March 13th Board Review Answers
Question 1 of 11
E-refer the boy to an endocrinologist for re-evaluation and possible hormonal therapy
A teenager is considered to have delayed puberty if there is no evidence of Sexual Maturity Rating stage 1 genital
development by 13 years in girls and 14 years in boys. Adolescents who present with evidence of delayed
pubertal development, such as the boy described in the vignette, require medical evaluation and need to be
screened for difficulties in psychosocial functioning. Individuals who have notable delays may have feelings of
poor self-image and low self-esteem. They may be teased or bullied by their peers, leading to withdrawal from
social activities as well as parental overprotection. Their school performance may decline, and they may wish to
avoid attending school. Boys who look younger than their chronologic age have fewer opportunities to engage in
activities with their peers and may feel unpopular. Girls experience less of an emotional impact from delays in
The amount of intervention in patients who have constitutional delay should be based, in part, on the amount of
emotional stress expressed by the adolescent. If puberty is expected to occur and the individual has minimal
emotional impact, simple reassurance may be enough. Adolescents who have significant emotional distress, such
as the boy in the vignette, may benefit from hormonal therapy to initiate or accelerate puberty. Therefore,
referral to an endocrinologist is indicated.
Additional caloric intake is not appropriate for an adolescent whose weight and height are normal; such an
intervention will not accelerate his rate of pubertal development. A psychoeducational evaluation is not indicated
for this boy because although his grades are declining, they still are above average. Behavioral counseling may
help the boy cope with his current level of distress, but it will not address his delayed puberty.
C-recommend psychological counseling to help the girl deal with her feelings regarding the changes in her body
Precocious puberty is defined as the appearance of breast development prior to age 6 to 7 years in Caucasian
girls and prior to 5 to 6 years in African-American or black girls, as is sexual development before 9 years in boys.
The incidence of precocious puberty in the United States is estimated at 0.01% to 0.05% per year, with a four to
ten times higher rate in girls than in boys.
Children who have precocious puberty tend to be shy and withdrawn with same-age peers and prefer to be with
older individuals, as described for the girl in the vignette. Both parents and teachers should be told to expect
age-appropriate behavior, even if the child appears older. Children who experience precocious puberty need to be
monitored because they are at risk for sexual abuse and possible pregnancy.
In view of this child's difficulty with same-age peers, she should receive counseling to help her deal with her
changing body image and guide her when interacting with peers. Her parents should treat her in an age-
appropriate manner. They should encourage positive social interactions with her peers. A pet should not be
obtained for the sole reason of trying to have her socialize less with the neighborhood children. Her parents
should not directly contact her peers to avoid further embarrassment. They may wish to discuss the situation
with school personnel, who may intervene in a less threatening manner. They should be wary of her gravitating
toward older age peers, who may take advantage of her.
Biochemical changes that occur during puberty can reflect underlying physical growth. For example, hemoglobin
and hematocrit values vary with pubertal stage and sex. Female adolescents have relatively stable values as they
progress from Sexual Maturity Rating (SMR) 1 through 5. In contrast, male adolescents show a progressive
increase in hemoglobin value as they progress to physical maturity at SMR 5, reaching a hemoglobin value of 14
to 18 g/dL (140 to 180 g/L). The increase in hemoglobin for males is due to the hematopoietic effects of
testosterone. Values for serum albumin, calcium, platelet count, and white blood cell count remain stable across
adolescent growth and development.
E polycystic ovary syndrome
Signs of androgen excess (especially hirsutism and acne) combined with oligomenorrhea or anovulatory bleeding,
as described for the adolescent girl in the vignette, should alert the clinician to the possibility of polycystic ovary
syndrome (PCOS). PCOS is the most common endocrinopathy in premenopausal women, but its clinical criteria
for diagnosis, pathophysiology, and treatment remain controversial. Definite or probable criteria for diagnosis
include laboratory or clinical hyperandrogenism, menstrual dysfunction, and exclusion of congenital adrenal
hyperplasia. Other criteria often used to support a diagnosis include insulin resistance, perimenarcheal onset,
elevated luteinizing hormone-to-follicle-stimulating hormone ratio, and ultrasonographic abnormalities.
