Health Assessment
Tanner Stages
Carnel C. Jackson, DNP, RN, FNP-BC
Case Study
Chief Complaint
“I have no facial hair like everyone else!”
Patient Profile
Name: Bobby Green
Age: 14 years old
Gender: male
History of Presenting Illness
Bobby is a 14-year-old Caucasian* boy with no significant past medical history that presents with concerns of delayed puberty.* He reports that most of his friends have begun to experience voice deepening, growth of facial hair, and pubic hair.* He reports that he is the shortest in his class as well.* His parents reported some concern regarding his slower growth rate over the past 18 months. The patient denies fatigue, weight loss, excessive exercise, and restrictive eating habits.*
Social History
- Lives with parents and two younger sisters
- Active in his high school math club
- Alcohol use: none
- Tobacco smoke: none
- Illicit drug use: none
Family History
- Mother: Seasonal allergies
- Father: Delayed puberty onset but “eventually caught up”*
- Maternal grandmother: Hypertension, diabetes mellitus type 2
- Maternal grandfather: Deceased—unknown history
- Paternal grandfather: Hyperlipidemia, hypertension, lung adenocarcinoma
- Paternal grandmother: Hypothyroidism, seasonal allergies, obesity
Review of Systems
- General: No weight loss, fatigue, or night sweats. Normal appetite.
- Skin: No acne or stretch marks.
- HEENT: No headaches, visual changes, or anosmia (loss of smell).
- Cardiovascular: No chest pain or palpitations.
- Respiratory: No shortness of breath.
- GI: No nausea, vomiting, diarrhea, or constipation.
- GU: No penile discharge, testicular pain, or gynecomastia. No history of cryptorchidism.*
- Musculoskeletal: No joint pain or swelling. Concern about short stature.*
- Neurologic: No weakness, seizures, or recent head trauma.
- Psych: Reports mild anxiety about delayed development but denies depression or mood swings.
- Hematologic: Denies easy bruising.
Physical Assessment
- Vital Signs: Within normal limits for age. Height: lower 25% percentile,* weight appropriate.
- General: Thin male child, appears stated age, cooperative.
- Height and Weight: Below the 5th percentile for age.
- HEENT: Normal, no visual field deficits.
- Thyroid: No enlargement or nodules.
- Chest: No gynecomastia.
- Genital Exam (Tanner Staging):
- Testicular volume: Tanner Stage I–II
- Penis: No significant enlargement (Tanner Stage I)
- Pubic hair: None or sparse, lightly pigmented (Tanner Stage I)
- Musculoskeletal: No scoliosis, full range of motion.
- Neuro: Intact, normal reflexes.
Diagnostic Testing
| Substance | Value | Normal Range |
|---|---|---|
| Total testosterone | 96 | 31-733 ng/dL |
| Free testosterone | 14 | 13-128 pg/mL |
| Luteinizing hormone | 0.9 | 0.1-7.8 IU/L |
| Follicular stimulating hormone | 3 | 0.3-10 mIU/mL |
| MRI head | ~ pending | benign/normal exam |
Assessment
- Most likely diagnosis: Delayed growth and puberty—supportive family history.
- Differentials include:
- Hypogonadotropic hypogonadism
- Hypergonadotropic hypogonadism
- Chronic illness
Treatment Plan
- Order additional labs including metabolic panel, thyroid panel, CBC, and bone age X-ray
- Monitor growth every 3-6 months
- Counsel with reassurance that this is likely a familial pattern
- Address self-esteem concerns
- Consider endocrine referral if labs suggest hypogonadism
Review Questions
Click the arrow to expand the section and view the correct answers.
- At what age is delayed puberty diagnosed in boys if no signs of testicular enlargement are present?
- 12 years
- 13 years
- 14 years
- 15 years
Answer:
C. 14 years
Feedback: In boys, delayed puberty is defined as the absence of testicular enlargement (≥4 mL) by age 14. In girls, its absence of breast development by 13. Testicular volume is measured with an instrument called an orchidometer.
- Which of the following findings would most strongly suggest a diagnosis of constitutional delay of growth and puberty (CDGP) rather than hypogonadotropic hypogonadism?
- Low FSH and LH levels
- Family history of delayed puberty
- Bilateral gynecomastia
- Bone age consistent with chronological age
Answer:
B. Family history of delayed puberty
Feedback: CDGP often has a familial pattern (“late bloomers”). Hypogonadotropic hypogonadism would present with low gonadotropins but without family history, and bone age would be normal or delayed in CDGP but significantly abnormal in pathologic cases.
- In males, Tanner Stage II is characterized by which of the following?
- Enlargement of testes and scrotum with minimal penile growth
- Coarse, curly pubic hair extending to the medial thigh
- Adult genitalia size and shape
- Sparse, downy pubic hair without testicular enlargement
Answer:
A. Enlargement of testes and scrotum with minimal penile growth
Feedback: Tanner Stage II marks the start of puberty in males: testicular volume increases (>4 mL), scrotum reddens and thins, but penile length remains largely unchanged.
- Which lab result pattern is most consistent with primary hypogonadism (hypergonadotropic hypogonadism) in a 14-year-old male?
- Low testosterone, low FSH/LH
- Low testosterone, high FSH/LH
- Normal testosterone, normal FSH/LH
- High testosterone, high FSH/LH
Answer:
B. Low testosterone, high FSH/LH
Feedback: In primary hypogonadism, the gonads fail, leading to low testosterone and compensatory high FSH and LH (hypergonadotropic). Secondary causes would have low testosterone and low gonadotropins.
- In evaluating short stature, which of the following would be the most appropriate initial imaging study?
- MRI of the brain
- CT scan of the abdomen
- Bone age X-ray
- Pelvic ultrasound
Answer:
C. Bone age X-ray
Feedback: Bone age X-ray is the first-line imaging to assess growth potential and diagnose constitutional delay. MRI is reserved if central causes are suspected.
- Pubic hair begins to appear during which Tanner stage in both males and females?
- Stage I
- Stage II
- Stage III
- Stage IV
Answer:
B. Stage II
Feedback: Pubic hair begins to appear in Tanner Stage II as sparse, lightly pigmented hair at the base of the penis or along the labia.
Clinical Pearls
All areas with asterisks are highlighted for a patient with this chief complaint.
Tanner Staging is used to assess pubertal development in children and adolescents. Providers’ staging is based on breast development (in cis gender girls) and genital development (in cis gender boys). Providers can also use pubic hair development in both sexes.
For girls:
- Thelarche (breast development)—usually precedes pubarche
- Menarche (first menstrual period)—usually follows 2 years after thelarche
- Early puberty (precocious) if < 9 years
- Delayed puberty > 13 years with no breast development
For boys:
- Testicular enlargement precedes pubic hair development
- Pubic hair (adrenarche) appears later in boys than girls
- Early puberty (precocious) if < 8 years
- Delayed puberty > 14 years without testicular enlargement
Additional tips:
- Track rate of height velocity, weight, and BMI, as early puberty may be associated with obesity in African American and Hispanic girls.
- Document clearly
- African American and Hispanic girls often enter puberty approximately 6 to12 months earlier than White peers.
- Boys show less racial difference in timing.
- Early puberty: < 8 years in girls, < 9 years in boys, evaluate for precocious puberty.
- Tanner staging is best documented separately for breasts/genitalia and pubic hair.
References
OpenAI. (2024). ChatGPT (June 7 version) [Large language model]. https://chat.openai.com/chat
Rosenfield, R. L. (2023). Normal puberty. UpToDate. Retrieved June 7, 2025, from https://www.uptodate.com/contents/normal-puberty
