Pediatric Examination and Board Review (131 page)

On physical examination she is 5'5" tall and weighs 215 lb. The BMI is 40 and the BP is 128/82. She has significant comedonal acne and a small amount of facial hair on sideburns and upper lip. She has moderate acanthosis nigricans on the back of her neck. She has boggy turbinates and enlarged tonsils and breathes mostly through her mouth. The abdominal examination is normal. She has completed her pubertal development (SMR 5).

SELECT THE ONE BEST ANSWER

1.
All of following statements regarding adolescent obesity are correct except

(A) higher birthweight predicts increased risk of overweight in adolescence

(B) genetic factors play a significant role in the development of adolescent obesity

(C) dissatisfaction with body image predicts onset of depression in adolescent girls

(D) obesity in adolescents is usually the result of endocrinopathies

(E) no exception. All of the above are correct

2.
All of the following syndromes are associated with obesity except

(A) Prader-Willi

(B) pseudohypoparathyroidism

(C) Alstrom syndrome

(D) Kallmann syndrome

(E) Klinefelter syndrome

3.
What is the current definition of overweight/obesity in children and adolescents?

(A) BMI greater than the 95th percentile for sex and age

(B) BMI greater than the 85th percentile for age and sex

(C) body weight of 20% greater than the ideal body weight for age and sex

(D) weight for height greater than the 95th percentile

(E) body weight of 30% greater than the ideal body weight

4.
Which of the following conditions are associated with increased adiposity in adolescence?

(A) increased rate of valvular disease

(B) pseudotumor cerebri

(C) gallbladder disease

(D) hypertension

(E) B, C, and D

5.
Regarding the epidemiology of obesity in adolescents, which one of the following statements is not accurate?

(A) the prevalence of obesity among adolescents has tripled during the past 2 decades

(B) adolescent boys and girls have the same prevalence of obesity

(C) about 15.5% of all adolescents aged 12-19 years are categorized as obese

(D) the prevalence of obesity in Latino boys is 12%

(E) the prevalence of obesity in African American girls aged 12-19 years is 26.6%

6.
Among the elements of the clinical history you need to explore now, which would be most relevant?

(A) detailed dietary history

(B) type, intensity, and duration of exercise

(C) television viewing time

(D) medication

(E) all of the above

7.
Among the following, which clinical finding will be the least helpful to distinguish endogenous from exogenous causes of obesity?

(A) height for age

(B) linear growth rate

(C) intertrigo

(D) pigmented striae

(E) myxedema

8.
In this patient, any of the following conditions could explain her menstrual delay except

(A) thyroid dysfunction

(B) pregnancy

(C) functional adrenal hyperandrogenism

(D) polycystic ovarian syndrome (functional ovarian hyperandrogenism)

(E) androgen insensitivity

9.
All of the following tests should be ordered at this time except

(A) fasting glucose and lipid profile

(B) estradiol and progesterone

(C) FSH/LH

(D) pregnancy test

(E) dehydroepiandrosterone sulfate (DHEA-S)

10.
The laboratory results indicate that her LH-to-FSH ratio is 5:1. Her testosterone level is 75; DHEA-S is 215. All other hormonal tests were within the normal range. A lipid profile showed a total cholesterol of 190 mg/dL and an LDL of 125 mg/dL. All of the following therapeutic interventions may be indicated at this time except

(A) weight management

(B) combined oral contraceptives

(C) topical acne medication

(D) insulin sensitizers

(E) statins

11.
Regarding the treatment of her moderate comedonal acne, all of the following are true except

(A) a single daily application of 5% benzoyl peroxide will be effective in most cases of mild comedonal and inflammatory acne

(B) 13-
cis
-Retinoic acid may be associated with severe teratogenic effects

(C) oral contraceptives containing low-androgenic progestins are helpful in the management of acne in adolescent girls

(D) depomedroxyprogesterone acetate is effective in controlling mixed comedonal-inflammatory acne

(E) some oral antibiotics used for the treatment of acne may lead to photosensitivity reactions

12.
All of the following could explain this patient’s increased tiredness and deteriorating school performance except

(A) depression

(B) obstructive sleep apnea

(C) hypothyroidism

(D) pregnancy

(E) hyperandrogenism

13.
Depression should be considered in the differential diagnosis of this adolescent with a history of excessive tiredness, social isolation, and declining school performance. Regarding the epidemiology of depression in adolescents, all of the following are correct except

(A) the incidence of major depressive disorder (MDD) increases from 2% in children to 4-8% in adolescents

(B) the cumulative incidence of MDD is 15-20%

(C) in children there is no gender difference in risk

(D) depression is more common in adolescent boys than in girls

(E) bipolar disorder develops in 20-40% of children and adolescents with MDD

14.
Depression in children and adolescents is associated with increased risk of suicidal behaviors. Which of the following statements about the epidemiology of suicidal ideation and attempts during adolescence is/are true?

