endocrinology board review september 24, 2010. growth
TRANSCRIPT
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ENDOCRINOLOGY BOARD REVIEW
September 24, 2010
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Growth
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Growth
After 18mos of age, growth curve should be followed closely Between 4y/o and adolescence, growth
below 4-5cm/yr should be assessed Percentiles should not be crossed
Pubertal growth spurt Girls early puberty Boys midpuberty
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Growth Rate per Year
Age Inches Centimeters
Birth to 1 year 7 to 10 18 to 25
1 to 2 years 4 to 5 10 to 13
2 years to puberty 2 to 2.5 5 to 6
Pubertal growth spurt-girls
2.5 to 4.5 6 to 11
Pubertal growth spurt-boys
3 to 5 7 to 13
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Question 1
Choose the correct statement comparing “familial or genetically determined short stature” and “constitutional delay of growth,” in regards to bone age.
A. Familial = delayed/ constitutional = advanced
B. Familial = equivalent/ constitutional = delayed
C. Familial = delayed/ constitutional = equivalent
D. Both are delayed
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Constitutional delay of growth Variant of normal growth and pubertal
development Period of decreased linear growth within
first 3yrs of life Downward crossing of percentiles
Linear growth resumes at normal rate Along lower growth percentiles
Family history of “Late Bloomers”
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Constitutional Growth Delay: Note deceleration followed by normal growth rate
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Question 2
The physical findings depicted below corresponds to which tanner stage?
A. IB. IIC. IIID. IVE. V
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Tanner Staging
Boys: Staged by genital development and pubic hair – starts at 9-14 Testis volume >= 4mL is pubertal
Mark of pubertal onset Girls: Staged by breast development and
pubic hair – starts at 10 ½ Stage II = breast buds
Mark of pubertal onset Stage IV = Areola elevated above breast
(secondary mound)
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Hypothalamus and Pituitary
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Hypothalamus
Neuroectodermal tissue
Inferior third ventricle
Pituitary stalk
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Pituitary
Anterior Upgrowth of
ectodermal cells from Rathke’s pouch
Posterior Downgrowth of
neural tissue cells from the hypothalamus
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Question 3
You are evaluating a patient in clinic and notice the abnormality pictured. Which of the following is most likely to be affected?
A. Growth hormone levels
B. Aldosterone levelsC. Catecholamine
levelsD. Insulin levels
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Anterior Pituitary
Growth Hormone
Secretion GH-releasing factor
Inhibition Somatostatin
IGF-1, IGF-BP3
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Anterior Pituitary
Growth Hormone Deficiency
Normal birth weight Normal growth pattern x
1 year “Kewpie” doll
appearance, “cherubic” Short, excess subq fat,
retarded body proportion changes and high-pitched voices
Diagnosed with stimulation test
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Anterior Pituitary
ACTH
Secretion CRF from
hypothalamus
Inhibition Cortisol from
adrenals Prolonged steroid
use
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Anterior Pituitary
Gonadotropins Secretion
GnRH Hypothalamus sends
pulses Increases during puberty
Inhibition Inhibin
FSH Aromatase (androgen to
estrogen) Spermatogenesis
LH Testosterone Androstenedione (estradiol)
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Anterior Pituitary
TSH
Secretion TRH
Inhibition Thyroid Hormone
Actions Increases iodide
uptake, thyroglobulin synthesis and thyroid hormone
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Anterior Pituitary
Prolactin Acts directly on target organ Initiation and maintenance of lactation Inhibited by dopamine from hypothalamus Hyperprolactinemia
Galactorrhea Pituitary adenomas Medication
Neuroleptics, antipsychotics, estrogens and anti-hypertensives
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Question 4
You are on call in the PICU and following a very sick patient admitted with meningococcal meningitis. He has not had any urine output in the last 8 hours despite fluid administration. You order a BMP and his Na is 125. What is the most likely cause of the hyponatremia in this patient?
