Pediatric Examination and Board Review (116 page)

(B) never have a parent in attendance during the physical examination

(C) always have a chaperone in the examining room when examining a teenager

(D) have a parent in attendance during the physical examination according to patient’s wishes

(E) tailor your decision according to patient’s age, level of cognitive and emotional maturity, and personal wishes

2.
Which of the following statements regarding confidential care of adolescents is always true?

(A) confidential care should only be provided to emancipated minors

(B) laws regarding minors’ access to confidential health care are legislated by individual states

(C) all patients younger than 18 years need parental consent to receive mental health services, including diagnosis and treatment of substance abuse

(D) minors cannot obtain confidential reproductive services if they are younger than 15 years

(E) minors cannot consent to care for sexually transmitted diseases/human immunodeficiency virus (STD/HIV)-related issues

3.
Which of the following topics would be appropriate to explore with this 14-year-old girl in her first visit?

(A) school performance

(B) history of physical and/or sexual abuse

(C) use of alcohol, cigarettes, marijuana, and/or inhalants

(D) dating and need for birth control

(E) all of the above

4.
Which is the most common cause of death among boys aged 15-19 years?

(A) malignancies

(B) suicide

(C) poisoning

(D) motor vehicle accidents (MVAs)

(E) homicide

5.
Regarding mortality rates in teenagers, which of the following is not true?

(A) the rate of unintentional injury in 15- to 19-year-olds is more than twice as high in males as in females

(B) among white youth, suicide rates in 15-19 yearolds are more than 4 times higher in males than in females

(C) homicide is the leading cause of death among African American males, age 15-24 years

(D) among African American youth age 15-19 years, suicide rates are higher in females than in males

(E) for both males and for females, unintentional injury is responsible for about 50% of deaths among 15- to 19-year-olds

6.
What are the main elements you will need to assess in this patient’s physical examination?

(A) height, weight, blood pressure (BP), and heart rate

(B) sexual maturity rating

(C) thyroid examination

(D) spine examination

(E) all of the above

7.
According to the American Medical Association Guidelines for Adolescent Preventive Services (GAPS), how often should an adolescent have a comprehensive examination?

(A) once a year

(B) every 6 months during the growth spurt

(C) one time during early, middle, and late adolescence

(D) only when it is requested

(E) every other year

8.
Under what circumstances is a pelvic examination recommended in an adolescent girl?

(A) in all cases of primary dysmenorrhea

(B) newly sexually active at age 16 years

(C) history of sexual intercourse and routinely after age 21 years

(D) before prescribing contraceptives

(E) A, C, and D

9.
During her private interview the patient denies sexual activity. Her physical examination is normal. Her last menstrual period was 4 months ago. What would be the appropriate course of action in this case?

(A) no testing is needed at this time. Reassure her that a period will come soon because she has had irregular periods all along and has only been menstruating for a year

(B) have your nurse run a pregnancy test in a urine sample collected earlier in the visit to determine whether the patient may be withholding information

(C) advise the patient that it is your policy to exclude pregnancy through urine testing in all patients of reproductive age whose menses are late

(D) ask her mother privately for permission to perform a pregnancy test

(E) have the patient come back for blood testing if she has not had a period in another 3 months

10.
Which of the following laboratory screening tests would be routinely recommended in an early adolescence visit?

(A) hemoglobin and hematocrit

(B) cholesterol

(C) HIV testing

(D) urinalysis

(E) none of the above

11.
If she has never had chickenpox or the varicella vaccine, what statement would apply?

(A) she should receive 1 dose of varicella vaccine at the present visit followed by a second dose within 4-8 weeks

(B) she will just need 1 dose of varicella vaccine

(C) there is no need to immunize her at this time because she most likely had a subclinical case of varicella during childhood; no testing is required

(D) varicella immunization should be given followed by a check of varicella titers 2 months after vaccination to document immunity

(E) varicella immunization should be given unless the patient has household members who are immunocompromised

12.
She returns 48 hours later for a reading of her purified protein derivative (PPD) that indicates 10 mm of redness and 8 mm of induration. At this point you would