(A) suicide is the third leading cause of death among 15- to 24-year-olds

(B) the rate of completed suicides in adolescents is higher for girls than for boys

(C) rates of suicidal attempts are higher for girls than for boys

(D) A and C

(E) all of the above

15.
All of the following are common symptoms suggestive of MDD in adolescents except

(A) irritable mood

(B) feeling of worthlessness

(C) psychomotor agitation or retardation

(D) difficulty concentrating

(E) hallucinations

16.
Which among the following is a predisposing factor for depression in adolescence?

(A) family history of depression in first-degree relatives

(B) prior depressive illness

(C) chronic illness

(D) family dysfunction

(E) all of the above

17.
What circumstances would indicate urgent psychiatric referral for an adolescent with depression?

(A) history of suicidal attempt or present suicidal ideation

(B) psychosis

(C) coexisting substance abuse

(D) family unable to monitor teen’s safety

(E) all of the above

ANSWERS

1.
(D)
It has been shown that higher birthweight predicts increased risk of overweight in adolescence and that having been born to a mother with gestational diabetes is associated with increased likelihood of being overweight in adolescence. However, the effect of gestational diabetes on an offspring’s obesity is controversial. Adjustment for a mother’s own BMI decreases the likelihood of a causal role for abnormal maternal-fetal glucose metabolism as a cause of obesity in the offspring. Dissatisfaction with body image is a common occurrence during adolescence, particularly among girls. It usually leads to unhealthy weight control practices and eating patterns and in some studies was found to predict the onset of depression. In most instances, obesity is a chronic multifactorial disease. Only 3% of obese adolescents have underlying endocrinopathies such as hypothyroidism, Cushing syndrome, or hypothalamic/pituitary diseases and pseudohypoparathyroidism. An additional 2% of obese adolescents have rare genetic syndromes associated with obesity. Obesity associated with mental retardation, short stature, cryptorchidism or hypogonadism, dysmorphism, and ocular or auditory defects should suggest a genetic origin. Prader-Willi syndrome is the most frequent of the genetic disorders associated with obesity. The remaining 95% of obesity in adolescents results from a combination of genetic and environmental factors not fully elucidated. Genetic factors play a significant role in the development of obesity and are known to explain 30-50% of its variability. Studies show that if one parent is obese, the risk of obesity for the offspring is 30%; if both parents are obese, the risk increases to 70%. Although some of these findings may be explained by environmental factors, there is a high correlation between the BMI of identical twins, even when reared in different households. Also, a strong correlation has been shown between the BMIs of adoptees and their biological parents, whereas none exists between those of adoptees and their adoptive parents.

2.
(E)
Alstrom syndrome is a rare disease with autosomal recessive inheritance. Retinal degeneration, truncal obesity, diabetes mellitus, and sensorineural hearing loss are characteristic features of this condition. Further variable symptoms include chronic hepatitis, asthma, and an impaired glucose tolerance test. Pseudohypoparathyroidism (PHP) is associated with biochemical hypoparathyroidism (eg, hypocalcemia and hyperphosphatemia) because of parathyroid hormone (PTH) resistance rather than with PTH deficiency. In this condition, target renal cells are unresponsive to PTH, leading to increased reabsorption of phosphate. PHP type 1 is the most common form and is associated with a combination of skeletal and developmental features known as Albright hereditary osteodystrophy. Clinical characteristics of this syndrome include short stature, obesity, round facies, short neck, brachydactyly, and mental retardation. Prader-Willi syndrome is characterized by early onset of obesity with hyperphagia, infantile hypotonia, hypogonadism, cryptorchidism, and mental retardation. Short stature, small hands and feet, strabismus, and increased incidence of diabetes mellitus are common findings in this condition. The incidence of the syndrome is 1:16,000. It results from deletions of a segment of the paternal chromosome 15. Klinefelter syndrome occurs in men who have an extra X chromosome leading to a 47,XXY karyotype. Its clinical features include small, firm testes, azoospermia, variable degrees of eunuchoidism, gynecomastia, mental abnormalities, and hypergonadotropic hypogonadism. A slim, tall body habitus is characteristic in this condition.