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Pediatrics
Examination
and Board Review

• 1,500+ board-style questions

with detailed answer discussions

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ANDREW PETERSON
Gra w KELLY WOOD
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McGraw-Hill Education Specialty Board Review

PEDIATRICS
EXAMINATION
AND BOARD

REVIEW
McGraw-Hill Education Specialty Board Review
PEDIATRICS
EXAMINATION
AND BOARD
REVIEW
Editedby

Andrew R. Peterson, MD, MSPH Kelly E. Wood, MD

Clinical Associate Professor Clinical Assistant Professor
Stead Family Department of Pediatrics Stead Family Department of Pediatrics
Carver College of Medicine Carver College of Medicine
University of Iowa University of Iowa
Iowa City, Iowa Iowa City, Iowa

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For VAC, RAP, MEP, MKP, KJT, and W. Thanks.
Andrew R. Peterson

To my family and friends. You made his happen.

Kelly E. Wood
Contents

Contributors 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ix 20 I nfecti o u s Di sease 42 1

Preface 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 xiii 21 Meta b o l i c Di sorders 459
1 Ado l escent Med ic i n e a n d Gynecology 0 0 0 0 0 0 0 0 0 0 0 1 22 M u scu loske l etal Di sorders 48 1
2 A l l e rg i c a n d I m m u nologic Di sorders 25 23 N e u rologic Di sorders 51 1
3 Behaviora l and Mental Health Issues 51 24 N utrition 539
4 B l ood a n d Neoplastic Di sorders 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 73 25 Patient Safety a n d Q u a l ity I m p rovement 561
5 Ca rd i o l ogy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 09 26 P h a rmacology: Pa i n Ma nagement
6 Cog nition, La n g u age, a n d Lea r n i n g a n d Sedation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 573
Disabi l ities 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 31 27 Poi so n i n g a n d Envi ro n menta l
7 Co l l a g e n Va sc u l a r a n d Other M u ltisyste m Expo s u re t o Hazard o u s S u bsta nces 595
Di sorders 1 51 28 Preve ntative Ped iatrics 625
8 Critica l Care
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 65 29 Psych osoc i a l Issues a n d C h i l d Abuse 643

9 Ea r, Nose, a n d Th roat Di sorders
0 0 0 0 0 0 0 0 0 0 0

1 79 30 Research a n d Statistics 66 1
10 Emerg e ncy Ca re 203 31 Ren a l a n d U rologic Disord e rs 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 669
11 Endocrine Di sorders 21 9 32 Res pi ratory Di sorders 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 697
12 Eth i cs 241 33 Skin Di sorders 727
13 Eye Di sorders 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 255 34 Sports Med ic i n e and Physical Fitness 759
14 Fetus a n d Newborn
0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 275 35 S u bsta nce Abuse 779

15 Fluid a n d El ectro lyte Meta bol i s m 0 0 0 0 0 0 0 0 0 0 0 0 0 0 299 Fi n a l Exa m 79 1
16 Ped iatric Gastroenterology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 323 An swe r Key 807
1 7 Genetics a n d Dysmorphology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 361
1 8 Gen ital Syste m Di sorders 377 Index 809
19 G rowth and Development 403

VII
Contributors

Dina Al-Zubeidi, MD Paula Cody, MD, MPH

Clinical Assistant Professor of Pediatrics Assistant Professor
Division of Gastroenterology Department of Pediatrics
Stead Family Department of Pediatrics, University of Wisconsin School of Medicine
Carver College of Medicine and Public Health
University oflowa Madison, Wisconsin [ 1 ]
Iowa City, Iowa [ 1 6]
Cassandra J . Collins, BSW, LISW
William Aughenbaugh, MD Clinical Social Worker
Associate Professor and Program Director Department of Social Service
Department of Dermatology University oflowa Hospitals & Clinics
Vice Chair of Education in the Department of Dermatology Iowa City, Iowa [29]
and Director of Specialty Clinical Medical Education and
Residency Preparation Amy L. Conrad, PhD
University of Wisconsin Assistant Professor
Madison, Wisconsin [33] The Stead Family Department of Pediatrics
University oflowa Children's Hospital
LaTisha L. Bader, PhD, LP, LAC,CC-AASP Iowa City, Iowa [ 6]
Center for Dependence, Addiction and Rehabilitation
(CeDAR) Linda J. Cooper-Brown, PhD
University of Colorado Hospital Clinical Associate Professor
Aurora, Colorado [35] Stead Family Department of Pediatrics,
Division of Pediatric Psychology
Rebecca Benson, MD, PhD The University of Iowa
Medical Director, Pediatric Pain and Palliative Care Program Iowa City, Iowa [3]
Medical Director for Clinical Ethics and Director,
Ethics Consult Service Vanessa A. Curtis, MD
Stead Family Department of Pediatrics Clinical Assistant Professor
University oflowa Children's Hospital, Department of Pediatrics
University oflowa Hospitals and Clinics Division of Endocrinology and Diabetes
Iowa City, Iowa [ 1 2] University of Iowa Carver College of Medicine
Iowa City, Iowa [ 1 1 ]
James D. Burkhalter, LISW
Director of DBT Programming Anthony J. Fischer, MD, PhD
Social Work Specialist, Department of Psychiatry Assistant Professor
University oflowa Hospitals and Clinics Department of Pediatrics
Iowa City, Iowa [29] Division of Allergy, Pulmonology, and Immunology
University oflowa Children's Hospital
Gayathri Chelvakumar, MD, MPH Iowa City, Iowa [32]
Nationwide Children's Hospital
Section of Adolescent Medicine
Columbus, Ohio [ 1 ]

IX
X Contributors

Chris Hogrefe, MD, FACEP Elizabeth H. Mack, MD, MS

Assistant Professor Associate Professor of Pediatrics
Department of Medicine-Sports Medicine Division of Pediatric Critical Care
Department of Emergency Medicine Medical University of South Carolina
Department of Orthopaedic Surgery-Sports Medicine Charleston, South Carolina [25]
Northwestern Medicine
Northwestern University Feinberg School of Medicine Jessie Marks, MD, FAAP
Chicago, Illinois [27] Clinical Assistant Professor
University of Iowa Carver College of Medicine
Sandy D. Hong, MS, MD Stead Family Department of Pediatrics,
Assistant Clinical Professor University oflowa Children's Hospital
Division of Rheumatology Iowa City, Iowa [ 14]
Department of Pediatrics
University oflowa Children's Hospital Ross Mathiasen, MD
Iowa City, Iowa [7] Department of Emergency Medicine
Department of Family Medicine
Erin Howe, MD Institute for Orthopaedics, Sports Medicine, and Rehabilitation
University oflowa Stead Family The University of Iowa Carver College of Medicine
Department of Pediatrics Iowa City, Iowa [35]
Iowa City, Iowa [ 1 9]
Satsuki Matsumoto, MD
Jennifer G. Jetton, MD Associate of Pediatrics
Clinical Assistant Professor Department of Pediatrics, Division of Neurology and
Division of Pediatric Nephrology, Dialysis and Transplantation Developmental and Behavioral Pediatrics
Stead Family Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine
University oflowa Children's Hospital University oflowa
Iowa City, Iowa [3 1 ] Iowa City, Iowa [23]

Kathleen Kieran, MD, MS Jennifer McWilliams, MD

Associate Professor of Urology Child and Adolescent Psychiatrist
Department of Urology Department of Behavioral Health
University of Washington/Seattle Children's Hospital Children's Hospital and Medical Center
Seattle, Washington [ 1 8] Omaha, Nebraska [3]

Todd Kopelman, PhD, BCBA Gary Milavetz, Pharm D, FCCP, FAPhA

Clinical Assistant Professor Associate Professor and Division Head
Department of Psychiatry The University of Iowa College of Pharmacy
University oflowa Hospitals and Clinics Department of Pharmacy Practice and Science
Iowa City, Iowa [ 6] Division of Applied Clinical Sciences
Iowa City, Iowa [26]
Kathy Lee-Son, MD, MHSc
Clinical Assistant Professor Sarah L. Miller, MD
Pediatric Nephrology Department Clinical Assistant Professor
Stead Family University oflowa Children's Hospital Department of Emergency Medicine
Iowa City, Iowa [3 1 ] University oflowa Hospitals and Clinics
Iowa City, Iowa [ 1 0]
Ashley Loomis, MD
Assistant Professor, Pediatric Critical Care Ashley A. Miller, MD, FAAP
University of Minnesota Pediatrician
Minneapolis, Minnesota [8] Pediatrics
Geisel School of Medicine at Dartmouth
Rebecca L. Lozman-Oxman, DNP, APRN, Hanover, New Hampshire [28]
MSN, BSN, MPH
Pediatric Nurse Practitioner Lisa K. Muchard, MD
Pediatrics, New London Hospital/Newport Assistant Clinical Professor
Health Center Department of Dermatology
New London, New Hampshire [28] University of Wisconsin
Madison, Wisconsin [33]
 Contributors XI

Blaise Nemeth, MD, MS Judith Regine Sabah, MD, PhD, MBA

Associate Professor (CHS) Ophthalmologist -Comprehensive
Pediatric Orthopedics, American Family and Pediatric/Adult Strabismus
Children's Hospital Operative Care, Eugene VA Healthcare System
Department of Orthopedics and Rehabilitation Eugene, Oregon [ 1 3 ]
University of Wisconsin School of
Medicine and Public Health Melanie A. Schmitt, MD
Madison, Wisconsin [22] Assistant Professor of Pediatric Ophthalmology
and Director of Ophthalmic Genetics
Benton Ng, MD Department of Ophthalmology and Visual Sciences
Pediatric Cardiologist University of Wisconsin-Madison
Pediatrics, All Children's Hospital Madison, Wisconsin [ 1 3 ]
St. Petersburg, Florida [5]
Laura Steinauer, Pharm D Candidate
Erin A. Osterholm, MD Student Pharmacist
Assistant Professor of Pediatrics The University of Iowa College of Pharmacy
Department of Pediatrics, Division of Neonatology Iowa City, Iowa [26]
University of Minnesota
Minneapolis, Minnesota [ 14] Natalie Stork, MD
Assistant Professor
Niyati Patel, MD University of Missouri-Kansas City School of Medicine
Assistant Professor, Pediatric Critical Care Department of Orthopedic Surgery
University of Minnesota and Department of Pediatrics
Minneapolis, Minnesota [8] The Children's Mercy Hospital, Division of Orthopedics
Section of Sports Medicine
Andrew R. Peterson, MD, MSPH Kansas City, Missouri [22]
Clinical Associate Professor
Stead Family Department of Pediatrics, Alex Thomas, MD
Carver College of Medicine Allergist/Immunologist
University of lowa Internal Medicine/Pediatrics
Iowa City, Iowa [30, 34] Presence Sts. Mary and Elizabeth Medical Center,
Advocate Children's Hospital
Catherina Pinnaro, MD Chicago, Illinois [2]
Pediatrics Resident, Department of Pediatrics
University of lowa Amy 0. Thomas, MD
Iowa City, Iowa [ 1 2] Allergist/Immunologist
Allergy and Immunology Department
Nathan Price, MD Dreyer Medical Clinic- Advocate Hospital System
Clinical Assistant Professor Aurora, Illinois [2]
Pediatric Infectious Diseases
Stead Family Department of Pediatrics Elizabeth C. Utterson, MD
Iowa City, Iowa [20] Assistant Professor of Pediatrics
Division of Pediatric Gastroenterology,
Gregory M. Rice, MD Hepatology and Nutrition
Associate Professor of Pediatrics, Division of Genetics Washington University
and Metabolism St. Louis, Missouri [ 1 6]
Co- Director, WSLH Biochemical Genetics Laboratory;
Director, Medical Genetics Residency Program Jeffrey Robert Van Blarcom, MD
University of Wisconsin School of Medicine and Public Health Assistant Professor
Madison, Wisconsin [ 1 7] Department of Pediatrics, Division of Inpatient Medicine
University of Utah
Eric T. Rush, MD, FAAP, FACMG Salt Lake City, Utah [ 1 5, 26]
Departments of Pediatrics and Internal Medicine
University of Nebraska Medical Center Susan S. Vos, PharmD, BCPS, FAPhA
and Children's Hospital and Medical Center Clinical Associate Professor
Omaha, Nebraska [2 1 ] The University oflowa College of Pharmacy
Department of Pharmacy Practice and Science
Division of Applied Clinical Sciences
Iowa City, Iowa [26]
XII Contri butors