A. Diabetes insipidusB. Psychogenic polydipsiaC. Inappropriate fluid administrationD. SIADH
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Posterior Pituitary
Hormones synthesized in hypothalamus and stored in posterior pituitary
Vasopressin AVP or ADH Released in response to increased osmotic
pressure in the blood Water balance
Increased reabsorption of water in collecting ducts of kidneys
Arteriolar vasoconstriction – HTN Increased thirst
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Posterior Pituitary
Vasopressin Overproduction
Head trauma, brain tumors, encephalitis, pneumonia
SIADH HA, apathy, nausea, vomiting, impaired consciousness Decreased plasma osmolarity
Underproduction Central Diabetes Insipidus (DI)
Pituitary tumors, head trauma, infiltrative diseases, autoimmune or surgical
Increased plasma osmolarity
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Posterior Pituitary
Vasopressin Resistant
Nephrogenic DI Tubules in kidney cannot respond Genetic or acquired (lithium)
Oxytocin Released in response to nerve stimulation Contraction of the smooth muscle of the
uterus and myoepithelial cells lining the ducts of mammary glands
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Thyroid
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Thyroid
Location Neck Base of tongue Mediastinum
Hormones Thyroxine (T4) Tri-iodothyronine (T3) Need iodine for synthesis Transported by TBG,
albumin and transthyretin Free hormone is active
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Thyroid
Goiter Hyper or hypo
Nodules 70-80% benign or cystic 1-1.5% of all childhood
cancers Neck irradiation, family
history of medullary carcinoma, rapid growth, fixation to adjacent structures, enlarged lymph nodes
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Question 5
A mother brings in her teenage daughter for hyperactivity and emotional lability. ROS is positive for diarrhea, weight loss and heat intolerance. On physical exam you notice tachycardia and a slight prominence of the eyes. A laboratory evaluation would most likely reveal:A. TSH, freeT4, + TSH receptor antibodiesB. TSH, free T4, + antithyroperoxidase antibodiesC. TSH, free T4, + TSH receptor antibodiesD. TSH, free T4, + antithyroperoxidase antibodies
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Thyroid
Hyperthyroid Soft and fleshy gland Tachycardia Weight loss Increased frequency of
bowel movements Heat intolerance Nervousness Widened pulse
pressure Tremor Fatigue
Warm, moist skin Fine, friable hair Separation of distal
margin of nail bed Restlessness Inability to sit still Emotional lability Short attention
span Excessive sweating
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Thyroid
Hyperthyroidism Graves Disease
Stimulating antibody to TSH receptor
Exopthalmos Proptosis and lid lag
Large gland Warm on palpation
Bruit Labs
Increased T3 and T4 Decreased TSH
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Thyroid
Congenital Hypothyroidism 1 in 4000 Cretinism
Broad nasal bridge Coarse facial features Mental retardation Short stature Puffy hands Protuberant tongue Delayed skeletal maturation
Treatment within 3-4 weeks
Newborn Screening
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Thyroid
Hypothyroid Hypothalamic abnormalities Pituitary abnormalities Iodine deficiency Chronic lymphocytic thyroiditis Hashimoto thyroiditis
Anti-thyroid antibodies Thyroglobulin Thyroperoxidase
Positive FH Increased TSH, decreased T4
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Thyroid
Hypothyroid symptoms Firm or bosselated gland Congenital vs Acquired Dry skin Constipation Hair loss Fatigue Cold intolerance Apathy Depressed or delayed relaxation
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Acquired hypothyroidism: Note the sharp deceleration in growth before the onset of symptoms. Following initiation of therapy significant catch-up growth is seen.
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Calcium and Phos Metabolism
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PTH
Bone: Increases release of Ca and Phos
Intestine: Increased re-absorption of Ca and Phos
Kidney: Increases excretion of Phos Decreases excretion of Ca Stimulates Synthesis of Vit D3
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Effects of PTH
Bone Intestine
Kidney Net Effect
Ca
Phos
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Vitamin D
Bone Increases release of Ca Increases release Ph
Intestine Increases absorption of Ca Increases absorption of Ph
Kidney Improves reabsorption of Ca Increases reabsorption of Ph
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Vitamin D
Bone Intestine
Kidney Net Effect
Ca
Phos
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Calcitonin
Bone Inhibits reabsorption of Ca Inhibits reabsorption of Ph
Intestine (no specific effects)
Kidney Decreases reabsorption of Ca Decreases reabsorption of Ph
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Net Effect of 3 Hormones
Ca Phos
Vit D
PTH
Calcitonin
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Hyperparathyroidism
Results in hypercalcemia
Manifestation of multiple endocrine neoplasia I (MEN 1) Autosomal dominant Islet cell tumors Zollinger-Ellison syndrome Pituitary tumors
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Symptoms:ParesthesiasIrritabilityMuscle CrampsTetanySeizures
Hypocalcemia
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Question 6
A two day old infant experiences a prolonged seizure with respiratory arrest requiring intubation. BMP reveals hypocalcemia, and CXR demonstrates absent thymic shadow. Genetic testing is likely to reveal:
A. Trisomy 21B. Trisomy 18C. Deletion of 22q11.2D. Deletion of 15q13.3E. DF508 Mutation
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Hypoparathyroidism
Idiopathic (Autoimmune) DiGeorge Syndrome
Dysmorphic features Cardiac defects Immune deficiency Thymic aplasia Low PTH Deletion of 22q11.2 May present with seizures secondary to
hypocalcemia
Ca low
P high
PTH low
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Pseudohypoparathyroidism
PTH is elevated Unresponsiveness to PTH
(Bone/Kidney/Both) Albright hereditary osteodystrophy
Suspect in short child with hypocalcemia
