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CASE 14.1

A 14-year-old male presents to your clinic with his mother for a routine well-child examination. The patient's mother has some questions about puberty. Her son enjoys playing sports and she is concerned that he may be too small to play football. The past medical history is unremarkable.

Question 14.1.1 Which of the following can you tell the mother will likely be the first sign of puberty in this boy?

A) Increase in penile length.

B) Enlargement of the testes.

C) Deepening of the voice.

D) Rapid increase in linear growth.

E) Coarsening of pubic hair.

Answer 14.1.1 The correct answer is "B." Increase in the volume of the testes is the first sign of pubertal development in boys. The age of onset of puberty in the past was 12 years (range 10–14), but recent studies have shown that the mean age of onset is now 1.5 to 2 years earlier than these historical norms. In a study including more than 4,000 healthy boys, the mean age for entering puberty was 10.14 years for Caucasian boys, 10.04 years for Hispanic boys, and 9.14 years for African-American boys. "E" is of special note. While pubic hair appears shortly after the onset of puberty, it is initially long and straight and not in a mature distribution. Coarsening of the pubic hair is a more advanced pubertal stage, occurring approximately 1.5 years after the onset of puberty; an increase in penile length occurs simultaneously. The maximal growth spurt occurs approximately 2 years after the onset of puberty. Changing of the voice is a secondary hormonal effect that is quite variable in nature.

From the mother, you learn that the patient's father began going through puberty during high school, and he did not reach his adult height until he was in college at about age 20. The patient's father is 5′ 10″ tall (∼178 cm). The mother is 5′ 3″ tall (∼160 cm). Physical examination reveals that your patient is Tanner stage I for genitalia and pubic hair. His height and weight continue to track along their previously established curves on the growth chart, both at approximately the fifth percentile. The remainder of the examination is unremarkable.

Question 14.1.2 What is your next step in evaluation of this patient's short stature?

A) Obtain hand radiographs to assess bone age.

B) Draw blood to test for growth hormone and testosterone levels.

C) Obtain an endocrinology consult.

D) Order computed tomography ...

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