Tammy L. Wilgenbusch, PhD Leah Zhorne, MD

Clinical Assistant Professor Clinical Assistant Professor
Stead Family Department of Pediatrics, Department of Pediatrics, Division of Neurology and
Division of Psychology Developmental and Behavioral Pediatrics
University oflowa Children's Hospital Roy J. and Lucille A. Carver College of Medicine
Iowa City, Iowa [ 6] University oflowa
Iowa City, Iowa [23]
Adam D. Wolfe, MD, PhD
Assistant Professor of Pediatric Hematology-Oncology Derek Zhorne, MD
Baylor College of Medicine Clinical Assistant Professor of Pediatrics
Children's Hospital of San Antonio Division of General Pediatrics and Adolescent Medicine
San Antonio, Texas [4] Stead Family Department of Pediatrics
Iowa City, Iowa [9]
Kelly E. Wood, MD
Clinical Assistant Professor
Stead Family Department of Pediatrics
Carver College of Medicine
University oflowa
Iowa City, Iowa [24, 29]
Preface
Welcome to the Pediatrics Examination and Board Review
book. This is a comprehensive board review designed to help
the reader study for the general pediatrics board examination.
This text covers all the content that the American Board of
Pediatrics (ABP) says you need to know for the board exam. The
35 chapters in this text correspond to the 3 5 sections of the ABP
content specifications and are written by specialists in the topic
areas. The majority of the content is presented as cases followed
by question/answer/discussion. The discussions are in depth but
written in an informal manner to avoid the feeling that you are
reading a textbook. For visual learners, we have included tables,
figures, and photos. The goal of this book is to make studying
for the boards more engaging.
Each chapter is meant to stand alone, allowing you to focus
on challenging content areas or those where you may need to
spend more time. A final exam is included at the end to help
you test what you have learned. Each question is referenced in
the book so you can go back and review what you may have
missed.
Pediatricians trying to pass a national board exam are not the
only ones who might benefit from this book. Anyone wanting
to learn more about pediatric medicine should read this book.
It provides a broad overview perfect for both early and seasoned
learners.
We are very proud of the final product and believe it pro­
vides the reader with an exceptional resource to cover the entire
breadth of pediatric medicine.
We would like to thank all of the authors who contributed to
this book. Without their hard work, this book would have never
come together. We would also like to thank Christie Naglieri,
Andrew Moyer, Alyssa Fried, and Samantha Williams at
McGraw-Hill for their help and guidance throughout. But most
of all, we would like thank our friends, family, and coworkers for
their love, understanding, and support during the final push to
complete this project.
Andrew R. Peterson, MD, MSPH
Kelly E. Wood, MD
XIII
Adolescent Medicine and Gynecology
Gaya t h r i C h e l va k u m a r a n d Pa u l a Cody
A 1 4-year-old boy presents to your office with concerns
of delayed puberty. The patient is shorter than most of
his classmates. He is active in basketball and is worried
that his lack of height will affect his ability to play. His
mother is 5 feet, 7 inches tall and had her first menses at
age 1 4 years. His father is 6 feet, 4 inches tall and reports
that he was a "late bloomer" and attained most of his
adult height in college. The patient is otherwise healthy,
developmentally appropriate, and not on any medications.
On physical exam he is a well-appearing, well-nourished
young male. He has mild acne, his testes are descended
bilaterally and 3 mL in volume, and there is scant pubic
hair and minimal penile development. He has grown 5 em
in the last year. (See Figure 1 - 1 .)
Question 1 - 1
Which of the following tests will most likely establish the
diagnosis for this patient?
A) CBC.
B) Calculation of midparental height.
C) Bone age.
D) Growth hormone levels.
E) Thyroid studies.
Discussion 1 - 1
The correct answer is "C' The age at which puberty is considered
delayed is 14 years in boys and 1 3 years in girls. Constitutional
delay of puberty is the most common cause, especially in boys.
This patient most likely has a constitutional delay of puberty­
short but normal growth rate and a positive family history. The
best test to establish the diagnosis would be a bone age. Delayed
puberty in boys is defined as lack of pubertal testicular devel­
opment (sexual maturity rating [SMR] 2) by age 14 years in
boys. (See Table 1 - 1 for details.) SMR is also known as Tanner
1
staging, after the pediatrician who first described the sequence
of secondary sexual characteristics. (See Figures 1 -2 and 1 -3 . )
Th e delay leads t o a comparative decrease i n growth velocity
compared to age-matched peers, leading to short stature as the
primary complaint in most patients. Prepubertal growth veloc­
ity is typically 4 to 6 cm/y in adolescent boys and increases to
a peak velocity of approximately 9.5 cm/y at SMR 3 to 4. Most
delayed puberty in boys is due to a constitutional delay from
delayed activation of the hypothalamic-pituitary-gonadal axis.
Once puberty begins patients generally have catch-up growth
and attain a normal adult height. Often there is a family his­
tory of "late bloomers" or other family members with constitu­
tional delay of puberty. Delayed puberty and short stature can
have significant effects on self-esteem, particularly in boys, and
short courses of androgen replacement therapy may be indi­
cated. (Think back to junior high when the girls towered over
the boys.) Underlying metabolic, endocrine, or systemic dis­
orders are an unlikely cause of delayed puberty in this patient
given his previous normal growth velocity and development
and otherwise healthy state. A bone age test will help establish
the diagnosis. In constitutional delay of puberty bone age will be
decreased compared with chronological age as it is more closely
related to skeletal maturity and pubertal stage. A normal bone
age would be seen with familial short stature and Turner syn­
drome. An advanced bone age is seen with precocious puberty
for which early closure of the growth plates will result in a short
adult unless treated.
• Helpful Tip
Calculation of a m i d p a renta l height ca n help determ i n e
a c h i l d's genetic height potentia l .
F o r g i rls: (Mother's height i n e m + Father's height i n
cm}/2 - 6.5 em
For boys: (Moth er's height i n em + Father's height i n
cm}/2 + 6.5 em
1
2 MCGRAW-HILL EDUCATION SPECIALTY BOARD REVIEW: PEDIATRICS

2 to 20 years: Boys NAME

Stature-for-age and Weight-for-age percentiles RECORD #
12 13 14 15 16 17 18 19 20
Mother’s Stature — Father’s St::ure — AGE cm
ature
1

1 sT
A
T
Calculate BMI: Weight (kg) + Stature (cm) + Stature (cm) x 10,000 U
or Weight (lb) + Stature (in) + Stature (in) x 703 R
in on: 10 11 E
1

62 1
S
T
A
T
U
R
E

W
E
I
G
H
T

W
E
l
G
H
T

AGE
2 3 4 5 6 7 8 91011121314151617181920
Published May 30, 2000 (modified 11/21/00).. 7,77"
SOURCE: Developed by the National Center for Health Statistics in collaboration with I I
the National Center for Chronic Disease Prevention and Health Promotion (2000). III/ll 4?
http:llwww.cdc.gov/growthcharts SAFER . HEALTHIER- PEOPLE”

FIGURE 1-1. Growth chart of boy in Case 1. (Reproduced with permission from the National Center for Health Statistics in collaboration with the National
Center for Chronic Disease Prevention and Health Promotion [2000]. http://www.cdc.gov/growthcharts.)
 CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 3

TA B L E 1-1 S EXUAL MATU RITY RAT I N G ( S M R ) I N MALES

SMRin
Males Pubic Hair Development Testicular Development Penile Development
1 No p u b i c h a i r Prepu berta l genita l i a Prepu berta l genita l i a
2 Spa rse, downy h a i r at base of E n l a rgement o f testis (vo l u m e > 4 ml), No c h a n g e
pe n i s scrota l sac e n l a rg es, red der in a ppea ra nce
3 H a i r beco mes thi cker, longer, Conti n ued e n l a rgement of testes a n d Pen i s beg i n s t o g row i n
a n d c u r l i er, sti l l i n l i m ited scrot u m length fi rst, then d i a m eter
m i d l i ne d i stribution
4 Ad u lt type hair in q u a l ity but Th icke n i n g a n d d a r ke n i n g o f scrota l sac Cont i n ued g rowth of pe n i s,
l i m ited d i stribution with conti n u ed g rowth of testes e n l a rgement of g l a n s
5 Ad u lt q u a l ity hair with spread Ad u lt a p peara n ce, a d u lt testi c u l a r vol u m e Ad u l t a p peara n ce
to med i a l t h i g h s o f 1 2-27 m l

Data from Bord i n i B, Rosenfield R. Normal pu berta l development pa rt I I : C l i n ica l as pects of puberty. Pediatr Rev. 2 0 1 1 ;32(7):2 8 1 -292; a n d
Nei n stein LS, e d . Handbook o fAdolescent Healthcare. P h i l a d e l ph ia, PA: Lippi ncott Wi l l ia m s & Wi l ki n s; 2009.

tender 0.5 em mass under both nipples. His testicular

exam reveals testicular volume of 6 mL and no masses.
Your next patient is a 1 3 -year-old boy who is distressed The remainder of his exam is normal, his growth and
because he reports that he is developing breasts. On development is otherwise normal, and he is not on any
exam you note that he has a firm, rubbery, mobile, and medications.

GIRLS

HEIGHT SPU RT
Height 3 in/y
G ROWTH RATE Weight 17.5 lb/y
AGE RANGE
Height 2 in/y ... 11.5-16.5 y
Weight 6 lb/y AGE RANGE 10-16.5 y
MENARCHE Average height 62.5 in (158.5 em)
Average weight 106 lb (48 kg)

B REAST

ffi ·1� � ��� [�1M bi�----

B reast buds
begin.
B reast and
areola grow.
Nipple and
areola form
Areola rejoins
breast contour
AGE RANGE separate and development
8-13 y mound , pro- is complete.
truding from AGE RANGE
breast. 12.5 -18.5 y

SEXUAL MATU RITY 2 3 4 5

RATING

I i r I�! r I� l r ll I l r 11
- - �

PUBIC HAI R

I n itial hair is Pubic hair Hair looks like I nverted triangular

straight and fine. becomes an adult's but limited pattern is established
AGE RANGE coarse, darkens, in area. AGE RANGE
8-14 y and spreads. 12.5-16.5 y
AGE 11 y 12 y 13 y 14 y 15 y
FIGURE 1-2. Adolescent fem a l e sexual matu ration a n d g rowth. (Reproduced with permission from Hay WW, Levin MJ, Deterd i n g RR, Abzug MJ, eds. Current
Diagnosis and Treatment Pediatrics. 22nd ed. New York, NY: McGraw- H i l l Education, I nc., 20 1 4; Fig. 4-4.)
4 MCGRAW- H I L L E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS

BOYS APEX ST RE NGTH SPURT

HEIGHT SPURT Height spurt 10-12 in (25-30 em)
Weight 44 lb (20 kg)

Height 4 in/y
G ROWTH RATE AGE RANGE
Weight 20 lb/y
Height 2 in/y 13-17.5 y
Weight 6.5 lb/y

lh\1 llf\�IY\�Ii\�
PE NIS
TESTES

Testes increase in size Penis grows in Penis grows in Development

and skin of scrotum length. width. is complete.
reddens. AGE RANGE
AGE RANGE 14.5-18 y
10-13.5 y
SEXUAL MATU RITY .......,,----.;;.2-,-...,
3 4 5
RATI NG

PUBIC HAI R
Straight hair Hair becomes Hair is full, Full development.
appears at curly, coarse, limited in area.
penis base. and dark. AGE RANGE
AGE RANGE 14.5-18 y
10-15 y
AGE 11 y 12 y 13 y 14 y 15 y 16 y 17 y
FIGURE 1-3. Adolescent m a l e sexual maturation a n d g rowt h . (Reproduced with permission from Hay WW, Levin MJ, Deterd i n g RR, Abzug MJ, eds. Current
Diagnosis and Treatment Pediatrics. 22nd ed. New York, NY: McGraw- H i l l Education, I nc., 20 1 4; Fig. 4-3.)

Question 2-1 Question 2-2

The most likely diagnosis for this patient is: Management for this patient would include:
A) Pseudogynecomastia. A) Testicular ultrasound.
B) Testicular tumor. B) Reassurance and follow-up exam in 6 months.
C) Gynecomastia. C) Measurement of gonadotropins.
D) Normal puberty. D) Measurement of prolactin.
E) Phytoestrogen consumption. E) Testosterone injections.

Discussion 2-1
The correct answer is "C:' Gynecomastia is a common con­
dition in adolescent males with a prevalence of 19.6% in
1 0 . 5 -year-old males, increasing to 64.6% by age 14 years. It is
caused by an imbalance of estrogen to testosterone in pubertal
males. The relative increased estrogen leads to proliferation of
glandular breast tissue. It is important to differentiate gyneco­
mastia from pseudogynecomastia, which results from excess
fat deposition as opposed to glandular tissue. In pseudogyne­
comastia, tissue tends to be more widely distributed and not
localized to the nipple areolar complex. This patient has a nor­
mal testicular exam, making a testicular cancer unlikely. But
take the opportunity to remind him to perform monthly self­
exams as testicular cancer usually presents as a painless mass.
Soy products contain phytoestrogen, but eating tofu won't give
you breasts. Have you ever seen an orchidometer? To avoid
confusion, be sure to explain that it is standard practice to
compare the patient's testicles to wooden beads on a string to
determine the testicular volume.
Discussion 2-2
The correct answer is "B:' Given that this patient has a nor­
mal testicular exam and no signs of exogenous estrogen
exposure or underlying disease, reassurance and follow up is
appropriate.
� QUICKQUIZ
You are seeing a 1 3-year-old boy who has testicular volume of
6 mL and light downy pubic hair.
What is his SMR staging?
A) Testicular volume SMR 2; pubic hair SMR 2.
B) Testicular volume SMR 1 ; pubic hair SMR 2.
C) Testicular volume SMR 2; pubic hair SMR 3 .
D) Testicular volume SMR 3; pubic hair SMR 3 .
E) Testicular volume SMR 2; pubic hair SMR 1 .
 CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 5

Discussion TA B L E 1-2 S EXUAL M ATU RITY RAT I N G ( S M R )

The correct answer is ''A:' I N FEMALES

SMRin Pubic Hair Breast

• Helpful Tip Females Development Development
:5.� The average age of menarche in the U n ited States is
i1 1r 1 2.6 yea rs, with ra nge o f 1 1 .0 t o 1 4. 1 . Menarche occu rs No pu bic h a i r Prepu be rta l brea sts
ea rlier in Africa n American a n d Mexica n American g i rls. 2 Spa rse, d owny Fo rmation of breast
hair b u d , g l a n d u l a r tissue
palpable u n d e r a reola;

� QUICKQUIZ
a reola i s s l i g htly wid-
ened a n d projects as a
small mound
What is the most common breast mass in adolescent females? 3 H a i r beco mes E n l a rgement of breast
A) Fibroadenoma. thicker, longer, with e l evation of
B) Fibrocystic changes. a n d c u r l ier, sti l l breast conto u r a n d
C) Rhabdomyosarcoma. i n l i m ited m i d - e n l a rgement o f a reola
D) Hemangioma. line d i stri bution
E) Galactocele. 4 Ad u lt type Areo la fo rms a sec-

Discussion
h a i r in q ua l - o n d a ry m o u n d ove r
ity but l i m ited conto u r of breast
The correct answer is "/\'. Most breast masses in adolescent d i stribution
girls are benign. A fibroadenoma feels like a rubbery, smooth,
5 Ad u lt q u a l ity Fu l ly mature breast
mobile, round mass. It is nontender and usually located in the
h a i r with spread with conti n u o u s con-
upper outer quadrant of the breast. Other common benign
to med i a l t h i g h s to u r between a reola
masses include fibrocystic changes, cysts, abscesses, and fat
a n d breast
necrosis from trauma. Options "D" and "E" are less common
benign causes. Malignancy such as option "C" is a rare cause. Data from Bord i n i B, Rosenfield R. Normal pu berta l development
Before a nipple is pierced or a hair is plucked, remember to pa rt II: C l i n ical a spects of p u berty. Pediatr Rev. 2 0 1 1 ;32(7):28 1 -292;
counsel that both can cause an abscess. and Neinstein LS, ed. Handbook ofAdolescent Hea/thcare. Philadelphia,
PA: Lippincott Wi l l ia m s & Wil kins; 2009.

Question 3-2
You are seeing a 14-year-old girl in your office for her
annual exam. When speaking with you confidentially, she
mentions that she is concerned that she has not yet started The first sign of puberty in females is typically:
her period like all of her friends. She reports breast devel­ A) Breast development.
opment starting approximately 1 year ago. On exam she has B) Development of pubic hair.
palpable breast tissue extending just beyond her areola and C) Menses.
pubic hair that is thick and curly and primarily midline in D) Body odor.
distribution. E) Acne.

