A 16-year-old girl is brought to the physician by her parents. Her mother is concerned because the girl has lost 10 pounds in the last 3 months. She constantly feels weak and tired. She is doing well in high school. The patient says that she eats well, although her appetite has decreased. Her last menstrual period was 3 months ago. She is not sexually active. She does not use tobacco, alcohol, or illicit drugs. Physical examination shows a young, thin girl with multiple brown freckles. The patient has a decreased amount of axillary and pubic hair for her age. Patchy brown spots are seen on her lips and buccal mucosa. Mild generalized muscular tenderness is present. She appears well-groomed, alert, and communicative and does not appear to be especially anxious. Her parents, on the other hand, are worried about her condition and want to know her diagnosis.
Which of the following is the most appropriate statement regarding this patient's case?

Question

A 16-year-old girl is brought to the physician by her parents.  Her mother is concerned because the girl has lost 10 pounds in the last 3 months.  She constantly feels weak and tired.  She is doing well in high school.  The patient says that she eats well, although her appetite has decreased.  Her last menstrual period was 3 months ago.  She is not sexually active.  She does not use tobacco, alcohol, or illicit drugs.  Physical examination shows a young, thin girl with multiple brown freckles.  The patient has a decreased amount of axillary and pubic hair for her age.  Patchy brown spots are seen on her lips and buccal mucosa.  Mild generalized muscular tenderness is present.  She appears well-groomed, alert, and communicative and does not appear to be especially anxious.  Her parents, on the other hand, are worried about her condition and want to know her diagnosis.
Which of the following is the most appropriate statement regarding this patient's case?

Quizplus · Accepted Answer

Explanation: This patient's history and physical examination are nondiagnostic but do show a number of features that could indicate a significant medical condition requiring additional evaluation. She has lost weight and has developed amenorrhea, myalgias, fatigue, and weakness. Her axillary and pubic hair pattern suggests the possibility of a developmental delay, sex hormone deficit, or other endocrine disorder. In cases such as this with a broad differential diagnosis, it is not always necessary to detail every possible condition. However, it is important for the clinician to explain his or her concerns so that the patient and family members understand the rationale for the tests being ordered. Following the initial encounter, the patient should understand what tests are to be done and the plan for communicating the results. (Choices A and B) Depression and eating disorders can cause decreased appetite and weight loss, especially in young women. However, there is no other information in the history, such as changes in behavior or cognition (eg, isolation, feelings of hopelessness, negative thoughts), functional impairment, or psychomotor retardation, to suggest a primary affective disorder. The clinician could make initial inquiries into the possibility of a concurrent psychiatric disorder, but the explanation to the patient at this initial stage should focus primarily on the planned diagnostic evaluation. (Choice C) When evaluating teenage patients, most clinicians prefer to include them in all discussions with the family. Absent any unusual cultural or family customs, it is unlikely that the parents would provide information separately from the patient that they would not disclose in her presence. Although physicians often request private talks with adolescent patients to gather important information that they do not want to disclose to their parents (eg, pregnancy, sexual relationships, HIV exposure, illicit drug abuse, alcohol use), this patient's history and physical examination findings suggest an undiagnosed metabolic disorder. (Choice D) This patient has clear indicators of an undiagnosed medical condition. Although clinicians must be careful not to express undue alarm, it is never appropriate to give false reassurance to patients or families before the necessary evaluations have been completed. Educational objective: When a patient's history or physical findings do not confirm a specific diagnosis, the physician should state in general terms what the most likely possibilities are and what testing is necessary. When giving an opinion about a patient's condition, the physician must be careful to avoid giving false reassurance or a premature diagnosis (especially an unconfirmed psychiatric diagnosis) that cannot be supported by the available clinical evidence. References: Interviewing adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/9400576)

A 16-Year-Old Girl Is Brought to the Physician by Her