Abnormalities observed in patients who have PCOS occur in four key areas: 1) increase in luteinizing hormone
secretion, 2) increase in adrenal androgen production, 3) increase in body mass, and 4) onset of adult patterns of
insulin resistance. Some girls have a transient period of hyperandrogenism during the first 3 years after
menarche; others have persistent PCOS symptoms. Patients who have PCOS are at increased risk for diabetes
mellitus, obesity, insulin resistance, infertility, and impaired quality of life.
Cushing syndrome is less likely in the absence of other stigmata of the syndrome, including weakness,
spontaneous ecchymoses, large purple striae (Item C73A), hypokalemia, and osteoporosis. A rapid onset of
hirsutism with virilization is characteristic of ovarian tumors. Hypothyroidism can cause menstrual irregularities
and weight gain, but is not associated with androgen excess. Patients who have Noonan syndrome (Item C73B)
may present with delayed puberty and associated amenorrhea, but they do not exhibit androgen excess and
B-azithromycin 1 g orally in a single dose plus cefixime 400 mg orally in a single dose
Urethritis is characterized by inflammation of the urethra and may be caused by infectious and noninfectious
agents. Young men who have urethritis commonly are asymptomatic or they may complain of a mucopurulent or
purulent discharge, dysuria, or urethral pruritus. Neisseria gonorrhoeae and Chlamydia trachomatis are common
infectious causes of urethritis, and both may be present. The Centers for Disease Control and Prevention (CDC)
Sexually Transmitted Diseases Treatment Guidelines, 2006 recommend that all patients who have confirmed or
suspected urethritis be treated for both gonorrhea and chlamydia. Further testing to determine the specific
causative pathogens is recommended because both gonorrhea and chlamydia are reportable infections, and a
specific diagnosis might enhance partner notification as well as treatment adherence. Culture, nucleic acid
hybridization tests, and nucleic acid amplification tests can detect both of the organisms, and amplification tests
can be performed on urine specimens.
Nongonoccocal urethritis (NGU) is diagnosed when microscopy shows inflammation without the presence of
gram-negative intracellular diplococci. C trachomatis is the etiologic agent in 15% to 55% of cases, but the cause
of most cases of nonchlamydial NGU is unknown. Other infectious agents implicated in NGU include Ureaplasma
urealyticum, Mycoplasma genitalium, Trichomonas vaginalis, herpes simplex virus, adenovirus, and enteric
bacteria (that might be associated with penetrative anal sexual activity). Diagnostic testing and treatment for
these organisms are reserved for when specific infections are suspected (such as with known partner contact) or
when NGU is not responsive to therapy.
Recommended treatment for urethritis includes a single 1-g oral dose of azithromycin or doxycycline 100 mg
orally twice a day for 7 days. Both are highly effective for chlamydial urethritis, but infections with M genitalium
may respond better to azithromycin, and single-dose therapy is preferred both for adherence and for the ability
to conduct direct observed treatment. The recommended treatment for N gonorrhoeae is ceftriaxone 125 mg
intramuscularly or cefixime 400 mg orally as single-dose therapy. Because the young man in the vignette is
homeless and diagnostic testing results will be unavailable for several days, empiric treatment of his urethritis is
advisable. Because of increasing fluoroquinolone resistance in the United States and Canada, the CDC no longer
recommends using these antimicrobials for the treatment of uncomplicated gonococcal urethritis and advises that
all patients be treated with either cefixime or ceftriaxone, regardless of the patient’s travel history or sexual
behavior. Acyclovir, benzathine penicillin, clindamycin, or metronidazole is not recommended for empiric therapy.