Discussion 3-2
Question 3-1
The correct answer is ''A:' Breast development (thelarche) is
Which of the following most accurately describes her SMR
typically the first sign of puberty in girls and typically occurs
staging?
between age 8 and 1 3 years (see Figure 1 -2 ) . Breast develop­
A) Breast SMR 1 ; pubic hair SMR 2.
ment typically precedes pubarche (pubic hair development)
B) Breast SMR 3 ; pubic hair SMR 2.
though in some girls pubarche may occur first or simulta­
C) Breast SMR 1 ; pubic hair SMR 4.
neously. Pubarche typically occurs 1 to 1 .5 years after breast
D) Breast SMR 3 ; pubic hair SMR 3.
development. Menarche occurs approximately 2.5 years after
E) Breast SMR 5; pubic hair SMR 5.
thelarche at an average age of 1 2 . 6 years in Caucasians and
earlier in African Americans and Mexican Americans. Girls
Discussion 3-1 reach their peak height velocity of 8.25 cm/y earlier than boys
The correct answer is "D:' The patient described in the vignette at approximately SMR 3 . Peak height velocity in girls always
has breast and pubic hair development consistent with SMR 3 . precedes menarche. Peak height velocity occurs at approxi­
(See Table 1 -2 for details.) mately SMR 4 to 5 in boys.
6 MCGRAW- H I L L E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS
• Helpful Tip
� The fi rst stage of puberty for m a l es is testi c u l a r
1 1 1r enla rgement, defi ned as a testis vol u m e of 4 m L
or g reater, or 2 . 5 e m i n d i a m eter. F o r g i rl s, i t is the
a ppea ra nce of b reast buds.
� QUICKQUIZ
Which of the following is correct?
A) Adrenarche results from testosterone secretion by the
gonads.
B) Activation of the hypothalamic-pituitary-gonadal axis
(HPA) causes gonadarche and adrenarche.
C) Estrogen secretion causes armpit hair development.
D) All of the above.
E) None of the above.
Discussion
The correct answer is "E:' Puberty encompasses gonadarche and
adrenarche. Both are separate events, but the timing typically
overlaps. Gonadarche, growth and maturation of the gonads
(testes, ovaries) , is under the control of the HPA secretion of
gonadotropin-releasing hormone (GnRH). Before puberty,
release of GnRH from the hypothalamus is inhibited. Adrenal
androgen secretion (dehydroepiandrosterone [DHEA] and
androstenedione) causes pubic and axillary hair development,
acne, and body odor (adrenarche) .
• Helpful Tip
� Detection of noctu rnal l utei n izing hormone (LH) p u l ses
I llr is the fi rst hormonal s i g n that puberty has sta rted . At
pu berty, the hypoth a l a m u s is no longer i n h i bited a n d
releases G n R H i n a p u l satile fas h ion. G n R H sti m u lates
the a nterior pitu ita ry to secrete gonadotropins-LH
fi rst, then fol l icle-sti m u lating hormone (FSH). FSH and
LH sti m u l ate the gonads to produce ga metes (eg g s or
sperm) a n d sex hormones (estra d i o l or testosterone).
Question 3-3
What is the next step in management of this patient?
A) Bone age.
B) Measurement of gonadotropins.
C) Reassurance and follow up in 6 months to a year if no menses.
D) Thyroid studies.
E) CBC.
Discussion 3-3
The correct answer is "C:' This patient is progressing through
the stages of puberty and will likely attain menarche in the next
6 months to 1 year. If no menses occur by age 1 6 further workup
would be warranted.
• Helpful Tip
� Don't forget that isolated G n RH d eficiency has been
1 1 1r associated with both Ka l l ma n syn drome a n d anosmia.
A mother brings her 1 7-year-old son for his annual health
maintenance exam. When you ask if she has any concerns
about him, she mentions that he sleeps all the time. She
also states that he was always a happy child but recently has
become more withdrawn and always seems tired. She reports
that his grades have been declining, and he does not seem to
enjoy activities he previously enjoyed, such as playing soccer
and video games with friends.
Question 4- 1
The next step in diagnosing this patient is:
A) Obtaining a CBC and iron studies.
B) Obtaining a complete psychosocial history from the patient.
C) Thyroid testing.
D) Intelligence testing.
E) Completion of Vanderbilt forms by parents and teachers.
Discussion 4- 1
The correct answer is "B:' Adolescence is time of rapid growth
and development. It can be a stressful time, manifesting as anxi­
ety, withdrawal, aggression, somatic complaints, depression, or
poor coping skills such as using drugs. The most common causes
of morbidity and mortality in adolescence are related to the
risk-taking behavior and experimentation that is a normal part
of adolescent development. Obtaining a thorough psychosocial
history is important in screening for these risk-taking behaviors
and identifying protective factors. The symptoms the mother
has described raise concern about depression in this patient. A
thorough psychosocial assessment using the HEADSSS screen­
ing tool with a follow-up depression screen will likely reveal the
cause of his symptoms. How many knew that Vanderbilt scales
assess for attention deficit hyperactivity disorder (ADHD) ?
• Helpful Tip
� H EADSSS was developed as a psychosocial scree n i n g
1 llr tooL
H- Home (Who l ives with the teen? How does the teen
get a l o n g with fa m i ly?)
E - Education (Is the teen in schoo l ? How is he or s h e
perform i n g i n s c h o o l ? S c h o o l performa nce can be a n
i m porta nt i n d ication o f h o w a teen is fu nctio n i n g .)
E- Eati ng (meal consi stency; body image)
A - Activities
D- Drugs (a lcohol, tobacco, m a rij u a na, and other drug
use, i n c l u d i n g prescription a n d over-the-cou nter)

S Sexua l ity (Sexual attraction: Are you attracted
-
to m a l es, fem a l es, both, neither? Sexua l behavior:
Have you ever had sex, how m a ny partners, h i story of
sexu a l l y tra n s m itted i nfection d i a g n osis and testi ng,
condom use, contraceptive u se, last sexua l activity,
h i story of forced sex?)
S- Su icide/Depression
S - Safety (Does the teen feel safe at home or school?
What is h i s or her exposure to violence?)
Through the HEADDSS assessment you learn that the patient
is attracted to males and recently entered a relationship with
a boy at school. He wrote a letter to the boy which another
student found and shared with the whole class. Since then the
patient reports that he is teased by many of his classmates and
has been skipping classes to avoid being teased. His depres­
sion screen is positive for sadness, anhedonia (no pleasure in
activities), excessive sleeping, and feelings of guilt. He denies
any thoughts of self-harm or suicidality.
Question 4-2
Adolescents who identify as lesbian, gay, or bisexual are at
increased risk for which of the following?
A) Eating disorders.
B) Substance abuse.
C) Depression.
D) Bullying.
E) All of the above.
Discussion 4-2
The correct answer is "E:' Sexual development is one part of ado­
lescent development. During early adolescence pubertal develop­
ment is just beginning. At this stage of development adolescents are
very focused on changes occurring in their bodies and question­
ing whether they are normal. Adolescents may begin to experience
sexual fantasies and experience sexual pleasure through masturba­
tion. Sexual intercourse at this stage is uncommon, but may occur.
Adolescents often experience crushes, which may be same sex or
opposite sex. These patterns of attraction may or may not persist
into future stages. In middle adolescence physical development is
nearing completion; at this stage adolescents are forming their sex­
ual orientation and identity. Sexual experimentation is common at
this stage and many adolescents may have intercourse for the first
time. By late adolescence the goal is to become a sexually healthy
adult with the ability to form long-lasting relationships. Sexual
orientation refers to an individual's pattern of physical and emo­
tional attractions to others and involves complex components such
as fantasies and feelings. Personal, family, cultural, developmen­
tal, and social factors can affect an individual's ability to identify,
accept, and act on his or her attractions. Adolescents who identify
as lesbian, gay, or bisexual are at an increased risk for a number of
conditions, including eating disorders, substance abuse, and men­
tal health illnesses, particularly depression and anxiety.
The patient has questions about how to stay safe when he
does become sexually active with his partner.
CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 7
Question 4-3
Which of the following is true about sexually transmitted
infection (STI) transmission?
A) HIV transmission rates are low with receptive anal
intercourse.
B) STis cannot be transmitted through oral sex.
C) Women who have sex with women are at a low risk for STis.
D) Condoms are effective at reducing STI transmission.
Discussion 4-3
The correct answer is "D:' HIV transmission rates are high
with receptive anal intercourse due to microtrauma during
intercourse. STis can be transmitted through oral sex, and it is
important to educate patients to use condoms when having oral
sex to reduce the risk of contracting an STI. Studies have shown
that women who have sex with women are at an increased risk
of contracting human papillomavirus (HPV) , trichomoniasis,
and HIV Condoms are an effective method of STI prevention
and when properly used have been shown to reduce rates of
transmission of HIV, gonorrhea, chlamydia, trichomonas, and
hepatitis B. They can also be effective at preventing STis trans­
mitted by skin-to-skin or mucosal contact, such as herpes sim­
plex virus (HSV) , syphilis, and HPV, but only if the affected area
is covered by the condom. Equally important is making sure
adolescents know how to put on a condom. Pregame practice
is a good idea.
Question 4-4
You also counsel the patient that the most common cause of
mortality in the adolescent population is:
A) Cardiac disease.
B) Unintentional injuries.
C) Suicide.
D) Homicide.
E) Cancer.
Discussion 4-4
The correct answer is "B:' The leading cause of death in the ado­
lescent population is unintentional injuries, with motor vehicle
collisions being the most frequent cause of such injury in this
population. (See Figure 1 -4.) Homicide is the second leading
cause of death, followed closely by suicide. Organic disease is
a less frequent cause of mortality in this age group. Screening
for risk factors such as substance use, mental illness, and expo­
sure to violence is important in this population to address the
leading causes of mortality. Good driving habits, including no
texting while driving, should be discussed.
� QUICKQUIZ
Which of the following is a risk factor for suicide?
A) Bullying.
B) Witnessing violence.
C) Social isolation.
D) Mental illness.
E) All of the above.
8 MCGRAW- H I L L E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS
U n i ntentional i n j u ry 1 -
- ---------------'
]
Homicide I concerns about irregular periods. The patient had her first
I
Suicide
Malignant neoplasms t:::J
H eart d isease � she has been working on more healthful eating, has cut all
0 2000 4000 6000 8000 1 0000 1 2000 1 4000
FIGURE 1-4. 20 1 0 Lea d i n g causes of death in youth ages 1 5 to 24 years of
age in the U n ited States. (Reproduced with permission from the Centers for
Disease Control a n d Prevention, National Center for I nj u ry Prevention a n d
Control, Web-based I nj u ry Statistics Query a n d Reporting System (WI SQARS).
Accessed J a n u a ry 28, 20 1 5 from http://www.cdc.gov/inj u ry/wisqa rs/.)
Discussion
The correct answer is "E:' Additional risk factors include family
history of suicide, history of abuse, previous attempt, access to
means such as firearms, alcohol and drug use, stressful events,
and sexual identification other than heterosexuality.
The patient's mother mentions that she recently caught him
smoking pot in the garage with some friends. She is request­
ing that you drug test him without letting him know.
Question 4-5
Your next step is to:
A) Do as the mother requests.
B) Notify the patient and perform testing regardless of his
wishes.
C) Notify the patient and perform the testing if he agrees.
D) Refuse to perform drug testing.
E) Reassure the mother that catching him guarantees he will
stop using.
Discussion 4-5
The correct answer is "C:' Recreational drug use is an under­
recognized cause of morbidity and mortality in adolescents.
Indications for drug testing in the acute care setting include
acute presentation with altered mental status, suicide attempt,
unexplained seizures, syncope, arrhythmias, or the pres­
ence of toxidromal signs. In the primary care setting volun­
tary drug testing can be helpful for assessment, therapy, and
monitoring. The American Academy of Pediatrics (AAP) cur­
rently cautions against involuntary drug testing of adolescents
in nonemergent settings. Testing of competent adolescents
without their knowledge is unethical and illegal, and without
their consent is impractical. If a pediatrician suspects that a
patient is abusing drugs and the patient refuses drug testing,
documentation of the refusal and referral to a mental health or
addiction specialist may be warranted. Given the limitations
of currently available drug tests, a thorough substance abuse
history often provides more useful information on drug abuse/
use than a drug test.
A 1 6-year-old girl and her mother present to your office with
menses at 12 years of age and had regular monthly periods
until 6 months ago when her periods stopped. She has had an
accompanying 50-pound weight loss over the past 6 months.
When asked further about the weight loss, she reports that
desserts and junk foods out of her diet, and eats a low-fat and
low-carb diet. In addition she has started running 3 miles a
day in order to "get healthy?' On physical exam her vital signs
are temperature 36.4°C {97.5°F) , heart rate 44 beats per min­
ute, blood pressure 96/60 mm Hg, and respirations 16 breaths
per minute. She appears thin, with sallow-looking skin and
dry hair. She is bradycardic on exam, with no murmurs and
a regular rhythm. Her heart rate increases by 19 beats during
positional changes from sitting to standing, with minimal
change in her blood pressure. Her pulses are strong and sym­
metric while her fingers and toes are cool to touch.
Question 5-1
Which of the following is the most likely cause of this patient's
symptoms?
A) Thyroid disease.
B) Anorexia nervosa.
C) Bulimia nervosa.
D) Diabetes mellitus.
E) Coarctation of the aorta.
Discussion 5-1
The correct answer is "B:' Eating disorders are a common but
often underdiagnosed condition in the pediatric population. The
12-month prevalence of anorexia nervosa among young females
in approximately 0.4%, the prevalence of bulimia nervosa is
approximately 1% to 1 .5%. Anorexia nervosa has a mortality rate
of 5% to 6%, the highest of any psychiatric illness. Patients with
anorexia nervosa generally present with rapid weight loss sec­
ondary to caloric restriction, which may present as elimination
of "junk food" from the diet; avoidance of certain food groups,
such as carbohydrates and fats; or changing to a restrictive vegan
or vegetarian diet. Patients may also try and reduce weight by
over-exercising or purging through self-induced vomiting or
use of diuretics and laxatives. In contrast, patients with bulimia
nervosa typically present with cycles ofbinging that trigger purg­
ing or inappropriate compensatory behaviors. Compensatory
behaviors could include self-induced vomiting, use of diuretics,
use of laxatives, fasting, or over-exercising. Patients with bulimia
nervosa are typically of normal weight or overweight. Patients
with anorexia nervosa often present with signs of malnutrition
(eg, bradycardia); hair, skin, and nail changes, often manifesting
as dry and brittle hair, nails, and skin; menstrual irregularities ( eg,
amenorrhea and oligomenorrhea); orthostatic vital sign changes;
cold intolerance; acrocyanosis; mood changes; and fatigue. The
DSM is revised periodically and eating disorder diagnostic cri­
teria often change. Due to copyright restrictions, we are unable
to print the DSM-5 diagnostic criteria for anorexia and bulimia.
 CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 9

