Mehl./UW Bullet cases: reproductive +NBME 10 1Q, 2Q Flashcards
Mehl. 7F + often really bad period pain + needs to miss class sometimes because it’s so bad + physical exam is normal = Dx?
primary dysmenorrhea = prostaglandin hypersecretion (PGF2alpha)= give NSAIDs.
Mehl. 14F has massive unilateral breast mass + mom is freaking out bc her sister died of breast cancer.
Dx?
Next step?
Follow-up in six months
virginal breast hypertrophy is normal during puberty.
Mehl.
15M has unilateral mass behind his nipple +/- tenderness of it. NEXT STEP?
answer = reassurance
physiologic gynecomastia of puberty (higher androgens are aromatized to estrogens).
Mehl. 14F + never had menstrual period + 6-month Hx of intermittent pelvic pain + BP normal + bluish bulge in upper vagina; Dx?
hematocolpos
blood collection in the vaginal canal, but not backed up to the uterus like hematometra
Mehl. 14F + never had menstrual period + 6-month Hx of intermittent pelvic pain + BP normal + bluish bulge in upper vagina; Tx?
Tx = cruciate incision of the hymen.
Mehl. 13F has never had a period + has suprapubic mass + nausea + vomiting; next best step in Mx?
do beta-hCG
she’s pregnant; this is HY. Correct, girls can get pregnant without ever having had a period -> must rule out
Mehl. 17F + 2-day Hx of right-sided pelvic pain + vitals WNL + beta-hCG negative + USS shows 3.5cm simple cyst; next best step in Mx?
observation (in peds nbme)
(should be noted OCPs is not an answer here; on one of the Obgyn NBME forms, observation is wrong; correct answer is “oral contraceptive pills and re-ultrasound in 6 weeks) -> therefore, choose the latter over observation if both listed (and no contraindications to OCPs); if only observation is listed, go with that.
Mehl. 14F + never had menstrual period + one-wk Hx of constant, severe pelvic pain + 6-month Hx of intermittent pelvic pain + BP of 90/50 + bluish bulge in upper vagina; Dx?
hematometra -> imperforate hymen with blood collection in the uterus -> vagal response causes low BP
Mehl. 14F + never had menstrual period + one-wk Hx of constant, severe pelvic pain + 6-month Hx of intermittent pelvic pain + BP of 90/50 + bluish bulge in upper vagina; Tx?
cruciate incision of the hymen.
NBME 10. 1Q.
An otherwise healthy 11-year-old girl is brought to the physician by her mother because of a 3-month
history of right breast tenderness. She is at the 50th percentile for height and weight. Breast development is Tanner stage 1 on the left and Tanner stage 2 on the right. The left breast is flat and nontender, and the right breast is slightly raised, enlarged, and tender; there is no nipple discharge. There is no axillary or pubic hair. Pelvic examination shows normal-appearing external genitalia. Which of the following is the most appropriate next step in management?
REASURANCE
NBME 10. 1Q.
Puberty in girls typically follows a predictable course of: ?
Thelarche -> pubarche (pubic hair) -> a growth spurt -> menarche.
NBME 10. 2Q.
A 13-year-old girl is brought to the physician by her mother because of a 10-day history of vaginal spotting. This is her first episode of vaginal bleeding. She has never been sexually active. She has mild asthma treated with an inhaled β-adrenergic agonist as needed. She is at the 75th percentile for height and 80th percentile for weight and BMI. Breast and pubic hair development are Tanner stage 4. The external genitalia are normal. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?
Follow-up examination in 6 months
The patient should be examined again in 6 months to ensure that her menstrual cycles are becoming more regular and to begin establishing a healthy physician-patient relationship with an adolescent patient.
UW.
A 13-year-old boy is brought to the office for a well-child visit. The patient is concerned that he is the shortest boy in his class. He is in 7th grade and participates in soccer and baseball. The patient is a picky eater whose diet consists primarily of cereal, fruit, pasta, and pizza. He has seasonal allergies and takes cetirizine and a daily multivitamin. His mother is 165 cm (65 in), and his father is 178 cm (70 in). Height is 140 cm (55 in) and weight is 39 kg (86 lb). The patient’s sexual maturity rating (Tanner stage) is 1. The remainder of the examination is unremarkable. A radiograph of the left wrist reveals a bone age of 10 years. His growth chart is shown below. (growth 2 percentiles). Dx?