D-hospitalize the patient and begin intravenous cefotetan 2 g plus doxycycline 100 mg every 12 hours
Pelvic inflammatory disease (PID) treatment regimens must provide broad-spectrum coverage of likely
pathogens, including Neisseria gonorrhoeae and Chlamydia trachomatis. Oral therapy can be used for women
who have mild-to-moderately severe acute PID; the Centers for Disease Control and Prevention (CDC) report that
clinical outcomes of women treated with oral therapy are similar to those seen in women treated with parenteral
therapy. The young woman described in the vignette was treated appropriately as an outpatient, but
subsequently was unable to tolerate an outpatient regimen and did not appear to respond clinically to an oral
regimen (eg, doxycycline and azithromycin). In addition, a single dose of benzathine penicillin is not adequate
therapy for PID. These are two criteria suggested by the CDC that indicate the need for hospitalization of women
who have PID. Other criteria for hospitalization include when surgical emergencies (such as appendicitis) cannot
be excluded; the patient is pregnant; the patient has a severe illness, nausea and vomiting, or high fever; and
the patient has a tubo-ovarian abscess. Although many practitioners may prefer to hospitalize adolescents who
have PID, no available evidence exists to support this strategy. Younger women who have mild-to-moderate
acute PID have similar outcomes in response to outpatient or inpatient therapy, and clinical response to
outpatient treatment is similar for older and younger women. The CDC states that the decision to hospitalize
adolescents who have acute PID should be based on the same criteria, as stated above, used for older women.
Because the patient has no signs or symptoms of herpes simplex virus infection, oral acyclovir with
hospitalization is not indicated.
The symptoms of mucopurulent or purulent penile discharge with dysuria and urinary frequency described for the
boy in the vignette are indicative of urethritis. Urethritis may be separated based on infectious etiology into
gonococcal (due to Neisseria gonorrhoeae) and nongonococcal forms. Nongonococcal urethritis (NGU) can be
caused by Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis,
herpes simplex virus, adenovirus, and enteric bacteria. Enteric bacteria (eg, Salmonella, Shigella) can be
associated with penetrative anal sexual activity. Although no symptoms or signs reliably distinguish between
gonococcal urethritis and NGU, infection with N gonorrhoeae usually is characterized by copious purulent
discharge, as exhibited by the boy described in the vignette. In NGU, the urethral discharge typically is more
scant and mucoid.
The absence of vesicles or ulcers makes herpes simplex infection less likely. NGU caused by T vaginalis accounts
for approximately 2% to 5% of all NGUs. Balanitis and cutaneous lesions of the penis also are characteristic of T
vaginalis infection. Primary infection with Treponema pallidum manifests as a chancre and tender inguinal
adenopathy, and secondary stage infection is characterized by rash or condyloma lata. Exophytic lesions, not
urethral discharge, signal infection with human papillomavirus.
E-successful violence intervention programs stress conflict resolution in conjunction with mentoring
Violence rates in the United States generally are declining, but rates for adolescent violence are increasing.
Adolescents are increasingly the perpetrators of violence as well as victims. School-associated violence
encompasses a wide variety of behaviors such as bullying, fighting, assault, and gang violence. Risk factors
associated with perpetrating school violence are similar to those for school violence victimization. Large urban
schools show higher rates of most types of school violence, including vandalism, fighting, larceny, and homicide.
Although violent school deaths occur in all communities, the estimated rate of school homicide in urban school
districts is nine times higher than that of rural school districts. Personal risk factors for school violence include
male sex, alcohol or other drug use, poor impulse control, gang involvement, younger age (12 to 14 years of
age), a history of carrying weapons, and a history of fighting and aggression.
Adolescent violence can beget further violence: both perpetrators and victims of violence are at risk of
committing future violent acts, including interpersonal violence, date rape, gang violence, and homicide. Effective
violence intervention programs have a multidisciplinary approach that involves families, physicians, mental health
professionals, social services, and often the criminal justice system. The goals of these programs are to identify
and modify characteristics associated with violence, promote self-esteem, promote anger management skills,
treat alcohol and other drug disorders, and prevent future violent behavior. Strategies to prevent youth violence
have been studied to develop best practice recommendations. Successful strategies to prevent youth violence
stress nonviolent problem-solving techniques, conflict resolution skills (eg, negotiation, mediation), and
mentoring. Other successful strategies include use of social-cognitive interventions to equip young people with
skills to deal effectively with difficult social situations, home visiting, and parent- and family-based interventions
designed to improve family relations.