TA B L E 1-3 COMMON F EATURES OF ANOREXIA

For bulimia nervosa:
N E RVOSA • Syncope
• Restricted eati ng • Hypokalemia
Low body wei g h t for age a n d sex • Severe hypochloremia ( <88 mmol!L)

• Fea r of g a i n i ng wei g h t or beco m i n g fat

• Esophageal tears
• Arrhythmia
• Behaviors that i nterfere with g a i n i ng wei g ht
• Hypothermia
• Distu rba nce of body i m a g e
• Suicidality
• Excessive i nfl ue nce o f body weight o r s h a pe o n
• Intractable vomiting
self-eva l u ation
• Hematemesis
• Lack of recog n ition of the seriousness of low body weight
• Failure of outpatient treatment

This patient warrants inpatient treatment due to her brady­

Summaries of their common features are included in Tables 1-3 cardia. Note that the AAP endorses electrolyte abnormalities
and 1 -4. But the reader should make themselves familiar with the as admission criteria for bulimia, but not anorexia. In reality,
current DSM criteria for both conditions. a patient with anorexia and severe electrolyte abnormalities
would also likely be admitted to the hospital. Also of interest
Question 5-2 is that hypothermia is defined for one but not both disor­
Which of the following would be a reason for inpatient hospi­ ders . The goal in hospital admission is medical stabilization,
talization for this patient? which is usually achieved through nutritional rehabilitation
A) Hypertension. and correction of any underlying electrolyte abnormalities.
B) Bradycardia. Fluid and electrolyte shifts can occur with the reintroduction
C) Hypokalemia. of nutrition in a patient who has been malnourished. This
D) Rapid weight loss. is called refeeding syndrome and most typically manifests as
E) Amenorrhea. decrease in phosphate, magnesium, and potassium, as well as
an increase in extracellular volume causing peripheral edema
Discussion 5-2 or congestive heart failure, or both. These fluid and electro­
The correct answer is "B:' The AAP suggests that the following lyte shifts can lead to cardiac arrhythmias; thus monitoring
signs and symptoms warrant inpatient hospitalization: of cardiac status, electrolytes, and fluid status is important in
For anorexia nervosa: the inpatient setting.
Bradycardia ( <45 bpm daytime or <45 bpm nighttime)
Question 5-3
•

• Hypotension ( <90 mmHg systolic)

Which of the following will likely NOT be a part of this
• Arrhythmia
patient's treatment?
• Hypothermia A) Nutritional rehabilitation.
• Weight <75% ideal body weight B) Psychotherapy.
• Body Fat < 10% C) Medical monitoring for complications of illness.
• Refusal to eat D) Use of an appetite stimulant.
• Failure of outpatient treatment E) Family therapy.

TABLE 1-4 COM M O N FEAT U R E S OF B U L I M I A
N E RVOSA ( M U ST B E P R E S E N T AT LEAST O N C E A
W E E K FOR 3 MONTHS)
• Eati n g a l a rg e a m o u nt of food ove r a short a m o u nt of
time
• Lack o f control d u ring t h e episode-feels as though o n e
ca nnot stop eati ng
• Behaviors to co m pe n sate fo r epi sodes of bi nge eati n g .
• Excessive i nfl u e nce o f body weight o r s h a pe o n
self-eva l u ation
• Diagnosis i s not bette r exp l a i ned by a d i agnosis of
a n o rexia ne rvosa
Discussion 5-3
The correct answer is "D:' Treatment of eating disorders is mul­
tidisciplinary and includes medical monitoring for complica­
tions of the illness such as refeeding syndrome; psychotherapy
to address eating disorder thoughts and body image concerns;
and nutritional rehabilitation, which involves reintroducing
meals and snacks in a stepwise fashion with a goal of restor­
ing body weight. The use of appetite stimulants is not recom­
mended as this does not address the disordered thoughts and
behaviors that are a part of the eating disorder. Treatment goals
include medical stabilization; nutritional rehabilitation as mea­
sured by restoration of body weight, usually at a rate of 0.25 to
1 kg per week in the outpatient setting; decrease in eating dis­
order thoughts and behaviors; and improvement in body image.
Healthy family involvement is always good.
10 MCG RAW-H I LL E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS
• Helpful Tip
� Anorexic patients a re at risk for refeeding syn d rome.
I llr Hypophosphatemia is the h a l l ma r k a n d the pri m a ry
c u l p rit of refeed i n g syn d rome.
Question 5-4
Which of the following laboratory findings would NOT be
expected in a patient with anorexia nervosa?
A) Hyperkalemia.
B) Leukopenia.
C) Normal laboratory results.
D) Hypoglycemia.
E) Elevated liver enzymes.
Discussion 5-4
The correct answer is "A:' Most patients with eating disorders
have normal laboratory findings. General laboratory workup
includes a CBC with white blood cell count differential; full
chemistry panel, including liver and renal studies; thyroid stud­
ies; nutritional markers, such as vitamin D and prealbumin; and
coagulation studies. Don't forget an ECG. Technically it isn't
a lab test but we needed to include it somewhere! Additional
testing may be indicated to exclude alternative diagnoses. Com­
mon laboratory abnormalities that may be seen in patients with
anorexia include hypokalemia (not hyperkalemia) and hypo­
chloremic metabolic alkalosis secondary to purging. Hypogly­
cemia can be seen secondary to malnutrition. Hyponatremia
may be seen as a sign of water-loading or excessive water intake.
Leukopenia can be seen, and in severe cases pancytopenia.
Mild elevation of liver enzymes can also be seen secondary to
malnutrition.
� QUICKQUIZ
What is NOT a complication of anorexia nervosa?
A) Diarrhea.
B) Gastroparesis.
C) Osteopenia.
D) Brain atrophy.
E) Pericardia! effusion.
Discussion
The correct answer is "A:' Anorexia causes constipation, not
diarrhea (unless the patient is taking laxatives) .
A 16-year-old Caucasian girl comes to the adolescent clinic for
the first time because she has never had a menstrual period.
She is a runner on her school's cross-country team and recently
was diagnosed with a stress fracture. Although she has had to
sit out practice and competitions for the past few weeks, she
has kept active by riding a stationary bike and swimming.
She is otherwise healthy and takes no medication. The patient's
breast development began at about 1 2 years of age and pubic
hair 2 years ago. Her brother has insulin-dependent diabetes
mellitus and her mother has hypertension. The mother states
that her own menses started at 14 years of age. The patient is
a sophomore in high school and is getting straight Xs. She has
a boyfriend but denies sexual activity. She denies all substance
use. Review of systems is negative for headaches, nausea, vom­
iting, abdominal pain, constipation, diarrhea, or vaginal dis­
charge. On physical exam she is 5 feet, 6 inches tall and weighs
1 10 pounds, with a heart rate of 56 bpm and a blood pressure
of 1 10/70 mm Hg. She is SMR 3 for breasts and pubic hair. The
rest of her exam is normal.
Question 6- 1
The definition of primary amenorrhea includes absence
of menses by what age, assuming normal secondary sexual
development?
A) 12 years.
B) 14 years.
C) 16 years.
D) 18 years.
Discussion 6-1
The correct answer is "C." Primary amenorrhea refers to the
absence of menses ( 1 ) by age 16 years with normal second­
ary sexual development; (2) by age 14 years in the absence
of any breast maturation; or ( 3 ) despite having attained
SMR 5 for 1 year or more, or despite the onset of thelar­
che 4 years previously. Focus on remembering the first and
second criteria.
Question 6-2
The most likely cause of primary amenorrhea in this patient is:
A) Hypothalamic amenorrhea.
B) Hypothyroidism.
C) Hyperprolactinemia.
D) Hypopituitarism.
E) Imperforate hymen.
Discussion 6-2
The correct answer is "A." Causes of primary amenorrhea
include conditions resulting from central dysfunction (hypo­
thalamic or pituitary) , ovarian dysfunction, or anatomic
abnormalities of the genital tract. Given this patient's clinical
presentation, the most likely diagnosis would be functional
hypothalamic amenorrhea, due to partial or complete inhibi­
tion of GnRH release. This inhibition can be due to nutri­
tional deficiencies, cystic fibrosis, eating disorders, excessive
exercise, stress, or severe or prolonged illness. Excessive
exercise is to blame in this teenage girl. She has developed a
stress fracture from excessive running. Signs and symptoms
of hypothyroidism include constipation, dry skin, weight

gain, and increased sensitivity to cold. When hypothyroid­
ism is present in children and teens, one may also see delayed
puberty and poor growth, resulting in short stature. Hyperp ­
rolactinemia is usually due to a prolactin- secreting adenoma
that also may cause headaches, visual changes (bitemporal
hemianopsia) , and galactorrhea. Hyperprolactinemia can
also be caused by physiologic hypersecretion of prolactin
(pregnancy) , hypothalamic-pituitary stalk damage, certain
systemic disorders, or drug-induced hypersecretion (eg, ris­
peridone) . With hypopituitarism, the pituitary gland fails
to produce or does not produce enough of one or more of
its hormones, and multiple body functions can be affected.
If the complaint relates to menstruation, always make sure
everything is anatomically correct. Young women need "girl
parts" to have periods and an open outflow path (eg, no
imperforate hymen) .
Question 6-3
If this patient lacked breast development, which of the
following would be included in the diagnosis?
A) Agenesis of miillerian structures.
B) Complete androgen insensitivity syndrome.
C) Asherman syndrome.
D) Pure gonadal dysgenesis (46,XX with streak gonads) .
Discussion 6-3
The correct answer is "D:' With pure gonadal dysgenesis, the
streak gonads are unable to produce sex hormones. In a female
with pure gonadal dysgenesis, the ovaries do not produce
estrogen, resulting in absence of breast development. Agenesis
of miillerian structures impacts the formation of the internal
reproductive tract (uterus, fallopian tubes, and upper third of
the vagina), not the ovaries, and has no effect on breast devel­
opment. Individuals with complete androgen insensitivity syn­
drome are resistant to testosterone due to defective androgen
receptors. They do not develop testosterone-dependent male
sexual characteristics, and the testosterone produced by the tes­
tes is aromatized into estrogen, leading to phenotypically female
appearance with normal breast development. Their genotype is
male ( 46,XY) but their external genitalia look female. Internal
female structures such as a uterus are not present as the tes­
tes make miillerian-inhibiting substance. Asherman syndrome
occurs when uterine synechiae or adhesions obstruct or obliter­
ate the uterine cavity, leading to amenorrhea. Adhesions may
develop after uterine infection or other disruption. Breast devel­
opment is not affected.
� QUICKQUIZ
Which of the following clinical characteristics would NOT
be seen in a patient with complete androgen insensitivity
syndrome?
A) Absent menses.
B) Normal breast development.
CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 11
C) Tanner 3 pubic hair.
D) Normal linear growth.
Discussion
The correct answer is "C' Patients with complete androgen
insensitivity syndrome are ( 46,XY) and have a defect in andro­
gen receptors. Thus they do not develop testosterone-dependent
male sexual characteristics, such as pubic and axillary hair.
Question 6-4
What tests should you order to assess primary amenorrhea in
this patient in order to confirm your diagnosis?
A) Pregnancy test.
B) Follicle-stimulating hormone (FSH) and luteinizing hor-
mone (LH) .
C) Prolactin.
D) Thyroid-stimulating hormone (TSH ) .
E) All of the above.
Discussion 6-4
The correct answer is "E:' Pregnancy should always be excluded,
even in patients who deny sexual activity. It is useful to obtain
FSH and LH levels to differentiate between hypothalamic (low
or normal LH and FSH) and ovarian insufficiency (elevated
LH and FSH) . A prolactin level would confirm the presence
of a pituitary microadenoma, which might (or might not) also
cause headache, galactorrhea, and bitemporal hemianopsia
(decreased vision in the outer half) . TSH level is used to diag­
nose thyroid abnormalities, which may impact menses. Even
though you suspect hypothalamic amenorrhea (suppression
from excessive exercise) , you should rule out both hyperprolac­
tinemia and thyroid abnormalities.
Question 6-5
Which of the following would make Turner syndrome an
unlikely diagnosis in a patient with amenorrhea?
A) Short stature.
B) Hypogonadotropic hypogonadism.
C) Hypergonadotropic hypogonadism.
D) Webbed neck.
E) Widely spaced nipples.
Discussion 6-5
The correct answer is "B:' Tuner syndrome ( 45,XO) is the most
common cause of primary gonadal failure (primary hypogo­
nadism) in adolescent girls and is characterized by ovarian
dysgenesis (accelerated stromal fibrosis and decreased or
absent oocyte production) , short stature, and a wide variety
of phenotypical abnormalities (widely spaced nipples, webbed
neck, coarctation of the aorta, lymphedema) , and elevated
gonadotropins. The hypothalamus and pituitary function nor­
mally but the ovary does not, so FSH and LH are elevated.
Most women with Turner syndrome do not develop breasts
or have periods (primary amenorrhea) but some develop
normally with secondary amenorrhea as their presenting
symptom. Short stature is a big clue.
12 MCG RAW-H I LL E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS
• Helpful Tip
= � To d ifferentiate between primary a n d secondary
r1 1 r hypogonadism, use FSH a n d LH to guide you r thi n king.
I n hypogonadotropic hypogonadism, the problem is
centra l (hypotha l a m us or pitu ita ry, or both) a n d FSH and
LH levels wi l l be low or norma l. I n hypergonadotropic
hypogonadism, the problem is the gonads (testes or
ova ries) a n d FSH a n d LH wil l be elevated.
You decide to proceed with a progesterone challenge in your
patient, which does NOT result in a withdrawal bleed.
Question 6-6
Which of the following are possible causes for failure of a
progesterone challenge?
A) Elevated estrogen level.
B) Ovarian cyst.
C) Transverse vaginal septum.
D) Septate hymen.
E) Bicornate uterus.
Discussion 6-6
The correct answer is "C:' A progesterone challenge helps deter­
mines the level of endogenous estrogen and confirm the patency of
the outflow tract. If no bleeding occurs after a progesterone chal­
lenge, either the anatomy is disrupted (imperforate hymen, vaginal
atresia, vaginal septum, miillerian agenesis, absent uterus) or there
is not enough circulating estrogen. Estrogen stimulates buildup of
the uterine lining, which is shed in the progesterone challenge. A
transverse vaginal septum is a thin horizontal membrane in the
vagina that may cause obstruction. A septate hymen has an extra
band of tissue in the middle that causes two vaginal openings but
not obstruction. A bicornate uterus is just shaped funny.
A 1 7-year-old girl presents to the adolescent clinic complain­
ing of irregular periods for the past 6 months. Menarche was at
1 1 years of age. Menses have been regular, coming every month
and lasting 5 days for the past 4 years until 6 months ago. In
the past 6 months, she has had only 2 periods, the last one was
2 weeks ago and lasted 10 days. She has gained 25 pounds in the
past year (current BMI is 33 kg/m2 ) . She has noticed increasing
acne and dark, velvety skin in her neck and axilla. She is sexu­
ally active with boyfriend of 1 year and uses condoms consis­
tently. The last sexual activity was about 3 weeks ago.
Question 7-1
Which of the following qualifies as dysfunctional uterine
bleeding?
A) Menstrual cycles occurring 19 days apart.
B) Menstrual cycles occurring 35 days apart.
C) Menstrual cycles lasting 7 days.
D) Menstrual cycles resulting in blood loss of 60 mL.
Discussion 7-1
The correct answer is ''A:' Dysfunctional uterine bleeding (DUB),
also known as anovulatory abnormal uterine bleeding, is defined
as menstrual cycles occurring less than 20 days or more than
45 days apart, and lasting longer than 8 days, or menstrual cycles
resulting in blood loss of greater than 80 mL. DUB is character­
ized as ( 1 ) oligomenorrhea-too few periods (> 45 days apart),
(2) polymenorrhea-too many periods ( < 20 days apart), (3)
metrorrhagia-too-frequent bleeding irregularly or between
periods, (4) menorrhagia-too-heavy blood loss (> 80 mL or
lasting > 7 days), and (5) menometrorrhagia-too-frequent and
heavy blood loss. Anovulation is a common cause of DUB in ado­
lescents. Without ovulation, progesterone secretion is disrupted,
resulting in estrogen-induced overgrowth of the endometrial lin­
ing. The thickened lining outgrows it blood supply and then is
shed irregularly.
• Helpful Tip
=t'll Anovulatory cycles a re com m o n in early menstru a l
r1 1r cycles a n d a re cha racterized by l a rge va riations i n
estrogen level s a n d l a c k o f progesterone. During
the first 2 yea rs fol l owing menarche, a n ovulation is
associated with 50% to 80% of bleed ing episodes. Two
to 4 yea rs after menarche, a novu lation is associated with
30% to 55% of bleed ing episodes. Fou r to 5 yea rs after
menarche, 20% of bleed ing episodes a re a n ovu latory.
• Helpful Tip
=t'll The fem a l e ath l ete triad i n c l udes osteoporosis,
r1 1r a m e norrhea, a n d d isorders of n utritional i nta ke.
A urine pregnancy test was negative. Based on the clinical
picture, you suspect polycystic ovary syndrome (PCOS) .
Question 7-2
What test should you order to help confirm the diagnosis?
A) CBC.
B) Estradiol level.
C) Total and free testosterone.
D) FSH level.
E) Ovarian ultrasound.
Discussion 7-2
The correct answer is "C:' Obesity, acanthosis nigricans (see
Figure 1 -5), and menstrual irregularities suggest PCOS. There are
several diagnostic criteria for PCOS. Essentially, there needs to
be evidence of ovulatory dysfunction and clinical or biochemical
 CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 13

