NMS Q&A Family Medicine

Care and Prevention, Ages 13 to 20 Years 269Examination Answers1. The answer is E. Psalter V fracture of the growing longbone refers to crush injury of the physis or growth plate,itself. Surgery is usually indicated. The Psalter classificationis invoked frequently by radiologists and orthopedicsurgeons. Psalter I involves simply the growth plate orphysis without deformity and can easily be missed onx-ray as this cartilaginous growth area is radiolucent, ofcourse. Psalter II fractures extend from the physis into themetaphysis (the widened end of the adjacent shaft of longbone). Psalter III breaks the other way, extending from thephysis into and through the epiphysis, or boney cap interposedbetween the growth plate, into the joint spacebeyond. Psalter IV involves a combination of Psalters IIand III, that is, from the physis into both the metaphysisand epiphysis. This fracture may require internal fixationas well.2. The answer is D, Osteosarcoma. This is a case of pathologicfracture in a young person. Osteosarcoma is themost common malignancy of bone in adolescents andyoung adults, comprising 60% of bone cancers in thatgroup. Typically, there has been pain and dysfunction inthe affected site. Ewing tumor is the second most common.Ewing’s sarcoma is in distant second place for cancersin this group, often presents with metastases in thelungs or spine. Fibrous dysplasia and enchondroma arebenign conditions of preadolescent children that can leadto pathologic fractures but usually are asymptomaticbeforehand. They have similar appearances on plain x-rayand can be treated by surgical curettage and bone graftingon occasion. Osteomyelitis is noted for pain but notpathologic fractures. Hematogenous osteomyelitis occursmore often in younger children, and exogenous infectionoccurs by contiguous spread from a surface wound.3. The answer is A. In AN elevated FSH does not occur.As opposed to the case of ovarian failure, the cause of secondaryamenorrhea (cessation after normal menarcheand menstrual periods for an extended period) in AN ispituitary, and FSH is lower than normal. Other criteria fordiagnosis of AN are refusal to allow weight to go abovebarely minimal for height; unreasonable and intense fearof obesity; distorted body image and the afore mentionedsecondary.4. The answer is D. Decreased sense of smell may indicatepituitary pathology. For growth delay of any cause,height attainment is defined as inadequate if growth rateis less than 3.7 cm (1.5 in.)/year or bone age is more than1.5 years behind expected for age. If this occurs, it cannotbe attributed to other than constitutional growth delay orfamilial short stature if the review of systems is normal;nutrition is appropriate; upper to lower body segmentratio is appropriate (longer lower segment does not occurin growth insufficiency); sella tursica is of normal size byscanning techniques; and the following laboratory studiesare within normal limits: count (CBC), erythrocyte sedimentationrate (ESR), urinalysis (UA), tetraiodothyronine(T4), lactic dehydrogenase (LH), FSH. Elevated alkalinephosphatase is normal for adolescent growth at any rate.5. The answer is C. White female individuals who arebetween 15 and 24 years of age attempt suicide at a ratethree times that of male individuals in the same age group.For all groups, the ratio between suicide threats and successfulsuicide ranges from 50:1 to 100:1.6. The answer is B. White male individuals who arebetween 15 and 24 years of age, which is a high-risk agegroup, are five times as likely to commit suicide as women.This age group produces the greatest number of bothattempts and completed suicides.7. The answer is C, between 1,200 and 1,500 mg/day. Thenew adolescent recommendations are close to the 1,500mg/day recommended for adults to help prevent osteoporosis.8. The answer is D, at the age of first sexual activity. Officially,most authorities maintain that Pap smears shouldbegin when sexual activity starts but, in any event, no laterthan at age 18.9 . The answer is B. Reduce the progestational componentof her BCP. Progestational agents in BCPs may causeside effects consisting of breast tenderness, hypertension,headaches, and, rarely, myocardial infarction (the latterpresumably related to the androgenic effects of progestationalagents that include reduced high-density lipoproteincholesterol and elevated low-density lipoproteincholesterol and increased insulin resistance). This patient’sblood pressure appears to be elevated for her age. Althoughit is true that many people experience migraine headacheswhen they begin oral birth control medications, manipulatingthe progesterone agent may address both the headachesand the possible hypertension lurking in the wingswith this patient, although hypertension may be causedby the estrogenic effects as well.10. The answer is E. Oily skin as a change in someonewho has started the BCP is caused by androgenic effects,which are due to the progestational agent. Related to that