ABIM Adolescent common mistakes
ABIM Adolescent · Understand the traps and how to avoid them.
Labels a healthy 13-year-old girl with Tanner 2 breasts and no menarche as having delayed puberty, then orders FSH/LH, karyotype, and pelvic ultrasound instead of observing.
The candidate memorized a single 'age 13' cutoff and conflates failure of pubertal onset with late menarche; anxiety about missing pathology overrides normal variation in tempo.
What to do instead
Separate the two diagnoses: delayed pubertal onset is no thelarche by 13 in girls or no testicular enlargement (≥4 mL) by 14 in boys, whereas delayed menarche is no menses by 15 or more than 3 years after thelarche. In a teen with normal growth velocity, normal exam, and a bone age consistent with chronological age, reassure and re-examine in 6 months.
Delivers only the 11–12-year vaccine set and never schedules a separate 16-year visit, so the MenACWY booster, MenB discussion, and HPV series completion are all missed.
Adult and early-childhood schedule habits dominate recall; the adolescent platform is really two distinct visits, and the candidate remembers only the first.
What to do instead
Memorize the two-visit platform. At 11–12: Tdap, MenACWY, HPV (2 doses if started before age 15), influenza annually. At 16: MenACWY booster, MenB shared clinical decision-making (16–23), HPV completion, plus catch-up for anything missed. Ask at every visit about the 16-year booster specifically.
Diagnoses major depressive disorder and starts an SSRI in a 15-year-old who describes five days of decreased need for sleep, grandiose plans, and unusually increased goal-directed activity.
Irritability and mood lability are automatically filed under depression; a mania screen is never performed, and collateral history from parents is not obtained.
What to do instead
Before prescribing any antidepressant, ask explicitly about past or current elevated or expansive mood, decreased need for sleep, racing thoughts, and any family history of bipolar disorder. Document the screen. If manic symptoms are present, treat as bipolar-spectrum illness and avoid antidepressant monotherapy.
Treats a sexually active 17-year-old with dysuria and a negative urinalysis as having a urinary tract infection and sends her home without a chlamydia/gonorrhea NAAT.
Anchoring on the familiar UTI frame; the candidate forgets that STIs are frequently asymptomatic and that urethritis classically produces dysuria with pyuria and a negative urine culture.
What to do instead
Any sexually active adolescent with dysuria, pyuria, pelvic pain, or abnormal discharge gets a NAAT for chlamydia and gonorrhea (and trichomonas where indicated), regardless of urinalysis results. Also build annual confidential chlamydia/gonorrhea screening for sexually active patients under 25 and offer HIV screening into every such visit.
Screens with 'Do you smoke?' plus a CAGE questionnaire, gets two 'no' answers, and documents 'no substance use.'
Nicotine is assumed to mean combustible cigarettes, so vaping and pouches are invisible to the question; CAGE was validated in adults and performs poorly in adolescents.
What to do instead
Use CRAFFT 2.1, which includes e-cigarette and cannabis items, and ask it alone rather than in front of a parent. Follow any positive with brief motivational interviewing and matched referral. Ask separately about alcohol, cannabis, nicotine/vaping, stimulants, and nonmedical prescription use.
Tells the family of a 14-year-old with a BMI of 26 kg/m² that he is 'obese' and counsels accordingly.
Adult BMI categories are applied directly to adolescents, ignoring that BMI must be interpreted against age- and sex-specific percentile curves because body composition changes through puberty.
What to do instead
Plot BMI on the CDC growth chart: 85th to under 95th percentile is overweight, 95th percentile or above is obesity. Pair the percentile with weight trajectory and comorbidity screening. Conversely, remember atypical anorexia nervosa in a patient with substantial weight loss whose BMI still looks normal.
Waits until the 18th birthday to first mention transition, then faxes records to an adult provider without a summary, self-management assessment, or warm handoff.
Transfer is treated as a single event triggered by a legal age rather than a multi-year skill-building process; the candidate has no model for what transition planning contains.
What to do instead
Start at 12–14 with a structured transition plan addressing disease self-management, medication and appointment independence, insurance literacy, and a written health summary. For youth with intellectual or developmental disability, begin guardianship or supported decision-making discussions well before 18, and confirm the adult provider accepts the patient before transferring.
Clears an athlete for same-day return to play once the post-concussion headache resolves, skipping any return-to-learn step.
The candidate is using abandoned concussion grading schemes; there is a reflex to equate symptom resolution with readiness, and the cognitive recovery phase is treated as optional.
What to do instead
Follow the stepwise protocol: complete return to learn first, then a graduated return to play with 24 hours at each stage and no more than light aerobic activity before full symptom freedom. Clear only after the athlete is asymptomatic at rest and with progressive exertion, and document each step.
Diagnoses candidal vaginitis in a 15-year-old with vulvar itching and discharge and prescribes fluconazole without any testing.
Adult gynecology patterns are carried over; the candidate does not recall that candida is uncommon in healthy adolescents unless there is recent antibiotic use, immunosuppression, or diabetes, and that bacterial vaginosis and physiologic discharge are far more likely.
What to do instead
Evaluate with vaginal pH, wet mount or KOH microscopy, and NAAT for trichomonas and chlamydia/gonorrhea as indicated; treat bacterial vaginosis with metronidazole rather than an antifungal. Use the presentation as an opening to take a confidential sexual history.
Discloses a 16-year-old's positive STI result to a parent because the parent is present and paying, or agrees not to examine the teen alone when a parent insists on staying in the room.
The candidate equates financial responsibility or parental presence with legal authority to receive information, and is unsure which services minors may consent to in their jurisdiction.
What to do instead
At the start of the visit, state confidentiality and its limits to both teen and parent, then interview the adolescent alone. Know that in most states minors may consent to STI testing and treatment and to contraception, and that billing and explanation-of-benefits can breach confidentiality. Disclose only with the teen's permission unless a safety exception applies.