C-if an adolescent poses a threat to self or others, confidentiality can be broken
Respect for the privacy of individuals dictates that the information shared by adolescent patients with clinicians
remain confidential unless there is a legal requirement to disclose information or the information reveals a serious
threat to the adolescent's or another individual's health. Research has shown that when adolescents perceive that
their health-care service is not confidential, they are less likely to seek care, especially for problems involving
reproductive health and alcohol and other drug use. Research also indicates that adolescents are more likely to
disclose sensitive information if clinicians make explicit statements about confidentiality.
It is a challenge to provide confidential services to adolescents, especially if they are covered by parental
insurance, because billing policies (and electronic medical record systems) may not always have safeguards for
confidentiality when billing for a specific test (such as sexually transmitted infection testing). State laws also vary
in the extent to which they protect confidentiality of minors, and no law can cover every situation. State laws
address alcohol and other drug abuse, but some specify only one or the other. Requirements of disclosure of drug
and alcohol use to parents also vary among states. The Center for Adolescent Health and the Law recently
published a compendium of state laws that addresses confidentiality and consent and allows clinicians to
determine the specifics of the law in their own states of practice.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects confidentiality of adolescents
who are considered minors under some circumstances. Parents and guardians have control over health
information access for nonemancipated minor children, except in situations in which minors are able to consent to
their own health care. The federal law of HIPAA defers to state laws that allow or prohibit disclosure of
confidential information to parents. HIPAA allows a physician to disclose information to a parent if a state law
requires the physician to do so. If the state law permits, but does not require, disclosure to a parent, HIPAA
allows physician discretion for disclosure. If state law prohibits the disclosure of information to a parent,
disclosure must not be made without the minor's permission. If there is no state law in place, the physician has
discretion about parental disclosure.
E-talking early and often with children about sexuality is an effective parental counseling strategy
Although the amount of reported sexual activity among adolescents in the United States has decreased, initiation
of sexual activity during adolescence remains the norm. Children and adolescents need accurate, timely, and
comprehensive information about sexuality to practice safer and healthy sexual behavior. Sexual health includes
both sexual development and reproductive health. Included in the development of healthy sexuality are the
ability to appreciate one's own body; develop and maintain interpersonal relationships; avoid exploitative
relationships; affirm one's own sexual orientation and respect the sexual orientation of others; and express
affection, love, and intimacy in accord with personal values.
Parents have influence on their adolescents' sexual behaviors. Research clearly demonstrates that talking early
and often with children about sexuality does not encourage them to become sexually active. Office-based
education and intervention by pediatricians can provide young people with personalized information, confidential
screening of risk status, and health promotion and counseling. School-based sexuality education programs vary
tremendously. Abstinence-only programs have not shown successful outcomes with regard to delaying the onset
of sexual activity or the use of safer sexual practices. Effective programs tend to provide practical skills, such as
increasing communication and negotiating skills. Programs that discuss human immunodeficiency virus
transmission prevention and contraception in addition to encouraging abstinence have been associated with
delayed initiation of sexual activity and increased use of contraception among sexually active young people.
Programs linking educational curricula with access to reproductive health services and comprehensive
community-based interventions also have demonstrated reductions in pregnancy rates. Office-based
interventions are most likely to contribute to reduced risks and promotion of sexual health if they occur in
conjunction with other educational and support methods in schools, communities, and families.