increased malignancy risk is the prolonged exposure of the

endometrium to unopposed estrogen that results from anovula­
tion. Women with PCOS are not at increased risk of ovarian,
breast, or cervical cancer.

Question 7-5
Other conditions that may show evidence of excess androgen
include:
A) Adrenal tumor.
B) Late-onset congenital adrenal hyperplasia.
C) Anabolic steroid use.
D) All of the above.

Discussion 7-5
The correct answer is "D:' Adrenal tumors can manifest as
FIGURE 1-5. Aca nthosis n i g ricans on the back of the neck. (Reprod uced virilization and can be diagnosed by means of an elevated
with permission from Hoffm a n BL, Schorge J O, Schaffer Jl, H a lvorson LM, dehydroepiandrosterone sulfate (DHEA-S) level. Late-onset
Bradshaw KD, C u n n i n g h a m FG, Ca lver LE, eds. William's Gynecology. 2nd ed. congenital adrenal hyperplasia may become apparent during
New York, NY: McGraw-H i l l Education, I nc., 2 0 1 2; Fig. 1 7-6.) mid-childhood and can lead to early pubic hair, accelerated
bone age, hirsutism, and possible mild clitoral enlargement.
This can be diagnosed based on elevated serum 1 7 -hydroxypro­
signs of androgen excess. Ultrasound evidence of polycystic ova­
gesterone. Anabolic steroids have effects similar to testosterone
ries is suggestive but not required for the diagnosis. Women with
in the body.
PCOS often have an increased level of both total testosterone and
free testosterone. FSH level will not be helpful on its own; how­
ever, in combination with LH level it may be helpful as half of
patients with PCOS have an LH:FSH ratio of 2.5: 1 . Most women � QUICKQUIZ
with PCOS have normal estradiol levels.
Which is a clinical feature of PCOS?
Question 7-3 A) Acanthosis nigricans.
Additional laboratory studies that should be ordered in B) Hirsutism.
patients with PCOS include: C) Acne.
A) Glucose. D) Obesity.
B) Lipid panel. E) All of the above.
C) Insulin.
Discussion
D) Glucose tolerance test.
E) All of the above.
The correct answer is "E:' Obesity, menstrual irregularities, and

Discussion 7-3
infertility are common. Hirsutism, male pattern alopecia, and
acne result from androgen excess. Acanthosis nigricans, as seen
The correct answer is "D:' PCOS patients are at higher risk for
in the patient in this case, is a manifestation of insulin resistance.
impaired glucose tolerance and insulin resistance, as well as
metabolic syndrome, which is a group of cardiovascular risk
factors that include dyslipidemia, type 2 diabetes mellitus,
hypertension, and obesity.

Question 7-4 The mother of a 14-year-old girl calls the clinic stating that
The type of cancer that people with PCOS are at risk for her daughter's first period began 2 weeks ago and she con­
includes: tinues to bleed heavily. Her daughter is complaining of feel­
A) Endometrial cancer. ing increasingly tired. Review of the girl's chart shows that
B) Ovarian cancer. the 14-year-old was previously healthy. She has never had
C) Breast cancer. any surgical procedures. The family history indicates that
D) Cervical cancer. both the mother and maternal grandmother had hysterecto­
E) None of the above. mies in their 30s due to heavy menstrual bleeding. You tell
the mother to bring her daughter to the clinic. At arrival, the
Discussion 7-4 girl's vital signs are heart rate of 1 20 bpm and blood pressure
The correct answer is "A:' Women with PCOS have an increased of 1 00/70 mm Hg. On exam, her skin is pale and vaginal exam
risk of developing endometrial cancer. A major factor for this shows active bleeding from the cervix.
14 MCG RAW-H I LL E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS
Question 8- 1
Which of the following conditions would be an unlikely cause
of abnormal vaginal bleeding in this patient?
A) Endometrial cancer.
B) Pregnancy-related condition.
C) Sexually transmitted infections.
D) Anovulatory cycle.
E) Bleeding disorder.
Discussion 8-1
The correct answer is "A:' Most cases of abnormal vaginal
bleeding in adolescence are secondary to dysfunctional uterine
bleeding from anovulatory cycles. Genital cancers are very rare
in young adolescents. The differential diagnosis includes:
• Pregnancy-related conditions (intrauterine or ectopic preg­
nancy, spontaneous abortion, and molar-trophoblastic
disease)
• Infections (vaginitis, cervicitis, endometritis, salpingitis, and
pelvic inflammatory disease)
• Other gynecologic conditions (ovarian cyst, genital cancers,
breakthrough bleeding associated with contraceptive use,
ovulation bleeding, polyps, endometriosis)
• Systemic disease (renal and liver failure)
• Bleeding disorders
• Direct trauma and foreign body
• Medications (anticoagulants and platelet inhibitors)
Question 8-2
The following tests should be included in the workup of this
patient:
A) Pregnancy test.
B) Hemoglobin/hematocrit.
C) Coagulation studies.
D) Nucleic acid amplification testing (NAAT) for gonorrhea
and chlamydia.
E) All of the above.
Discussion 8-2
The correct answer is "E:' A pregnancy test is essential to exclude
complications of pregnancy. Hemoglobin and hematocrit val­
ues will help determine the magnitude of bleeding. Coagulation
studies may reveal coagulopathies or blood dyscrasias, partic­
ularly in this case of heavy bleeding since onset of menarche
and a family history of abnormal vaginal bleeding. STis such
as gonorrhea and chlamydia are common causes of prolonged
or irregular vaginal bleeding. Other causes to consider include
endocrine abnormalities such as hypothyroidism.
The pregnancy test was negative. Her hemoglobin is 8.5 g/dL.
Question 8-3
What is the next appropriate step?
A) Reassurance.
B) Start a multivitamin with iron.
C) Start a combined oral contraceptive pill daily.
D) Admit to hospital for higher doses of estrogen and possible
blood transfusion.
E) Uterine dilational and curettage.
Discussion 8-3
The correct answer is "D." Treatment of abnormal uterine
bleeding depends on the severity of the bleeding, hemoglo­
bin level, and degree of associated hemodynamic changes.
Mild cases associated with a hemoglobin level of 1 2 g/dL or
higher require only reassurance, a multivitamin with iron,
and close follow up. Individuals with a hemoglobin level of
10 to 12 g/dL should take a combined oral contraceptive pill
(OCP) every 6 to 12 hours for 24 to 48 hours until the bleed­
ing stops, taper to one pill per day, and then continue daily
O CPs for 3 to 6 months. Patients with a hemoglobin level
of less than 10 g/dL may require hospitalization and initial
treatment of higher doses of estrogen if hemodynamically
unstable. This patient has anemia and is subsequently tachy­
cardic. She needs aggressive management.
Question 8-4
The most common inherited bleeding disorder, which often
presents as menorrhagia in adolescent females is:
A) Factor VIII deficiency.
B) Factor IX deficiency.
C) von Willebrand disease.
D) Protein C deficiency.
E) Antiphospholipid syndrome.
Discussion 8-4
The correct answer is "C:' The most common inherited bleeding
disorder in the United States population is von Willebrand dis­
ease, with an estimated prevalence of 1 % to 2%. The prevalence
of von Willebrand disease rises in studies involving women with
menorrhagia, with estimates ranging as high as 10 % to 20% in
Caucasian women, and 1 % to 2% among African American
women. Von Willebrand factor helps with formation of the ini­
tial blood clot (binds platelets and factor VIII). Other bleeding
disorders seen in adolescents with menorrhagia are disorders
of inherited platelet dysfunction, clotting factor deficiencies,
thrombocytopenia, and disorders of the fibrinolytic pathway.
People with antiphospholipid syndrome and protein C and S
deficiencies are at increased risk for thromboembolism, not
menorrhagia.
A 16-year-old girl comes to your clinic requesting birth
control. She just started having sexual intercourse with her
boyfriend of 1 year. They have used condoms with each epi­
sode of vaginal intercourse. Menarche was at 12 years of age.
Menses occurs every month, lasts for 5 days, and is associ­
ated with mild cramps. Her past medical history consists of
 CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 15

well-controlled absence seizures diagnosed at 16 years of age Question 9-2

for which she takes a medication. She had an appendectomy Combined OCPs can safely be used by an adolescent with any
in the past year; imaging during the diagnostic evaluation of the following conditions EXCEPT:
showed a left ovarian cyst measuring 1 .6 x 2 x 1 .8 em. Her A) Migraine with aura.
mother takes medication for high blood pressure and her B) Blood pressure of 1 3 5/80 mm Hg.
father has high cholesterol. C) Hypothyroidism.
D) History of ovarian torsion.
Question 9- 1 E) Asthma.
Which of the following contraceptive options has the lowest
failure rate during typical use in adolescence? Discussion 8-2
A) Male condom. The correct answer is "A:' According to the Centers for Disease
B) Combined OCPs. Control and Prevention's (CDC) US Medical Eligibility Criteria
C) Implantable etonogestrel rod. for Contraceptive Use, absolute (level 4) contraindications to
D) Injectable depo-medroxyprogesterone. combined OCP use include current breast cancer or estrogen­
E) Progestin-only pills. dependent tumor, thromboembolic disease or high risk for

Discussion 9- 1
thromboembolism (thrombogenic mutation, antiphospholipid

The correct answer is "C' See Table 1 - 5 for failure rates of dif­
antibody), migraine with aura, blood pressure of 1 60/ 1 00 mm
Hg or higher, cardiovascular disease, liver disease, and cerebro­
ferent methods of contraception. With so many choices, why vascular events.
aren't all sexually active adolescents using contraception and
STI protection? Perhaps the adolescent has difficultly planning
ahead, fails to recognize potential consequences, lives in the
moment, fears a pelvic exam or side effects, or has concerns over
confidentiality.
� QUICKQUIZ
Which is a noncontraceptive benefit of estrogen-progestin­
containing birth control?
TABLE 1-5 FA I LU R E RATES WITH P E R F ECT U S E
A) Increased risk of ovarian cancer.
A N D TYP I C A L U S E O F D I F F E R E N T CO NTRAC E PTIVE
B) Increased acne.
M ETHODS
C) Worsening menstrual cramps.
Failure Rate D) Decreased bone density.
E) Prevents menstrual migraines without aura.
With Perfect With Typical
Contraceptive Use (%) Use (%)
Discussion
Withd rawa l m ethod 4 22 The correct answer is "E". Combined hormone- contain­
Rhyt h m meth od/ 5 24 ing pills, patch, and vaginal ring improve bone density
period ic a bsti nence and decrease ( 1 ) risk of ovarian and endometrial cancer;
M a l e co ndom 2 18 (2) menstrual cycle disorders, including menorrhagia
and dysmenorrhea; ( 3 ) acne; and (4) p elvic pain from
Fem a l e co ndom 5 21
endometriosis.
Co m b i ned OCPs 0.3 9

