Pediatric Examination and Board Review (70 page)

18.
(C)
2.5 cm. A phallus smaller that 2.5 cm in a term newborn would be considered a micropenis. This measurement should be adjusted for gestational age. Micropenis can be caused by decreased testosterone exposure in the second and third trimester, which can be caused by LH deficiency or partial androgen insensitivity. Growth hormone deficiency can also cause micropenis. These infants should be screened for the possibility of panhypopituitarism.

19.
(A)
Clitoris. In females the genital tubercle forms the clitoris; in males it forms the phallus.

S
UGGESTED
R
EADING

Antal Z, Ping Z. Congenital adrenal hyperplasia: diagnosis, evaluation and management.
Pediatr Rev.
2009;30:e49-e57.

Lee PA, Houk CP, Ahmed SF, Hughes IA. Consensus statement on management of intersex disorders.
Pediatrics.
2006;188:e488-500.

MacGillivray MH, Mazur T. Management of infants born with ambiguous genitalia. In: Radovick S, MacGillivray MH, eds.
Pediatric Endocrinology
,
A Practical Clinical Guide
. Totowa, NJ: Humana Press; 2003:429-449.

Witchell SF, Lee PA. Ambiguous genitalia. In: Sperling MA, ed.
Pediatric Endocrinology.
3rd ed. Philadelphia, PA: WB Saunders; 2008:127-164.

CASE 44: A 13-YEAR-OLD GIRL WITH RAPID WEIGHT GAIN

A 13-year-old girl comes into your clinic with the complaint of rapid weight gain over the last 2 years. She claims that she does not eat more than others in the family, and she has gym class 3 times weekly. Her typical day consists of going to school, doing homework, and then watching television or playing video games for several hours daily. Other family members are also overweight. On physical examination, she is overweight but in no apparent distress.

SELECT THE ONE BEST ANSWER

1.
Which formula would you use to calculate BMI?

(A) kg/m

(B) kg/m
²
(C) kg
²
/m

(D) kg/cm

(E) kg/cm
²

2.
Which BMI defines an overweight (but not obese) child?

(A) between 55th and 65th percentile

(B) between 65th and 75th percentile

(C) between 75th and 85th percentile

(D) between 85th and 95th percentile

(E) higher than 95th percentile

3.
BMI is not a good estimate of adiposity in which of the following situations?

(A) body builder

(B) endogenous obesity

(C) short stature

(D) exogenous obesity

(E) tall stature

4.
Which of the following is not an adequate method of measuring the degree of obesity?

(A) dual-energy x-ray absorptiometry (DEXA) scan

(B) weight greater than the 90th percentile of normal

(C) skinfold thickness

(D) bioelectrical impedance analysis

(E) waist circumference

5.
You calculate the patient’s BMI as greater than the 95th percentile for age. On further questioning, she has always been “chubby” with a very large appetite except when she was an infant when she had feeding difficulty and hypotonia. What would be the likely diagnosis?

(A) Cushing syndrome

(B) exogenous obesity

(C) Prader-Willi syndrome

(D) Laurence-Moon-Bardet-Biedl syndrome

(E) hypothyroidism

6.
Which of the following features would you not expect to find in the child described in question 5?

(A) tall stature

(B) developmental delay

(C) hyperphagia

(D) relatively small hands and feet

(E) almond-shaped eyes

7.
Her mother is convinced that her daughter has hypothyroidism as a cause of her obesity. Which of the following would mitigate against this diagnosis?

(A) normal growth velocity

(B) delayed bone maturation

(C) fatigue

(D) family history

(E) coarse hair

8.
On physical examination, your patient is short and has purple striae on the abdomen. Which of the following would you be most concerned about?

(A) hypothyroidism

(B) genetic obesity syndrome

(C) exogenous obesity

(D) Cushing syndrome

(E) Prader-Willi syndrome

9.
On physical examination, the patient’s BMI is greater than the 95th percentile and you notice that she has darkening and thickening of the skin on the posterior neck and in the axilla. Which of the following would you be most concerned about?

(A) Addison disease

(B) hypothyroidism

(C) prolactinoma

(D) Cushing syndrome

(E) hyperinsulinism

10.
Your patient reports that she has had several vaginal yeast infections recently. Which of the following tests is most important in your workup?

(A) CBC

(B) cortisol

(C) immunoglobulin levels

(D) fasting blood sugar

(E) urine culture

11.
Which of the following is not a feature of the metabolic syndrome?

(A) hypertension

(B) insulin resistance

(C) dyslipidemia

(D) type 1 diabetes mellitus

(E) hypercoagulability

12.
On physical examination, your patient is of normal stature, but you notice hirsutism and moderate inflammatory acne. What part of the history will be important to narrow your differential diagnosis?

(A) nutrition history

(B) menstrual history

(C) developmental history

(D) school performance

(E) growth history

13.
Which of the following is the best test to diagnose the condition in question 12?

(A) fasting insulin level

(B) hemoglobin A1c

(C) free testosterone

(D) FSH

(E) estradiol

14.
Excess body fat in which area of the body has been associated more strongly with health risks than fat stored elsewhere?

(A) neck

(B) chest

(C) abdomen

(D) buttocks

(E) thighs

15.
How likely is a 13-year-old child with a BMI at the 90th percentile (who has an overweight parent) to remain overweight as an adult?

(A) less than 30%

(B) 40%

(C) 50%

(D) 60%

(E) more than 70%

16.
Which of the following is not a comorbid condition associated with exogenous childhood obesity?

(A) short stature

(B) sleep apnea

(C) type 2 diabetes mellitus

(D) slipped capital femoral epiphysis

(E) pseudotumor cerebri

17.
Which of the following is true regarding the prevalence of obesity in children?

(A) it has been stable in the last 10 years

(B) it has been stable in the last 5 years

(C) it has been increasing in all children aged 2-19 years in the last 10 years

(D) it has been increasing only in children aged 12-19 years in the last 5 years

(E) There is no difference in prevalence among various racial/ethnic groups

18.
Which of the following statements regarding obesity is true?

(A) genes have a more important role than environment in the obesity epidemic