D-most youth who died as occupants in passenger vehicle crashes were not wearing seatbelts
Motor vehicle crashes are the leading cause of death for teenagers. Seat belt use is the most effective
countermeasure to prevent injuries and fatalities in motor vehicle crashes. The failure of adolescents to use
seatbelts contributes greatly to mortality risk; in 2005, 56.8% of youth 16 to 20 years of age and 54.8% of youth
10 to 15 years of age who died as passenger car occupants were not wearing seatbelts. Fortunately, the
percentage of high school students who reported rarely or never wearing a seatbelt when riding in a car driven by
someone else decreased from 25.9% in 1991 to 10.2% in 2005, as measured by the National Youth Risk
Behavior Survey. Teens who have been drinking are less likely to use seatbelts, and male teens are less likely to
use a seatbelt than female teens.
Pediatricians should address the wearing of seatbelts throughout adolescence and support legislation setting
more rigorous safety belt and child restraint laws that specify primary enforcement and mandatory use by all
occupants. Pediatricians also should advise parents to set a good example of requiring all occupants to use
seatbelts, not drink and drive, and not speed.
The adolescent described in the vignette has a clinical history and physical examination findings compatible with
an imperforate hymen, which probably is the most common obstructive anomaly of the female reproductive tract.
An adolescent patient who has an imperforate hymen may be asymptomatic or may have a history of cyclic
abdominal pain that may occur for several years before the diagnosis is made. A bluish, bulging hymen may be
seen on genital inspection (Item C24), and a distended vagina may be palpated on rectoabdominal or abdominal
examination. If the vagina becomes substantially enlarged with accumulated blood, the patient may experience
back pain, pain with defecation that can result in constipation, nausea and vomiting, or difficulty in urinating.
Bladder outlet obstruction occurs rarely, and although it produces a suprapubic mass, it does not cause cyclic
abdominal pain. Megacolon also is unlikely and does not cause cyclic pain, although colonic irritation may develop
from the pressure produced by the mass. An ovarian cyst typically causes a right- or left-sided (not midline)
mass, and endometriosis is an unlikely cause of a palpable mass, although it can cause cyclic and acyclic pain in
C-monitor menses and reassure the girl
Young women of low gynecologic age (ie, a few years after the onset of menstruation) often have anovulatory
cycles due to immaturity of the hormonal feedback system of the hypothalamic-pituitary-ovarian axis. During the
adolescent years, when ovulation does not occur with every cycle, both frequent and infrequent menstruation can
result. By 2 years after menarche, 55% to 82% of cycles are ovulatory, and by 5 years after menarche, 80% to
90% are ovulatory, resulting in more regular menses. The girl described in the vignette has no signs of androgen
excess or evidence of weight loss that may be associated with an eating disorder but does have scant irregular
periods without cramps or heavy prolonged menses. Because these findings suggest physiologic anovulatory
cycles, no further laboratory studies, such as measurement of follicle-stimulating hormone, luteinizing hormone,
and prolactin, are necessary.
Her continued normal linear growth obviates the need for a bone age measurement. The girl's normal growth
coupled with no evidence of fatigue or skin dryness make thyroid disease unlikely. Pelvic ultrasonography is not
indicated in the absence of signs of androgen excess or other symptoms suggestive of ovarian pathology. The
possibility of pregnancy always should be assessed in the presence of amenorrhea.
A- anorexia nervosa
The diagnosis of an eating disorder is not always straightforward, but the decreased appetite and early satiety,
large weight loss, amenorrhea, and disturbed body image with a low body mass index reported for the girl in the
vignette strongly suggest anorexia nervosa. Participating in a body-conscious sport such as diving, becoming a
vegetarian as a way to restrict the diet, and the presence of constipation also may be associated with this
The lack of diarrhea or hematochezia makes inflammatory bowel disease less likely. Weight loss, doing well in
school, and maintaining a strong exercise program are uncommon in hypothyroidism. Depression can accompany
an eating disorder, but the early satiety, constipation, amenorrhea, and good school performance are unlikely to
occur if depression is the sole diagnosis. A hypothalamic tumor typically presents with neurologic symptoms or
signs of increased intracranial pressure.
A limited laboratory evaluation that includes a complete blood count; metabolic panel; urinalysis; measurement
of free thyroxine, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, and prolactin;
and electrocardiography may be useful in ruling out other possible organic causes of this patient's weight loss and