Question 9-3
Co m b i ned tra n sder- 0.3 8
m a l patch
Which of the following antibiotics interferes with the contra­
Co m b i ned vag i n a l 0.3 8 ceptive effectiveness of the OCP?
ring A) Amoxicillin.
Progest i n -o n ly p i l l 0.3 9 B) Rifampin.
I njecta ble D M PA 0.2 6 C) Cephalosporin.
I m pl a nta ble 0.05 0.05
D) Sulfonamides.
etonog estre l rod
Levonorg estrei i U D 0.2 0.2 Discussion 9-3
The correct answer is "B:' Rifampin is the only antibiotic proven
Copper I U D 0.6 0.8
to decrease the contraceptive effectiveness of the pill. Amoxicil­
D M PA, d epot med roxyprogesterone acetate; I U D, i ntra u terine lin, cephalosporins, and sulfonamides do not affect birth con­
device; OCP, ora l contraceptive p i l l . trol effectiveness. Griseofulvin, an antifungal medication used
Data from Hatcher RA, Trusse l l J, N e l s o n AL, e t a l . Contraceptive to treat tinea infections, also speeds up metabolism of OCPs,
Technology. 20th rev ed. New York, NY: Ardent Media; 201 1 . decreasing their effectiveness.
16 MCG RAW-H I LL E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS

Question 9-4 classmate while at a party 3 months ago. She has not told any­
Which of the following antiseizure medications decreases the one about the assault and still sees the person who assaulted
contraceptive effectiveness of the OCP? her at school. She does not want to report the incidence
A) Gabapentin. because she doesn't want her boyfriend to know that he may
B) Phenobarbital. not be the father of her child.
C) Valproate.
Question 9-7
D) Levetiracetam.
E) All of the above.
Legally, you:
Discussion 9-4
A) Agree to her wishes to not disclose the assault.
B) Arrange for her boyfriend to undergo paternity testing.
The correct answer is "B:' Antiepileptics that induce the cyto­
C) Inform her that it is your legal obligation to report the
chrome P450 system (increasing metabolism), and therefore
assault to the authorities because she is a minor.
make the birth control pill less effective, include carbamazepine,
D) Inform her that you are going to tell her parents.
felbamate, phenobarbital, phenytoin, primidone, and topira­
mate. Lamotrigine clearance is increased in presence of estro­
gen-containing birth control options, meaning the effectiveness Discussion 9-7
of the seizure medication is decreased. The correct answer is "C:' All sexual assaults involving a minor
must be reported to authorities, even if the minor does not want
Your patient does not think she would remember to take a the assault disclosed.
birth control pill every day and would like to hear about the
other options.

Question 9-5
� QUICKQUlZ
Which of the following correctly matches the contraceptive
True or false: Pregnancy related risks in adolescents are age
with its duration of action?
dependent.
A) Transdermal patch; 3 weeks.
A) True.
B) Vaginal ring; 3 months.
B) False.
C) Levonorgestrel intrauterine device (IUD); 10 years.

Discussion
D) Copper IUD; 10 years.

The correct answer is ''A:' Younger adolescents are at increased

E) None of the above.

Discussion 8-5
risk for pregnancy complications, including poor weight gain,
anemia, pregnancy-induced hypertension, and poor prenatal
The correct answer is "D:' The birth control patch needs to be
care; are less likely to finish high school; and are more likely
changed weekly. The birth control ring is typically replaced after
to be single parents. They may lack the maturity to care for an
3 weeks. There are two different levonorgestrel IUDs; one lasts
infant. Infants of adolescent mothers are at increased risk for
for 3 years and the other for 5 years. The copper IUD is replaced
prematurity and low birth weight. Pregnant adolescents are
every 1 0 years.
more likely to live in poverty, not finish high school and require
governmental assistance. Care should be multidisciplinary,
She returns 6 months later and tells you that she is pregnant.
involve community resources, stress the importance of school,
Question 9-6
and provide positive reinforcement for successes.
Which of the following would put her at higher risk for an
ectopic pregnancy?
A) Prior episode of pelvic inflammatory disease.
B) History of OCP use.
C) History of labial adhesions requiring estrogen cream.
D) Frequent yeast infections. A 16-year-old girl presents to clinic with dysuria and vaginal
E) All of the above. discharge. She has had four sexual partners in her lifetime:
three male and one female. She started having sex at 12 years
Discussion 9-6 of age. The pH of the vaginal discharge obtained during
The correct answer is ''A:' Risk factors for ectopic pregnancies saline mount (wet prep) collection is 7.
include previous ectopic pregnancy; infection of the uterus,
fallopian tubes, or ovaries (pelvic inflammatory disease); preg­ Question 1 0-1
nancy when an IUD is in place; or pregnancy after tubal ligation. Which of the following is an unlikely cause of the vaginal
discharge?
She hasn't told anyone about her pregnancy. Upon further A) Bacterial vaginosis.
questioning, she discloses that she was sexually assaulted by a B) Trichomoniasis.
 CHAPTER 1 • A D O L E S C E N T M E D I C I N E A N D GYN ECOLOGY 17

� QUICKQUlZ
C) Vaginal candidiasis.
D) Gardnerella vaginalis.
E) None of the above.
Which is NOT an indication for a pelvic exam?
Discussion 1 0-1 A) Amenorrhea.
The correct answer is "C:' The pH for yeast infection is less B) Pregnancy.
than 4.5 ( acidic) , and budding yeast or pseudohyphae can be C) Yearly checkup.
seen on KOH prep. The pH for bacterial vaginosis ( caused D) Persistent vaginal discharge.
by Gardnerella vagina/is) and trichomoniasis is greater than E) Dysuria in a sexually active female.

Discussion
4.5.

O n speculum exam, you see a red and friable cervix and
white, frothy discharge in the cul-de-sac.
Question 1 0-2
On the wet mount, you are likely to find:
A) Trichomonads.
B) Budding yeast.
C) Pseudohyphae.
D) Clue cells.
E) No-clue cells.
Discussion 1 0-2
The correct answer is "A:' The clinical appearance of the dis­
charge provides important clues to the diagnosis. Gray, frothy
discharge is consistent with trichomoniasis (along with the
appearance of the red, friable cervix, or "strawberry cer­
vix") . The discharge associated with yeast infections is usually
described as thick and curdlike, and adheres to vaginal walls.
The discharge associated with BV is usually described as thin,
grayish, and foul smelling. With BV, clue cells are present on
wet prep and the whiff test is positive. No one likes a fishy odor.
If you chose option "E;' it suggests that you were clueless about
this question.
The correct answer is "C". The guidelines for Papanicolaou
(Pap) testing have changed and noninvasive STI testing is avail­
able, so fewer adolescents need pelvic exams. (See Table 1 -6.)
A Pap smear and pelvic exam are no longer required at the
onset of sexual activity or before prescribing birth control.
Current guidelines recommend performing the first Pap test at
age 2 1 years, with these exceptions: ( 1 ) immunocompromised
(includes HIV) adolescents need annual tests once sexually
active, and (2) adolescents who have already been found to have
cervical intraepithelial neoplasia ( CIN) 2 or 3 or carcinoma
need periodic screening and, in the case of CIN 3, treatment.
• Helpful Tip
� Consider acute retrovira l synd rome i n a ny sexua l l y
r1 1r active adol escent with nonspecific vira l sym ptoms,
i n c l u d i n g fever, m a l a ise, lym phadenopathy, a n d skin
ras h . The synd rome occu rs i n the fi rst few weeks of
i nfection, before a nti body testing is confi rmed as
positive. The test to order for acute retrovira l syn d rome
is a n H I V PCR-D N A or H I V plasma RNA. Acutely infected
patients a re h i g h ly contagious d u ri ng t h i s stage.

Question 1 0-3 The patient does not want her parents to know that she is
What additional diagnostic tests should you order? being tested for STis.
A) Urine pregnancy test.
B) NAAT for gonorrhea.
C) NAAT for chlamydia.
TA B L E 1-6 I N D I CATI O N S FOR P E LV I C
D) HIV.
EXA M I NATION
E) All of the above.
Persi stent vag i n a l discharg e Sex u a l l y active with
Discussion 1 0-3 dys u ri a or u ri n a ry tract
The correct answer is "E:' The patient admits to having unpro­ sym pto m s
tected sex and already has been diagnosed with one STI ( tricho­ Dysmen orrhea n ot hel ped by Amenorrhea
monas) . She is at risk for other infections as well as pregnancy. NSAIDs
The CDC's STI screening guidelines for sexually active adoles­ Abnormal vag i n a l Lower abdom i n a l
cents include ( 1 ) annual Chlamydia trachomatis screening for bleed i n g pa i n
all females younger than 25 years old, (2) C. trachomatis screen­ I U D o r d i a p h ra g m contracep­ Perform P a p test
ing of males in certain settings, and (3) annual Neisseria gonor­ tive co u n se l i ng
rhoeae screening in all at-risk females. HIV screening should be
S u s pected or reported /ra pe Preg na ncy
discussed and encouraged for sexually active adolescents and
o r sex u a l a buse
those who use injection drugs. Screening for certain STis in
asymptomatic adolescents ( eg, syphilis, trichomoniasis, hepati­ I U D, i ntra uteri ne device; N S A I D, nonsteroidal a nti-infl a m matory
tis B) is not recommended. drug.
18 MCG RAW-H I LL E D U CAT I O N S P E C I A LTY BOARD REVI EW: P E D I ATRICS

Question 1 0-4 3 months after treatment. Reinfection rates are high, especially
You tell her: if partners are not treated.
A) Minors can consent to STI testing without parental
notification.
B) Minors require parent or guardian consent for STI testing. • Helpful Tip
=.� Empiric a ntibiotic prophylaxis after possible STI
i1 1 r exposu re incl udes ceftriaxone (250 mg intra m uscu l a r
C) Minors can consent to STI testing but parents must be
notified.
D) None of the above. i njection) for gonorrhea, azith romycin ( 1 g ora l ly) or
doxycyc l i n e ( 1 00 mg twice d a i l y for 7 days) for c h l a myd ia,

Discussion 1 0-4
and metron idazole (2 g ora l ly) for trichomoniasis.

The correct answer is ''A:' All 50 states and the District of

Columbia allow minors to consent to STI services without
parental notification. Eighteen states allow, but do not require,
a physician to inform a minor's parents that he or she is seek­
ing or receiving STI services when the physician deems it in the
minor's best interests. A key consideration is that you can't con­
trol what is on the insurance claims.
The patient wants to know what type of complications could
occur if she was exposed to gonorrhea.
The patient is seen in the emergency department 2 months
later with a 3-day history of fever and abdominal pain, but no
dysuria, vomiting, or diarrhea. She states that a new vaginal
discharge developed 1 week ago. She continues to be sexually
active with sporadic use of condoms and has had one new male
sexual partner. Her last episode of unprotected sex was 2 weeks
ago. On exam, she is febrile to 38.5°C ( 1 0 1 .3°F) and has pain
and rebound tenderness in the left lower quadrant. On pelvic
exam, her SMR is 5 with normal external genitalia. On spec­

Question 1 0-5
ulum exam, there is discharge coming from the cervical os.
On bimanual exam, cervical motion tenderness and fullness
You explain that gonorrhea can cause all of the following
of the left adnexa are present.
EXCEPT:
Question 1 0-7
A) Rash.
B) Arthritis.
Which is NOT a diagnostic criterion for her acute condition?
C) Pelvic inflammatory disease.
A) Uterine tenderness.
D) Painless ulcer.
B) Adnexal tenderness.
E) Perihepatitis.
C) Lower abdominal pain.

Discussion 1 0-5
The correct answer is "D:' Gonorrhea infection can cause muco­
purulent cervicitis, intermenstrual bleeding, and pelvic inflam­
matory disease. Disseminated gonococcal infection occurs in
1% to 3% of individuals with gonorrhea. It can present as pete­
chial or pustular skin lesion, tenosynovitis, septic arthritis, and
perihepatitis (Fitz-Hugh-Curtis syndrome) . A painless ulcer is
indicative of primary syphilis (chancre), granuloma inguinale,
or lymphogranuloma venereum.
The patient's boyfriend has a history of chlamydia, which was
picked up on routine screening.
Question 1 0-6
What is the treatment of chlamydial infections in men?
A) Azithromycin.
B) Ceftriaxone.
C) Penicillin.
D) Metronidazole.
E) Fluconazole.
Discussion 1 0-6
The correct answer is ''A:' The preferred treatment of chlamydia
consists of a single 1 g oral dose of azithromycin or a 1 -week
course of doxycycline ( 1 00 mg twice daily) . Those who test
positive for chlamydia or gonorrhea should have a test of cure
D) History of sexual activity.
E) Positive result for Neisseria gonorrhoeae.
Discussion 1 0-7
The correct answer is "E:' Pelvic inflammatory disease (PID) is
an infection of the upper reproductive tract, including endo­
metritis, salpingitis, tubo-ovarian abscess, and pelvic peritoni­
tis. Adolescent girls are disproportionately affected. Infection
occurs when lower genital tract (vagina, cervix) bacteria move
into the upper genital organs. Symptoms range from mild to
severe. The CDC recommends treatment for presumed PID in a
sexually active woman at risk for STis presenting with the mini­
mum clinical criteria of ( 1 ) lower abdominal or pelvic pain and
(2) uterine, adnexal, or cervical motion tenderness. Supportive
criteria include fever (> 38.3°C [ 1 00.9°F] ) , mucopurulent dis­
charge (vaginal, cervix), white blood cells on saline microscopy,
elevated inflammatory markers, and known positivity for N.
gonorrhoeae or C. trachomatis. Don't forget you have to rule out
alternative causes first. (See Table 1 -7.)
Question 1 0-8
Which is a bacterial cause of PID?
A) Neisseria gonorrhea.
B) Chlamydia trachomatis.
C) Ureaplasma urealyticum.
D) Haemophilus influenzae.
E) All of these bacteria can cause PID.
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 At the bar as prysoner holding vp his hand. 1559, 63.

[84] Whiche in other’s cause, coulde. 1559, 63.

[85] Lyke. 1559, 63.
[86] As mummers mute do stand N.
[87] Vnable to vtter a true plea of denyall. 1559, 63.
[88] When that. 1559.
[89] For halfe a ryall. 1559, 63.
[90] We could by very arte haue made the black. 1559, 63.
[91] And matters of most wrong, to haue appered most right.
1559, 63.
[92] Most wise, may chance be too too weake. N.
[93] But may be brought to stand. 1578.
[94] Stanzas 5 and 6 added 1571.
[95] Behold me one vnfortunate amongst this flocke. N.
[96] Cal’d sometime. N.
[97] By discent a gentleman. 1559, 63.
[98] ‘And’ omitted. N.
[99] State. N.
[100] To whom frowarde fortune gaue a foule checkmate.
1559, 63.
[101] In all our common. N.
[102] What so wee. 1559, 63.
[103] We did conclude. N.
[104] Both life, death, lands, and goods. N.
[105] So great gaine we did get. 1559, 63.
[106] And sises. 1578. N.
[107] Still chiefe. N.
[108] We let hang the true man. 1559, 63.
[109] Doth neuer keepe. 1559, 63.
[110] Whiche though it haue enough yet dothe it not suffyse.
1559, 63. And more at no time doth suffise. 1578.
[111] And drinke they neuer so much, yet styl for more they
cry. 1559, 63.
[112] So couetous catchers toyle. 1559, 63.
[113] Gredy and euer needy, prollyng. 1559, 63.
[114] Fayth we did professe. 1578.
[115] Makyng a solempne oth in no poynt to dygresse. 1578.
[116] Wretches. 1559, 63.
[117]

Of the judge eternall, more high to be promoted,

To mammon more then God, all wholly were deuoted.
1578.

