Adolescent QOD

1. Adolescent QOD (trust me, they have more than one question a day)

2. 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.

3. Of the following, the MOST appropriate next step is • a course of an oral antibiotic • pelvic ultrasonography • reassurance of both the mother and child • recommendation that the child douche regularly • vaginoscopy

4. 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.

5. 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

6. 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.

7. Of the following, the MOST likely cause of this girl's osteopenia is • decreased overall caloric intake • increased caffeine and soda intake • lack of weightbearing exercise • primary ovarian insufficiency • rickets from vitamin D deficiency

8. 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 medication-induced, 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

9. 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.

10. Of the following, the MOST appropriate response is that • 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

11. 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

12. 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.

13. Of the following, evidence suggests that the MOST likely outcome of such programs is that • 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

14. 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

15. 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.

16. Of the following, the MOST appropriate visit schedule for testing for this girl is • 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

17. 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 ofC 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

18. 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.

19. Of the following, the MOST likely fatal adverse effect of combined oral contraceptives for this girl is due to the development of • breast cancer • cholestatic jaundice • diabetes • hypertension • venous thrombosis

20. 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.

21. 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

22. 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.

23. Of the following, the MOST likely explanation for this boy's symptoms is abuse of • alcohol • cocaine • dextromethorphan • LSD • marijuana

24. 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

25. 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.

26. Of the following, the medical literature indicates that MOST youth • 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

27. 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.

28. 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

29. 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.

30. Of the following, the MOST likely cause of this boy's findings is • anticholinergic intoxication • depression with psychotic features • early-onset schizophrenia • marijuana use • phencyclidine (PCP) use

31. 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.

32. 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

33. 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.

34. Of the following, the BEST advice to give this father is to • 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

35. 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.

36. 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.

37. Of the following, the MOST appropriate next step is • follow-up evaluations every 6 months for 1 year • hand and wrist radiograph for bone age • luteinizing hormone and follicle-stimulating hormone assessment • pelvic ultrasonography • thyroid function testing

38. 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.

39. 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.

40. Of the following, the factor MOST likely to be associated with a poor prognosis for this girl is • absence of binging and purging • comorbid psychiatric illness • early onset of illness (<14 years) • good family support • short duration of illness

41. 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.

42. 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.

43. Of the following, the MOST appropriate interpretation of the evaluation is that • 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

44. 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.

45. 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.

46. Of the following, the MOST appropriate next step is to • obtain a vaginal swab for a wet mount evaluation only • perform a speculum & bimanual examination • perform an external genital inspection only • provide an antifungal prescription • send a urine specimen for culture only

47. Question 14 Answer B 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 Chlamydiatrachomatis 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.

48. 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.

49. Of the following, the MOST appropriate treatment for this girl is • 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

50. Question 15 Answer C 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.