Constitutional growth delay
UW.
6 y/o girl + breast and pubic hair development. Her parents noticed that she started developing breasts several months ago, and she recently started growing coarse axillary and pubic hair. The patient has had no changes in her behavior or school performance. She has no headaches, visual changes, vomiting, or vaginal bleeding. The patient has no chronic medical conditions and no previous surgery. She takes no daily medications and has no known allergies. BMI is at the 50th percentile for age. Physical examination reveals axillary hair; pubic hair is Tanner stage 3, and breasts are Tanner stage 3. The remainder of the examination is unremarkable. Bone age is consistent with age 8. Basal LH level is high. Which of the following is the best next step in evaluation of this patient?
MRI OF THE BRAIN
High basal LH - central precocious puberty (idiopathic, CNS tumor)
UW.
A 5-year-old girl is brought to the office for evaluation of pubic hair. Her mother first noticed dark hair in the genital area while helping her daughter bathe several weeks ago. The patient has also developed axillary hair and adult-type body odor over the last 2 weeks. She has no known medical conditions and takes no daily medications. She started kindergarten 3 months ago. The girl’s mother underwent menarche at age 12. Weight is at the 75th percentile, height is at the 90th percentile, and BMI is at the 25th percentile. Fundoscopic examination and pupillary reaction are normal bilaterally. Cardiopulmonary examination is normal. The abdomen is soft and nontender; no masses are palpable. Breasts are prepubertal. Sparse, dark, coarse hair is noted in both axillae and over the mons pubis and labia majora. There is no clitoromegaly. Mild comedonal acne is present on the forehead, nose, and chin. Which of the following is the best next step in evaluation of this patient?
BONE AGE EVALUATION
UW. A 6-year-old girl is brought to the office by her parents after they noticed the development of axillary and pubic hair. She has also had a significant growth spurt over the past year. There has been no change in her behavior or school performance. The patient has no headaches, vomiting, or visual disturbances. She has no chronic medical conditions and takes no medications. Family history is unremarkable. BMI is at the 97th percentile for age and sex. The abdomen is soft, nontender, and nondistended. Axillary hair is present and pubic hair is Tanner stage 3; external genitalia are normal. The breasts are Tanner stage 3. Neurologic examination is normal. Bone age is advanced. Serum FSH and LH levels are elevated. Which of the following is the most likely etiology of this patient’s symptoms?
EARLY ACTIVATION OF THE HYPOTHALAMIC-PITUITARY-OVARIAN AXIS
Central precocious puberty (CPP) results from early activation of the hypothalamic-pituitary-gonadal (HPG) axis.
UW. 7-year-old boy is brought to the office for evaluation of severe facial acne that has developed over the past few months. His mother treated it with topical benzoyl peroxide and a salicylic acid face wash with no improvement. She also reports a significant increase in her son’s height and says he is now much taller than his fraternal twin brother. The patient is otherwise healthy with no chronic medical conditions. He takes no medications. Height is at the 98th percentile for age and sex, and weight is at the 85th percentile. Neurologic examination is normal. Skin examination is notable for severe cystic acne involving the face and shoulders. Coarse pubic and axillary hair are noted. Testicular volume is consistent with prepubertal staging. Bone age is 2 standard deviations higher than chronologic age. Additional evaluation reveals that baseline LH level is low and does not increase after administration of a GnRH agonist. Which of the following is the most likely diagnosis in this patient?
nonclasic congenital adrenal hyperplasia (which belong to peripheral precocious puberty type)
UW. A 5-year-old girl is brought to the office for evaluation of pubic hair. Her mother noticed dark hair under the girl’s arms and in her pubic area several days ago when helping her bathe. The patient has no headaches, visual changes, abdominal pain, or behavioral changes. She is obese and currently on a diet and exercise program. Several maternal relatives have type 2 diabetes mellitus. The patient’s height has been tracking along the 50th percentile and weight at the 97th percentile. Physical examination shows a cooperative girl with mild facial acne. No breast buds are palpable. She has dark, coarse hair across the pubis and under both axillae. External genitalia appear normal. Bone age is normal. Which of the following is the most likely diagnosis for this patient?
PREMATURE ADRENARCHE