[118] We interpreted. 1559, 63.

[119] Like a. 1559, 63.
[120] Many one. 1559, 63.
[121] To serue kings in al pointes men must sumwhile breke
rules. 1559, 63.
[122] Ful nie. 1559, 63.
[123] To crepe into whose fauour we. 1559, 63.
[124] Auayle. 1578.
[125] Wurde. 1559, 63. Sense. 1578.
[126] Sence, 1559, 63.
[127] Of land. N.
[128] Wyll. 1578.
[129]

The king thus transcendyng the limittes of his lawe,

Not raygning but raging by youthfull insolence,
Wise and wurthy persons did fro the courte wythdraw,
There was no grace ne place for auncient prudence:
Presumpcion and pryde with excesse of expence,
 Possessed the palays and pillage the countrye;
Thus all went to wracke vnlike of remedye. 1559, 63.

[130] Baronye. 1559, 63.

[131] Seing no reason. 1578.
[132] Maugre all. 1559.
[133] Maugre his princely mynde they. 1578. His kingly might.
N.
[134] All men vnchecked. 1578.
[135] Which. 1578.
[136] Regally. 1571, 78.
[137] That Richard. 1578.
[138] Order. 1578.
[139]

In whyche parliament muche thynges was proponed

Concerning the regaly and ryghtes of the crowne,
By reason kyng Richarde, whiche was to be moned,
Full lytell regardynge his honour and renowne,
By synister aduyse, had tourned all vpsodowne:
For suerty of whose estate,[143] them thought it did
behooue
His corrupt counsaylours, from hym to remooue. 1559,
1563.

[140] In the beginning of the parliament was called Robert

Veer, duke of Irelande, Alexander Neuell, archebishop of
Yorke, Mighell de la Poole, erle of Suffolk, sir Robert Tresilian,
chiefe iustice of Englande, to answere Thomas of Woodstock,
duke of Gloucester, Richard, erle of Arondel, Thomas, erle of
Derby, and Thomas erle of Nottyngham, vpon certaine articles
of high treason, which these lordes did charge them with. And
for as much as none of these appered, it was ordeyned by the
whole assent of the parliament that they shoulde be banished
for euer: and their landes and goodes, moueable and
vnmouable, to be forfeit and seased into the kinge’s hand, the
landes entayled onely except.
 Shortly after this, was founde Robert Tresilian, chiefe
iustice, lurkyng in a poticarie’s house at Westmynster, and
there founde the meanes to have spyes daylie vpon the lordes
what was done in the parliament: for all the dayes of his lyfe
he was craftie, but at the last his craft turned to hys
destruction: for he was discouered by his owne seruant, and
so taken and brought to the duke of Gloucester, and the same
daye had to the Towre, and from thence drawen to Tyborne,
and there hanged.
The morow after, syr Nicholas Pembroke, which afore had
been maior of the citie of London, against the citezen’s will,
was brought foorth. Grafton.
This man (Tresilian) had disfigured himselfe, as if he had
beene a poore weake man, in a frize coat, all old and torne,
and had artificially made himselfe a long beard, such as they
called a Paris beard, and had defiled his face, to the end he
might not be knowen but by his speach. Stowe.
[141] Tharchbyshop of Yorke was also of our band, 1578.
[142] See Statutes at large, temp. Rich. II. viz. 11. c. I. II. III.
20. c. VI. and 31. c. XII. XIII.
[143] State, 1559.
[144] Judge. 1578.
[145] To dye there as. 1578.
[146] The fickle fee of fraud. 1578.
[147] Ye iudges now liuing. 1578.
[148] Fye on stynkyng lucre, of all vnryght the lure, Ye judges
and ye justicers let my most iust punicion. 1559, 63.
[149] Al pure. 1578. Still pure. N.
[150] What glory is more greater in sight of God. 1578.
[151] By the pathes of equytie. 1559, 63.
[152] And truely. 1578.
[153] Alwayes. 1559, 63.
[154] Lawes for to scan. N.
[155] Reward. 1559, 63. That justice may take place without
reward. 1578.
[156] Take. 1559, 63.
[157] The righteous. 1578. The most iust. N.
[158] Of mortals displeasure. N.
[159] Closde. 1578.
[160] Worldly hyre. 1559, 63. Way not this worldly mucke.
1578.
[161]

If som in latter dayes, had called vnto mynde,

The fatall fall of vs for wrestynge of the right,
The statutes of this land they should not haue defynde
So wylfully and wittingly agaynst the sentence quyte:
But though thei skaped paine, the faut was nothing light,
Let them that cum hereafter both that and this compare,
And waying well the ende, they will I trust beware. 1559,
63.

[162] George Ferrers. These initials first added, 1571.

[163] This. 1559, 63. 71.
[164] When finished was this tragedy. 1578.
[165] Syr Roger Mortimer, earle of March, and heyre
apparaunt of England, whose. 1578.
[166] Purposed matter. 1578.
[167] Of these great infortunes, and as they be more auncient
in tyme, so to place their seuerall plaintes. 1578.
[168] Two earles of the name of Mortimer. 1578.
[169] One hanged in. 1559, 63.
[170] In the tyme of king Edward. 1578.
[171] Another in Richard the seconde’s time, slayne in Ireland.
1578.
[172] Fauours. 1578.
[173] Personage of the earle Mortimer, called Roger, who full
of bloudye woundes. 1578.
[174] To Baldwin, in this wise. 1578.
[175] The dates added 1571—Fabian has given a summary of
the life of the second Roger Mortimer, and upon which the
poet relied, as of 1387, but the death of Mortimer happened
about 1398.
[176] On. 1578.
[177] Thred, vntimely death dyd reele. 1578.
[178] Brought from boote to extreme bale. 1578.
[179]

——the queene so much was stir’d,

As for his sake from honour she did scale. 1578.

[180] Merye gale. 1559, 63.

[181]

And whilest fortune blew on this pleasaunt gale,

Heauing him high on her triumphall arch,
By meane of her hee was made earle of March. 1578.

[182] Breded. 1559, 63.

[183] Pride folly breeds in. N.
[184] Hym, 1559, 63.
[185] For where he somwhat hauty was before. 1559, 63.
[186]

Whence pryde out sprang, as doth appeare by manye,

Whom soden hap, aduaunceth in excesse,
Among thousandes, scarse shal you fynde anye,
Which in high wealth that humor can suppresse,
As in this earle playne proofe did wel expresse:
For whereas hee too loftye was before,
His new degree hath made him now much more. 1578.

[187] Ne recks. N.
[188] Respecting none saue only the queene mother. 1578.
[189] Which moued malice to foulder. 1578.
[190] Which deepe in hate, before. 1578.
[191] Th’one as well as th’other. N.
[192] They did the earle attaynt. 1578. He was soone attaint.
N.
[193] Such crimes as hidden lay before. 1578.
[194] For hydden hate. 1578. For enuy still. N.
[195] Biddes small faultes to make more bad. 1578.
[196]

Causing the king to yelde vnto the Scot,

Townes that his father, but late afore had got. 1578.

[197] Had, wanting, in 1559, 63. N.

[198] Yeuen to the Scots for brybes and priuie gayne. 1578.
[199] That by. 1578.
[200] Most, wanting. 1559, 63, 71. N. Most cruelly. 1578.
[201] And last of all by pyllage. 1578.
[202] Had spoyld. 1578.
[203] Dampned he was. 1578.
[204] Syr Roger Mortymer was accused before the lordys of
the parlyament of these artycles with other; whereof v. I fynde
expressyd. And firste was layed vnto his charge that by his
meaneys syr Edwarde of Carnaruan, by mooste tyrannouse
deth, in the castell of Barkley, was murderyd; secondaryly, that
to the kynge’s great dyshonoure and dammage, the Scottys,
by his meanys and treason, escapyd from the kyng at the
parke on Stanhope, whiche then shuld haue fallen in the
kynge’s daunger, ne had been the fauoure by the sayde Roger
to them than shewyd; thyrdely, to hym was layed, that he, for
execucion of the sayd treason, receyued of the capytane of
the sayd Scottis, namyd syr Iamys Dowglas, great summys of
money, and also for lyke mede he had, to the kynge’s great
dyshonoure and hurte of his realme, concludyd a peace
atwene the kynge and the Scottis, and causyd to be delyuered
vnto theym the charter or endenture called Ragman, with
many other thynges, to the Scottys great aduauntage and
impouerysshynge of this realme of Englande. Fourtlye, was
layed to hym, that where by synystre and vnlefull meanys,
contrary the kynge’s pleasure and wyll, or assent of the lordys
of the kynge’s counceyll, he had gotten into his possessyon
moche of the kynge’s treasoure, he vnskylfully wasted and
myspent it; by reason whereof the kyng was in necessyte, and
dryuen parforce to assaye his frendys. Fyfthlye, that he also
had enproperyd vnto hym dyuerse wardys belongynge to the
kynge, to his great lucre and the kynge’s great hurt, and that
he was more secret with quene Isabell, the kynge’s mother,
than was to Godde’s pleasure, or the kynge’s honoure: the
whiche artycles, with other agayne hym prouyd, he was, by
auctoryte of the sayde parlyament, iugyd to deth, and vpon
seynt Andrewys euyn next ensuynge, at London, he was
drawyn and hangyd. Fabyan.
[205] My coosins fall might. 1578. My cosin then might. N.
[206] Brybing, adultery and pride. 1578.
[207] I wene. 1578.
[208] ‘Deare,’ omitted. N.
[209] That dyd, 1559.
[210]

——heire of Lyonell,
Of king Edward the third the second sequell. 1578.
The third king Edward’s sonne, as stories tell. N.

[211] Cald. 1578.

[212] By true. 1578.
[213] Of ladies all the. 1578.
[214] Left in me. 1559, 63.
[215]

After whose death I onely stood in plight,

To be next heyre vnto the crowne by right. 1578.

[216] Of the. N.
[217]
 Touching the case of my cousin Roger,
(Whose ruful end euen now I did relate)
Was found in tyme an vndue atteindre. 1578.

[218] By lawe eche man of. 1578. By law each one of. N.
[219]

Should be heard speake before his iudgement passe,

That common grace to him denyed was. 1578.

[220] In court of. 1578.

[221] His atteindre appering erroneous. 1578.
[222]

A president worthy, in record left,

Lorde’s lygnes to saue, by lawless meanes bereft. 1578.

[223] While fortune vnto me her grace did deigne. N.

[224] The. 1559, 63.
[225] Looser. N.
[226]

Whyle fortune thus did frendly me receyue,

Rychard the king, that second was by name,
Hauing none heire after him to reigne. 1578.

[227] That vnderstoode my bent. 1578.

[228]

And me to serue was euery manne’s entent,

With all that wyt or cunning could inuent. 1578.

[229] In hope. 1578.

[230] Chaunge their hue. 1578.
[231] For whiles fortune so luld. 1578.
[232] Dame. 1578.
[233] To dash me downe. 1578.
[234] Irish kernes. 1578.
[235]

My landes of Vlster vniustly to bereaue,

Which my mother for heritage did me leaue. 1578.

[236] Whom I did not regard. N.

[237]

The wylder sort, whom I did least regard,

And therfore the rechlesse manne’s reward. 1578.

[238] By auctoryte of the same parliament [in 1585-6] syr

Roger Mortymer, erle of the Marche, and sone and heyre vnto
syr Edmunde Mortymer, (and of dame Phylyp, eldest daughter
and heyer vnto syr Lyonell, the seconde sone of Edwarde the
thyrde) was soone after proclaymyd heyer paraunt vnto the
crowne of Englande; the which syr Roger shortly after sayled
into Irelande; there to pacyfye his lordeshyp of Wulstyr, whiche
he was lorde of by his foresayde mother: but whyle he was
there occupyed abowte the same, the wylde Irysshe came
vpon in noumbre, and slewe hym and moche of his company,
Fabyan.
[239] Nor helpe of frendes. 1578.
[240] Or. 1578.
[241] No law of armes they know. 1578.
[242] No foes. N.
[243] Their booty chiefe, they coumpt a dead man’s heade.
1578.
[244]

Their chiefest boote is th’aduersarie’s head,

They end not warre till th’enemie be dead. N.

[245] Their foes when they doe faine. N.

[246]
 Nor yet presume to make their match amisse,
Had I not so done, I had not come to this. 1578.
——I had been left aliue. N.

[247]

At naught I set a sort of naked men,

And much the lesse, seeming to flye away,
One man me thought was good ynough for ten,
Making small account of number more or lesse,
Madnesse it is in war to goo by gesse. 1578.

[248]

See here the stay of pompe and highe estate,

The feeble hold of this vncerteyn lyfe. 1578.

