16-yo girl, recent weight loss, weak etc etc.

[DrMetal]

{UW question 5471}
16-yo girl, lost 10 lbs in 3 months, feels weak/tired, decreased appetite, last menstrual was 2 months ago, denies sex and drugs (with mom present), PE only remarkable for decreased axillary/pubic hair and mild myalgias.

Question stem is "Which of the following is the most adequate statement to make about her case?
a) seems to be anorexia nervosa
b) seems to be a medical condition (27%)
c) seems to be depression
d) there is nothing to worry about
e) let me ask her some questions in private before giving an opinion (59%)

Correct answer according to UW is b). With respect to e), the explanation states that this is wrong, but does not give a clear reason why. It states that questioning in private is a good thing to do to collect more history, but that this is not necessary in this case, that we have enough information already and "there is no need for a private talk".

I kinda disagree (and apparently the majority of respondents picked answer E). She could be depressed and not admitting to something in front of her parent, or lying about sex/drugs. In any case, it certainly wouldn't be a waste of time to talk to her in private, and doing so might yield important information. no? thoughts?

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[Gliabelle]

I'm not in med school, and not even going in that direction, but I can tell you my immediate thoughts reading this. For most 16-year-old girls, unless they were already very thin, 10 lbs would not be enough visible weight loss to arouse immediate concern in parents, and the tiredness/weakness and loss of appetite seem more likely to be self-reported than parental observations, rendering anorexia unlikely. Ten pounds over three months is also not normally enough weight loss, nor rapid enough weight loss, by itself, to trigger ammenorrhea, and taken together with the axillary/pubic hair reduction and myalgia it all seems to point fairly clearly to a hormone problem.

 

[DrMetal]

I'm not in med school, and not even going in that direction, but I can tell you my immediate thoughts reading this. For most 16-year-old girls, unless they were already very thin, 10 lbs would not be enough visible weight loss to arouse immediate concern in parents, and the tiredness/weakness and loss of appetite seem more likely to be self-reported than parental observations, rendering anorexia unlikely. Ten pounds over three months is also not normally enough weight loss, nor rapid enough weight loss, by itself, to trigger ammenorrhea, and taken together with the axillary/pubic hair reduction and myalgia it all seems to point fairly clearly to a hormone problem.

Yes, I see your logic, and that what seems to be the logic of USMLE world. I agree that a hormonal problem should be in the differential (higher than anorexia and if the question were asking for a diagnosis that's what I'd pick). However, also in the differential would be major depressive disorder (she's answering some of the SIGECAPS stuff affirmatively, with a duration of sx > 2 wks). I think there's not enough info to make a hard diagnosis, and so obtaining more info via a private interview would be useful.

In any case, talking to her privately is always a good idea (in my book at least, even if you're positive about the diagnosis, and that's what we were taught to do in all adolescent encounters). And it makes sense to do so. When I was 16, I certainly wouldn't have felt comfortable discussing sex/drugs in front of my parents at a doctor's visit (not like i was getting either ). thanks for the discussion.

 

[XPaeZX]

Yes, I see your logic, and that what seems to be the logic of USMLE world. I agree that a hormonal problem should be in the differential (higher than anorexia and if the question were asking for a diagnosis that's what I'd pick). However, also in the differential would be major depressive disorder (she's answering some of the SIGECAPS stuff affirmatively, with a duration of sx > 2 wks). I think there's not enough info to make a hard diagnosis, and so obtaining more info via a private interview would be useful.

In any case, talking to her privately is always a good idea (in my book at least, even if you're positive about the diagnosis, and that's what we were taught to do in all adolescent encounters). And it makes sense to do so. When I was 16, I certainly wouldn't have felt comfortable discussing sex/drugs in front of my parents at a doctor's visit (not like i was getting either ). thanks for the discussion.

I totally agree with you.. I also picked answer E), seems funny because I remember similar questions from Step 2 CK Qbank and uworld for step 2 in which the correct answer was something like: Get more information in private, inquire more, perform a private interview, ask the parents to leave the room etc. etc.

If I have the same question on the exam I would probably still go with answer E).. Getting more information is almost always never wrong.. unless the pt is crashing of course.

 

[prometheus09]

{UW question 5471}
16-yo girl, lost 10 lbs in 3 months, feels weak/tired, decreased appetite, last menstrual was 2 months ago, denies sex and drugs (with mom present), PE only remarkable for decreased axillary/pubic hair and mild myalgias.

Question stem is "Which of the following is the most adequate statement to make about her case?
a) seems to be anorexia nervosa
b) seems to be a medical condition (27%)
c) seems to be depression
d) there is nothing to worry about
e) let me ask her some questions in private before giving an opinion (59%)

Correct answer according to UW is b). With respect to e), the explanation states that this is wrong, but does not give a clear reason why. It states that questioning in private is a good thing to do to collect more history, but that this is not necessary in this case, that we have enough information already and "there is no need for a private talk".

I kinda disagree (and apparently the majority of respondents picked answer E). She could be depressed and not admitting to something in front of her parent, or lying about sex/drugs. In any case, it certainly wouldn't be a waste of time to talk to her in private, and doing so might yield important information. no? thoughts?

I have never seen depression or any drug/sexual activity result in decrease in axillary and pubic hair.

 

[DrMetal]

I totally agree with you.. I also picked answer E), seems funny because I remember similar questions from Step 2 CK Qbank and uworld for step 2 in which the correct answer was something like: Get more information in private, inquire more, perform a private interview, ask the parents to leave the room etc. etc.

If I have the same question on the exam I would probably still go with answer E).. Getting more information is almost always never wrong.. unless the pt is crashing of course.

I agree with your agreement. Yeah I do remember those questions in the Step 2 qbank. Perhaps management changes from Step 2 to Step 3?! Not . . . I think it's a bad question, or they're defending the wrong answer choice. I stand by answer E) . . .it's what I'll pick on the real test, and (more importantly) what I'd do in real life. It's just common sense.

 

[Rickson]

{UW question 5471}
16-yo girl, lost 10 lbs in 3 months, feels weak/tired, decreased appetite, last menstrual was 2 months ago, denies sex and drugs (with mom present), PE only remarkable for decreased axillary/pubic hair and mild myalgias.

Anorexia nervosa:
it's symptoms do include hair loss, fatigue, Amenorrhea, decreased apetite
pretty sure it is Anorexia nervosa