(A) obtain a chest radiograph and start isoniazid (INH)

(B) obtain further exposure history

(C) notify the local board of health

(D) determine whether the patient has received the Bacille Calmette-Guérin (BCG) vaccine abroad

(E) repeat the PPD in 1 month

13.
Which of the following statements regarding tuberculosis testing is not true?

(A) incarcerated teens should have annual PPD screening

(B) HIV-infected teens should be tested for tuberculosis yearly

(C) tuberculosis skin testing should be performed before initiation of immunosuppressive therapy, including prolonged steroid administration

(D) previous BCG administration is a contraindication to tuberculosis skin testing

(E) about 10% of immunocompetent children with culture-documented tuberculosis may be initially PPD negative

14.
How would you counsel this patient regarding pregnancy and STD prevention?

(A) there is no need to address this issue at the present time because she is only 14 and not sexually active

(B) refer her to a gynecologist for such discussions

(C) this discussion should better be left to her parents’ discretion

(D) ask her if she has any questions or concerns regarding sexuality; explain that you will be available to her in the future for further discussion of this issue, if needed

(E) A and C

15.
Both the patient and her mother express some concerns about her facial acne. Of the following, which is not involved in the development of acne vulgaris?

(A) retention hyperkeratosis

(B) increased sebum production

(C) overgrowth of
Propionibacterium acnes
(D) inflammation

(E) dietary factors

16.
What medication would you use in the initial management of this patient’s mild comedonal acne?

(A) azelaic acid cream 20% twice a day

(B) benzoyl peroxide gel 5% once daily or topical tretinoin 0.025% once daily

(C) oral macrolide antibiotic

(D) topical antibiotics twice daily

(E) oral tetracycline antibiotic

17.
How long after starting the therapy you selected in question 16 would you like to see this patient again?

(A) 2 years

(B) 1 month

(C) 6 months

(D) 3 months

(E) 2 weeks

ANSWERS

1.
(E)
When considering this question it is important to bear in mind the adolescent’s age, developmental stage, and level of cognitive and emotional maturity. The presence of a parent during the physical examination is generally reassuring for younger teens and for those with developmental delays. Most middle or older adolescents prefer to have parents wait outside the room during the examination. Under such circumstances, the decision is best deferred to the patient. When performing a pelvic examination in an adolescent, it is recommended to have a chaperone in the room.

2.
(B)
Minors’ access to confidential health care differs state by state, so the best policy is to know your state’s laws in this area. In general, state laws require parental consent for the provision of medical care to minors. However, there are legal provisions that authorize minors to consent to health care, either because of the status of the minor or the type of services requested. All states have specific provisions that allow minors to consent to certain services, including pregnancy-related care, diagnosis and treatment of STDs, HIV/AIDS, examination and treatment of sexual assault, as well as diagnosis and treatment of mental health issues, including drug and alcohol problems.

3.
(E)
One of the most important goals of the adolescent visit is to assess the functional status of teens regarding their families, peer relationships, and school/work performance. A thorough clinical history in an adolescent should include the presenting complaint and its progression, past medical history, family history, and review of systems. In addition, it is essential to obtain detailed information about family composition and dynamics, major recent life changes, and specific health concerns. The provider should also address immunizations, nutrition, including diet and eating patterns, body image, school performance, relations with friends and family, vocational goals, and use of tobacco, alcohol, marijuana, inhalants, and other drugs. A developmentally appropriate, detailed sexual history should be obtained. It is also important to screen for depression, suicidal ideation, and any history of physical, emotional, and/or sexual abuse. Injury risks should be assessed with special attention to seat-belt use, helmet use, drunken driving, and use of weapons.

4.
(D)
In 2006, the National Center for Health Statistics reported that the leading cause of death in older teenagers is unintentional injuries, and of those, the most common was MVAs (40%). The next 4 causes of death, in order of likelihood, are homicide, suicide, malignant neoplasm, and heart disease. These data underscore the need for appropriate screening and anticipatory guidance for adolescents, particularly regarding motor vehicle safety, injury prevention, exposure to violence, alcohol and other substance use, drunken driving, and mood disorders.