[249] Hauing fayre fruict by my belooued wyfe. 1578. Syr

Roger had issu Edmunde, and Roger, Anne, Alys, and
Elanoure. Fabyan.
[250] Cavil. The “Ca.” was first affixed in 1571, and is repeated
in all the subsequent editions, except that of 1578, where
there appears “T. Ch.” the supposed signature of Thomas
Churchyard. As from that edition we shall have to notice,
presently, another similar alteration, it makes it doubtful
whether the same can be considered a misprint, though it
does not appear in the enumeration of his own pieces made
by Churchyard. See Bibliographia Poetica. Since this note was
printed the claim of ‘Master Chaloner’ to this signature has
been discovered. See postea, p. 53, n. 1.
[251] Was, omitted. 1578.
[252] Not to be treated of, 1559, 63.
[253] In the seuententh yere (1394) came oute of Scotlonde
certayne lordes into Englonde, to gete worshypp by fayte of
armes. The earl of Morris chalenged the erle marchall of
Englonde to juste wyth hym on horsbacke wyth sharpe
speres. And soo they roode togyder certayne courses, but not
the full chalenge. For the Scottyshe erle was caste bothe
horse and man, and two of his rybbes broken wyth the same
fall, and soo borne home into his inne. And anone after was
caryed homeward in a lytier. And at Yorke he deyed. Syre
Wyllyam Darell banerer of Scotlonde, and syre Pyers
Courteney the kynge’s banerer of Englonde roode togyder
certayne courses of warre hitte and assayed. The Scottisshe
knyghte seenge that he myghte not haue the better, yaue it
ouer: and wold noo more of the chalenge. Thenne one
Cokburne, squyer of Scotlond, and syre Nicholl Hauberk,
roode fyue courses, and at euery course the Scot was caste
bothe horse and man. Polychronicon.
[254] And whan thys ryall maryage was done and fynysshed
kynge Rycharde wyth dame Isabel his quene came into
Englonde. And the mayre of London, with all his brethren,
wyth grete multytude of the comyns of the cyte and the
craftes, receyuyd hym worshypfully at Blackheth, and brought
hym to Saynt Georges barre. And there taking their leue, the
kyng and quene roode to Kenignton. And after that wythin a
whyle the quene came to the toure of London, at whose
comyng was moche harme doo, for on London bridge were ix
persones thrust to deth, of whom the priour of typre was one.
Polychronicon. The prior of Tiptor, in Essex, was one. Stowe.
[255] Muche myndyng, 1559, 63.
[256] Date, added. 1571.
[257] Is stablysht. 1559, 63. Who stablisht is in state, seeming.
1578.
[258] Turne thine eare to. 1578.
[259] Prest in presence on fortune to. 1578.
[260] Of the. 1559, 63.
[261] Who by discent was of the. 1578.
[262] Nought. N.
[263] Before, eyther since. 1559. Or since. N.
[264] Most false fayth. 1578.
[265] Marcht. N.
[266] Thus hoysted high on fortune’s whyrling wheele. 1578.
[267] For whan fortune’s flud ran with. 1559, 63.
[268] I beynge a duke discended of kinges. 1559, 63.
[269] In. 1559, 63.
[270] Esperaunce. 1559, 63, 71. Assurance. 1578.
[271] All, omitted. N.
[272] To appoynt. 1559, 63.
[273] And for to settle others in their place. N.
[274] So, omitted. N.
[275] On a bell. N.
[276] Or. 1559, 63.
[277] Haply, omitted. N.
[278] For doyng on. 1559, 63. On, omitted. N.
[279] A sore checke. 1559, 63. I vnaduised caught a cruell
checke. N.
[280] Renown’d. N.
[281] For the tale of the rats, whence originates the proverbial
observation, “Who shall bell the cat?” see the vision of Pierce
the Plowman, by Crowley, ed. 1550, fol. iii. by Dr. Whitaker,
1813, p. 9.
[282] Expound. N.
[283] To curb. N.
[284] ’Bout. N.
[285] T’obay. N.
[286] It fits not a subiect t’haue. N.
[287] Thys by wurde. 1559, 63.
[288] And, omitted. N.
[289] Erle. 1559, 63.
[290] We by our power did call a parlament. N.
[291] With our. N.
[292] Playnely we depriued him of. 1559, 63.
[293] T’vnderstand. N.
[294] Thus wrought. 1578.
[295] By subiectes thus in bondage to bee brought. 1578.
[296] His. 1559, 63.
[297] Former cause of rancour to. 1578.
[298] Accoumpt. 1578.
[299] Were by me. 1559, 63.
[300] In the twentyest yere kynge Rycharde dide holde a grete
feeste at Westmestre. Att whyche feest aryued the souldyours
that hadde kepte Breste, and satte att dyner in the halle. And
after dyner the duke of Glocestre sayd to the kynge: “Syre,
haue ye not seen those fellowes that sate at dyner in your
halle.” And the kinge demaunded who they were. And he
sayde: “Thyse ben your folke that haue serued you, and ben
come from Breste. And now wote not what to doo, and haue
ben euyl payed.” Thenne the kynge sayde that they sholde be
payed. Thenne answered the duke of Gloucetre in a grete
furye: “Syre, ye oughte fyrste to put your body in deuoyre to
gete a towne, or a castell by fayte of warre vpon youre
enmyes, er ye sholde selle or delyuer ony townes that your
predecessours, kynges of Englonde, haue goten and
conquered.” To the whyche the kynge answerde ryght angrely:
“How saye ye that?” Thenne the duke his vncle sayd it
agayne. Thenne the kynge beganne to wexe wrothe, and
sayd: “Wene ye that I be a marchaunte or a foole to sell my
londe. By saynt Iohnne Baptyst naye: but trouthe it is that our
cosyn of Brytayne hath rendred and payd to vs the somme
that my predecessours had lent vppon the sayd towne of
Breste, and syth he hath payd, it is reason that this towne be
delyuered to hym agayne.” Thus beganne the wrath bitwene
the kynge and his vncle. Polychronicon.
[301] To claime entertainment the town beyng solde. 1559, 63.
To clayme their wages. 1578.
[302]

Of hate in hys hert hourded a tresure. 1559, 63.

Fulfyld his hart with hate. 1578.

[303] Nor. 1559, 63.

[304] But frendship fayned, in proofe is found vnsure. 1578.
[305] With long sicknesse diseased very sore. 1578.
[306] I was confedered before. 1578.
[307] Such aduauntage. 1578.
[308] Eame. This word is used repeatedly in the legends by
Ferrers. In the above passage it means uncle. It was also a
term for a gossip, compeer, or friend.
[309] To goe before. 1578.
[310] Preparedst a playne waye. 1578.
[311] What measure to others we awarde. 1578.
[312] The initials of George Ferrers, first added, 1571.
[313] This. 1559, 63, 71.
[314] Tragedy of the Lord Mowbray, the chief wurker of the
duke’s distruction, 1559, 63.
[315] To the state of a duke, added. 1571.
[316] Lykely. 1559, 63.
[317] Marke, I will shew thee how I swerued. 1559, 63.
[318] A vertuous mynde. 1559, 63.
[319] The herte to evyll to enclyne. 1559, 63.
[320] Kynde. 1559, 63.
[321] I thanke her, was to me so kynde. 1559, 63.
[322] Neyther of vs was muche to other holde. 1559, 63.
[323] Misprinted ‘thought’ by Higgins and Niccols.
[324] Wrong’d. N.
[325] Of England. 1578.
[326] Bad officers. N.
[327] Afore had. N.
[328] Aye seeks. N.
[329] The kinge’s fauour. 1578.
[330] Pryde prouoketh to. 1578.
[331] To poll and oppresse. 1578.
[332] And still. N.
[333] Him to. N.
[334] For pryde prickt me first my prince to flatter. 1578.
[335] Who so euer. 1578.
[336] Nere. N.
[337] Because of holdes beyond the sea that he solde. 1578.
[338] My. 1559, 63.
[339] Though vnto all these ils I were a frend. N.
[340] The duke of Gloucester for me did send. N.
[341] From place. 1578.
[342] Bewrayed the king. 1559, 63, 71, 78.
[343] At Arundell was a counseylle of certayne lordes: as the
duke of Gloucetre, tharchebysshop of Caunterbury, the erles
of Arundeel, Warwyck, and Marchall, and other, for to
refourme the rule abowte the kynge. Whyche lordes promysed
eche to abyde by other and soo departed. And anone after the
erle Marchall, whiche was captayne of Calays, bewrayed and
lete the kyng haue knowleche of all theyr counseylle:
wherupon the xxv daye of August, the duke of Glocetre was
arested at Plassheye in Estsex, and brought to the toure of
London. And from thence sent to Caleys and there murthred
and slayne wyth out processe of lawe or justyce.
Polychronicon.
[344] Earle. 1559, 63.
[345] It out. 1559, 63, 71.
[346] The palme represse. N.
[347] Earle. 1559, 63.
[348] Earle. 1559, 63.
[349] Manteyneth. 1559, 63.
[350] An. N.
[351] Earle. 1559, 63.
[352] Warly. 1559, 63.
[353] Misprinted, brest. 1587.
[354] In the same yere (1398) fel a great debate and
dyssencyon bytwene the duke of Herforde, erle of Derby, on
that one partye, and the duke of Norfolke, erle marchall, on
that other partye. In soo moche that they waged battaylle and
caste downe their gloues whiche were take vppe before the
kynge and ensealed, and the day and place assigned at
Couentree. To whyche place the kinge came, the duke of
Lancastre, and other lordes. And whan both partyes were in
the feelde redy for to fyghte, the kyng toke the matere in his
owne honde: and forthwyth he exyled and banysshed the
duke of Herforde for ten yeres, and the duke of Norfolke for
euermore. The duke of Norfolke deyed at Venyse.
Polychronicon.
[355] Doubtfull. 1578.
[356] That. N.
[357] Shame. N.
[358] Are iust to. 1578.
[359] Is. 1559, 63.
[360] Herewyth. 1559, 63, 71, 78.
[361] Which made them thinke mee worse then any feende.
1578.
[362] For other griefe. 1578.
[363] I parted thence and. 1578.
[364] The duke of Norffolke whiche supposed to haue been
borne out by the kynge, was sore repentant of his enterprise,
and departed sorowfully out of the realme into Almaine, and at
the laste came to Venice, where he for thoughte and
melancolye deceassed. Hall.
[365] More pleasure and reliefe. 1578.
[366] Which was not longe. 1578.
[367] Loo! thus his glory grewe great, by my dispite. 1578.
[368] So enuy euer, her hatred doth acquite. 1578.
[369]

Sorrowe and false shame,

Whereby her foes do shine in higher fame. 1578.

[370] Running. 1559.

[371] T. Ch. This signature first added in the edition of 1571,
and has been uniformly believed to mean Thomas
Churchyard. However, it may be more confidently assigned to
Master Chaloner, i. e. Sir Thomas Chaloner.—In the British
Museum there is a fragment of the original edition of the Mirror
for Magistrates, as printed in folio, during the reign of Queen
Mary, and suppressed, as already noticed, by the Lord
Chancellor. The fragment consists of two leaves, and which,
unfortunately, are duplicates, commencing with the
interlocutory matter before the legend of Owen Glendower,
and ends with the eighteenth stanza of the same legend. It
begins “Whan Master Chaloner had ended thys so eloquent a
tragedy,” and therefore appears conclusive that the above was
written by Thomas Chaloner, and that the legend of Richard
the Second, by Ferrers, which now follows, was first written for
the edition of 1559.
When the legend of Jane Shore was added in 1563,
Baldwin says: “This was so well lyked, that all together
exhorted me instantly to procure Maister Churchyarde to
vndertake and to penne as manye moe of the remaynder as
myght by any meanes be attaynted at his handes:” which
compliment proves that the author was a new candidate, and
upon the signatures being first added in 1571, we find his
name affixed to “Shore’s Wife,” in full, Tho. Churchyarde, to
distinguish it from the above abbreviation for Thomas
Chaloner.
[372] About the feeste of seynt Bartholmew fell dyscension
and discorde atwene the duke of Herforde and the duke of
Norfolke, wherefore the duke of Herforde accusyd that other
that he had taken iiii M. marke of the kynge’s, of suche money
as he shulde therewith haue wagyd certeyne sowdyours at
Calays, he lefte vndon, and toke the same money to his owne
vse. But another wryter sayeth, that as the sayd ii dukys rode
vpon a tyme from the parlyament towarde theyr lodgynges,
the duke of Norfolke sayde vnto that other: “Sir, see you not
howe varyable the kynge is in his wordis, and how shamefully
he puttyth his lordes and kynnes folkys to deth, and other
exylyth and holdyth in pryson; wherfore full necessary it is to
kepe, and not for to truste moche in his wordis, for with out
dowte in tyme to come, he wyll by such lyke meanys bryng vs
vnto lyke deth and distruction.” Of which wordys the sayd duke
of Herforde accusyd that other vnto the kynge; wherefore
eyther wagyd batayle, &c. Fabyan.
[373] For where as maister Hall, whom in thys storye we
chiefely folowed, making Mowbray accuser and Boleynbroke
appellant, mayster Fabyan reporteth the matter quite contrary,
and that by the reporte of good authours, makyng
Boleynbroke the accuser, and Mowbray the appellant. Which
matter, &c. 1559, 63.
[374] Recordes of the parliament. 1578.
[375] We referre to the determinacion of the haroldes, or such
as may cum by the recordes and registers of these doynges,
contented in the mean whyle with the best allowed iudgement
and which maketh most for. 1559, 63.
[376] Richard the 2. 1578.
[377] I woulde (quoth one of the cumpany) gladly say
sumwhat for king Richarde. But his personage is so sore
intangled as I thynke fewe benefices be at this daye, for after
hys imprisonment, his brother. 1559, 63.
[378] King, omitted. 1559, 63.
[379] Thinke. 1559, 63, 71, 78.
[380] In the kinge’s behalf. 1559, 63.
[381] See him all. 1559, 63.
[382] Vpon a beere in. 1578.
[383] Makyng his mone in thys sort. 1559, 63.
[384] From his seat, and miserably murdred in prison. 1559,
63.
[385] Vertue to folow and vyces to keepe vnder. 1578.
[386] Boast of high byrth, sword, scepter, ne mace. 1578.
[387] Rayne do drops of thunder. 1578.
[388] Let kinges therfore the lawes of God embrace. 1578.
[389] That vayne delightes. 1578.
[390] Do gase vpon me. 1559, 63.
[391] Lyeth, for whom none late myght rout. 1559, 63.
[392] Princes. 1578.
[393] Loute. 1559, 63, 71. Dead and least dread, to graue is
caryed out. 1578.
[394] But earth and clay. 1578.
[395]

Behold the woundes his body all about,

Who liuing here, thought, 1578.

[396] Wilt nowe declare. 1571, 78.

[397] My vicious story, 1559, 63.
[398] They kepe not, doutles say I dare. 1559, 63.
[399] Tyll the one. 1559, 63.
[400] Without respect of. 1578.
[401]

I am a kynge that ruled all by lust,

That forced not of vertue, right. 1559, 63.

[402] But alway put false flatterers most in trust, 1559, 63.
In false flatterers reposinge all my trust. 1578.
[403] Embracinge sutch. 1578.
[404] Fro counsell sage I did alwayes withdrawe. 1578.
[405]

By faythfull counsayle passing not a strawe;

What pleasure prickt, that thought I to be iust:
I set my minde, to feede, to spoyle, to iust. 1559, 63.

[406] Of God or man I stoode no wise in awe. 1578.

[407] More. 1578.
[408]

And to augment my lecherous minde that must

To Venus’ pleasures alway be in awe. 1563.

The edition of 1559 reads “and all to augment,” &c.

[409] Which to mayntayne I gathered heapes of golde. 1578.