A 15-year-old boy is brought to the office by his parents due to concerns about his pubertal development. The patient says, "I am the only one of my friends whose voice has not changed and who does not have any body hair. I'm tired of being called 'weak' in gym class." The patient has been fatigued lately, which he attributes to staying up late talking with friends; he otherwise feels well. He has had no recent headaches, vomiting, or vision changes. The patient has a good appetite and eats a well-varied diet. His father is 178 cm (5 ft 10 in) and his mother is 160 cm (5 ft 3 in). Blood pressure is 116/70 mm Hg and pulse is 78/min. Weight and height are at the 15th and 3rd percentiles, respectively, unchanged from his last visit 12 months ago. The patient's height has increased 4.5 cm (1.8 in) since then. Physical examination shows a well-appearing, quiet adolescent with no dysmorphic features. The thyroid is palpable and not enlarged. There is no gynecomastia. Cardiopulmonary examination is normal. The testes are soft and measure 2 mL (Tanner stage I). The phallus is normal in length. There is no axillary or pubic hair. The rest of the physical examination is normal. Bone age x-ray is consistent with age 13. When the family is asked if there are any concerns, the patient answers, "I'm worried that my body will never change and I'll be this way for the rest of my life. I'm stressed about changing in the locker room in front of my soccer teammates because I don't think I look like I should at my age. It makes me want to quit the soccer team." Which of the following statements would be the best response to this patient's concerns?

Question

A 15-year-old boy is brought to the office by his parents due to concerns about his pubertal development.  The patient says, "I am the only one of my friends whose voice has not changed and who does not have any body hair.  I'm tired of being called 'weak' in gym class."  The patient has been fatigued lately, which he attributes to staying up late talking with friends; he otherwise feels well.  He has had no recent headaches, vomiting, or vision changes.  The patient has a good appetite and eats a well-varied diet.  His father is 178 cm (5 ft 10 in) and his mother is 160 cm (5 ft 3 in).  Blood pressure is 116/70 mm Hg and pulse is 78/min.  Weight and height are at the 15th and 3rd percentiles, respectively, unchanged from his last visit 12 months ago.  The patient's height has increased 4.5 cm (1.8 in) since then.  Physical examination shows a well-appearing, quiet adolescent with no dysmorphic features.  The thyroid is palpable and not enlarged.  There is no gynecomastia.  Cardiopulmonary examination is normal.  The testes are soft and measure 2 mL (Tanner stage I).  The phallus is normal in length.  There is no axillary or pubic hair.  The rest of the physical examination is normal.  Bone age x-ray is consistent with age 13. When the family is asked if there are any concerns, the patient answers, "I'm worried that my body will never change and I'll be this way for the rest of my life.  I'm stressed about changing in the locker room in front of my soccer teammates because I don't think I look like I should at my age.  It makes me want to quit the soccer team."  Which of the following statements would be the best response to this patient's concerns?

Quizplus · Accepted Answer

Explanation: If a specific underlying disorder is identified in patients with delayed puberty, treatment should be targeted toward that disorder. The most likely diagnosis in this patient is constitutional delay of puberty, and it is likely that he will begin puberty soon. However, associated psychological issues caused by delayed puberty should be addressed, and a confidential interview with this patient is indicated to screen for possible depression and anxiety. The health care provider should also evaluate for bullying, as the patient mentioned that he is repeatedly called "weak" by his peers. If psychosocial concerns are severe, or if puberty is significantly delayed, short-term testosterone therapy in boys, or estrogen therapy in girls, may be considered. Pharmacotherapy, however, should be used only in boys age >14 or girls age >12. (Choice A) A psychiatric referral may be necessary, but not before a more in-depth assessment of this patient's current mental state. (Choice B) Although regular follow-up to assess for puberty onset and to monitor psychosocial issues is required, it is not appropriate to defer discussion of possibly serious psychological concerns for another 3 months. (Choice D) Recommending a change of sports may provide a temporary solution to this patient's stress about changing in the locker room, but it does not address his concerns about being criticized in gym class, his peer interactions, or his future physical development. (Choice E) It is not appropriate to provide reassurance without first understanding the severity of the patient's concerns. Educational objective: Pubertal delay can cause significant embarrassment and stress for adolescents. When psychosocial concerns are expressed, a confidential interview should be conducted to screen for depression and anxiety. References: Screening for major depressive disorder in children and adolescents: a systemic review for the U.S. Preventive Services Task Force. (http://www.ncbi.nlm.nih.gov/pubmed/26857836)

A 15-Year-Old Boy Is Brought to the Office by His