Page 1 of 8: recall MCCQE1

soko · Credits: 10608 My Scrapbook

LET US POST SOME

drsahar · Credits: 2137 My Scrapbook

there was this qs where
a father brings his 7 yr old son with tanner stage 2
you gotto choose wat investigations u want to do...there were 20 choices and you had to choose upto 5

soko · Credits: 10608 My Scrapbook

Sex steroid levels

Measurement of serum testosterone is useful in boys with suspected precocious puberty.
Early morning testosterone levels in boys in early puberty are higher than afternoon levels because LH and testosterone levels rise with sleep onset in early puberty.
The stages of puberty as indicated by serum testosterone levels are as follows:

Testosterone level less than 30 ng/dL – Generally prepubertal (Depending on the laboratory, testosterone levels of 11-30 ng/dL may represent early puberty)
Testosterone level of 30-100 ng/dL – Early pubertal
Testosterone level of 100-300 ng/dL – Mid-to-late pubertal
Testosterone level of more than 300 ng/dL – Adult
For girls, estradiol measurements are less reliable indicators of the stage of puberty. Many commercial assays are not sufficiently specific or sensitive enough to demonstrate an increase during early puberty. Levels that exceed 20 pg/mL usually indicate puberty, but some girls who are clearly pubertal may have levels of less than 20 pg/mL. In addition, estradiol levels may fluctuate from week to week. Girls who have ovarian tumors or cysts often have estradiol levels that exceed 100 pg/mL.
Levels of adrenal androgens (eg, dehydroepiandrosterone [DHEA], dehydroepiandrosterone sulfate [DHEAS]) are usually elevated in boys and girls with premature pubarche. DHEA-S, the storage form of DHEA, is the preferred steroid to measure because its levels are much higher and vary much less during the day. In most children with premature pubarche, DHEA-S levels are 20-100 mcg/dL, whereas in rare patients with virilizing adrenal tumors, levels may exceed 500 mcg/dL.
Consider obtaining a 17-OH serum progesterone study if congenital adrenal hyperplasia is suspected. If a random level is within the reference range, the diagnosis can be excluded; however, if the random 17-OH progesterone level is elevated, an adrenocorticotropic hormone (ACTH) (ie, Cortrosyn) stimulation test provides the greatest diagnostic accuracy.
Gonadotropins

Because of the development of more sensitive third-generation assays for LH, which can detect levels as low as 0.1 IU/L or lower, the random LH is now the best screening test for central precocious puberty (CPP). An LH level of less than 0.1 IU/L is prepubertal, and levels of 0.3 IU/L or more are pubertal. Random FSH levels do not discriminate between prepubertal and pubertal children. Suppressed levels of LH and FSH accompanied by highly elevated testosterone or estradiol levels point to precocious pseudopuberty rather than CPP.
A definitive diagnosis of CPP may be confirmed by measuring LH and FSH levels 20-40 minutes after infusion of GnRH (100 mcg); in CPP, the ratio of LH to FSH is usually 0.75 or greater. An increase in FSH levels much greater than the increase in LH levels suggests that the child is prepubertal. Some studies suggest that an increase in LH levels to more than 8 IU/L is diagnostic of CPP, but this depends on the specific LH assay used. No increase in LH and FSH levels after the infusion of GnRH suggests precocious pseudopuberty. As sensitive LH assays have become more widely available, GnRH testing is needed less often to diagnose CPP.
Thyroid: Thyroid tests are not a routine requirement in the evaluation of precocious puberty. Severe hypothyroidism rarely leads to precocious puberty. Major clues of severe hypothyroidism are growth arrest instead of growth acceleration, galactorrhea, and signs of thyroid hormone deficiency.

Imaging Studies

Radiography: Radiography of the hand and wrist used to determine bone age is a quick and helpful means to estimate the likelihood of precocious puberty and its speed of progression. If bone age is within one year of chronological age, puberty has not started (eg, a 2-year-old girl with premature thelarche) or the duration of the pubertal process has been relatively brief. If bone age is advanced by 2 years or more, puberty likely has been present for a year or more or is progressing more rapidly.
Head MRI

MRI may be indicated to look for a tumor or a hamartoma after hormonal studies indicate a diagnosis of CPP. Ask the radiologist to obtain a high-resolution study that focuses on the hypothalamic-pituitary area.
For healthy girls aged 6-8 years with no signs or symptoms of CNS disease, the likelihood of finding a tumor or hamartoma is only about 2%; therefore, this test may be unnecessary depending on the clinical situation.
The younger the child with CPP, the greater the chance of finding CNS Pathology (among children younger than 6 y).
For boys younger than 9 years, the incidence of CNS findings is much higher than in girls, and MRI should be part of the evaluation.
Pelvic ultrasonography

Ultrasonography is unnecessary for girls with a definite diagnosis of CPP. If performed, however, ultrasonography usually reveals bilaterally enlarged ovaries, often with multiple small follicular cysts, and an enlarged uterus with an endometrial stripe.
Pelvic ultrasonography is essential when precocious pseudopuberty is suspected in girls (based on examination or hormone levels) because an ovarian tumor or cyst may be detected.

soko · Credits: 10608 My Scrapbook

POST SOME MORE!!

Marzoukrz · Credits: 2496 My Scrapbook

the first thing you should determine :is it central or pripheral precocious puberty.pay attention to physical exam (testes ,penis lenght and width) ,Skin(cafe aulait spots),blood pressure,Height and weight , abdominal mass, .H/o(Headach ,vomitting),Abdominal pain.investigation start with bone age and end with MRI of the brain of course your are not suppose to do all these thing the guide is the history and phsical findings.back to the senario which says that the boy is tanner stage 2 which means that the teste is not large,so the problem is sparse pubic hair which could be normal or secondary to excessive androgen the source is either the adrenal gland(CAH,virilising adernal tumor)or the testes ,if the testes is the culprite there shoud be unilateral testecular enlargment.I think a valuable informations are missing.Good luck to every body.

drsahar · Credits: 2137 My Scrapbook

there was this one
What is the side effect of therapeutic level of TCA
a. Ectopic beats
b. bradycardia
c. PVC
d. arrhythmia
d. heart block( something like that)

drsahar · Credits: 2137 My Scrapbook

next
this couple come to youbecause they have 3 daudhters and this next child is also a girl. and they want a boy so they are here for an abortion the wife is 18 wks preg. what will you do
a. find out wat other alternative methods they can find to choose something else
b. consult with your collegue and see how you can help them
c. refer them to a gynecologist who can respect their autonomy
d. refuse to do it because its not considered morally acceptable to you
d. refer them to another physician who can help them.

munnacanada · Credits: 5077 My Scrapbook

For the first one I will choose Arrythmias

;Watch out for the 3 C's of TCA-Cholinergic bloackade, Convulsions and Cardiac arrythmias

2nd question:
couple come to youbecause they have 3 daudhters and this next child is also a girl. and they want a boy so they are here for an abortion the wife is 18 wks preg. what will you do
a. find out wat other alternative methods they can find to choose something else

like what !-get a male pet-lol, just joking

b. consult with your collegue and see how you can help them******************
c. refer them to a gynecologist who can respect their autonomy
d. refuse to do it because its not considered morally acceptable to you
d. refer them to another physician who can help them

asooma · Credits: 6422 My Scrapbook

c. refer them to a gynecologist who can respect their autonomy

kangaroos · Credits: 253 My Scrapbook

refer to a gynecologist for the abortion.
no question asked . we have to respect what they want.

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