidosis, and the lack of
abdominal pain and menstrual bleeding along with a negative pregnancy test makes ectopic pregnancy an unlikely
cause of the vomiting.