Ca lowP highPTH high
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Albright hereditary osteodystrophy
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Vitamin D-Deficient Rickets
Vitamin D deficiency may result from Inadequate sunlight exposure Malabsorption Drugs that affect Vit D
Phenytoin, phenobarb Signs/Symptoms
Poor linear growth Delayed walking Muscle weakness Bone pain Hypotonia Anorexia
Ca NL/lowP lowPTH highAlkP high
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Vitamin D-Deficient Rickets
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Others
Vitamin D-Resistant Rickets Resistance to Vit D, even when high
amounts used Findings in first months of life
Pseudovitamin D-Deficiency Rickets AKA 1 -a hydroxylase deficiency or Vit-D
dependent rickets type I Findings appear in early infancy Autosomal recessive
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Adrenals
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Adrenal Gland
Cortex Glucocorticoids Mineralocorticoids Androgens
Medulla Epinephrine Norepinephrine
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Adrenal Glands
Cushing Excessive glucocorticoids
Endogenous or exogenous steroid exposure
Causes Adrenal tumors Pituitary adenomas (Cushing disease) Ectopic ACTH production
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Adrenal Gland
Features of Cushings Rounded facies Plethora Central obesity Impaired linear growth Fatigue Hypertension Buffalo hump Muscle weakness and muscle wasting Skin is thin and easily bruised Osteopenia/osteoporosis
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Adrenal Gland
Cushings Labs Elevated 24-hour
urine free cortisol excretion
Elevated salivary cortisol
Delineating the cause High- and low-
dose dexamethasone suppression tests
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Adrenal Gland
Addison’s Disease Insufficiency
Glucocorticoid Mineralocorticoid
Causes Autoimmune destruction Tuberculosis Autoimmune polyendocrine syndromes Adrenoleukodystrophy, Wolman disease, hereditary
unresponsiveness to ACTH, Allgrove syndrome, and congenital adrenal hypoplasia
Massive adrenal hemorrhage can occur with meningitis or traumatic births
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Adrenal Gland
Addison’s Weight loss Wasting of
subcutaneous tissue
Hyperpigmentation Weak Confused Decreased
circulating plasma volume
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Adrenal Gland
Addison Labs
Hyponatremia Hyperkalemia
Less pronounced disease in ACTH deficiency
If untreated Weaken Vascular collapse
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Question 7
A 3-week-old female infant is brought to the ER for vomiting, decreased oral intake and lethargy of 3 days’ duration. Because the infant had not regained her birthweight at the 2-week visit, the mother was instructed to wake her every 2 hours to breastfeed. On PE, the infant’s temp is 98.6F, HR 190, BP 60/30. She appears thin and lethargic and has a poor suck. Her anterior fontanelle and eyes appear sunken, and her CR is 3 secs. You note an enlarged clitoris and partial labial fusion. Assessment of serum electrolytes in this infant is MOST likely to reveal
A. HyperchloremiaB. HyperglycemiaC. HypernatremiaD. HypokalemiaE. Hyponatremia
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Adrenal Gland
CAH Autosomal recessive Symptoms reflect specific defect
21-hydroxylase deficiency Most common Decreased glucocorticoid
Hypoglycemia Decreased mineralocorticoid (severe forms)
Salt-wasting Hyperkalemia/hyponatremia
Elevated 17-hydroxyprogesterone Excess androgens
Masculinization Shock and death if untreated
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Adrenal Gland
Other forms of CAH Less severe 21-hydroxylase deficiency
May present later Premature pubarche, rapid growth, skeletal
maturation
11β-hydroxylase
17α-hydroxylase Delayed puberty Undervirilization of males
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Adrenal Gland - Medulla
Pheochromocytoma Rare Catecholamine-secreting tumor
Norepinephrine, Epinephrine, Dopamine (rarely) Symptoms
HA, diaphoresis, palpitaions, tremor, nausea, weakness, anxiety, weight loss
Hypertension (episodic), AMS, arrhythmia Syndromes
MEN 2A, 2B, NF, VHL Diagnosis
Plasma metanephrines, 24-hour urine catecholamines and metanephrine
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Sexual Differentiation
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Sexual Differentiation
SRY gene Short arm of Y chromosome Promotes differentiation of Sertoli cells Mutations lead to male to female sex
reversal Ambiguous genitalia
“the baby” Endocrine, urology, psychologist or social
worker Palpate for gonads
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Sexual Differentiation
Ambiguous Genitalia CAH
No palpable gonads 17-hydroxyprogesterone
Leydig cell hypoplasia, inborn errors of testosterone synthesis, androgen insensitivity Palpable gonads LH, FSH, testosterone,
dihydrotestosterone Complete androgen
insensitivity Externally female Uterus absent Labial or inguinal gonads
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Sexual Differentiation
Persistent mullerian duct syndrome Persistance of structures
in normal 46,XY male Cryptorchidism or
testicular ectopia Defect in anti-mullerian
hormone Agenesis of the phallus
Developmental
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Question 8
You are examining a 2-week-old male infant for the first time and note an undescended right testicle. His mother asks when is the optimal time to correct this problem.
The MOST appropriate time at which to recommend surgical repair for this infant if spontaneous descent has not occurred is
A. 4 monthsB. 12 monthsC. 24 monthsD. 36 monthsE. 48 months
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Cryptorchidism
Migration Kidneys to scrotum 3% of male infants Treatment
6-12 months Orchiopexy
Increased risk for malignancy Surgical intervention
does not alter risk
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Precocious Puberty
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Precocious Puberty
Girls <8
Boys <9
Central Gonadotropin-dependent
Activation of HPG axis FSH, LH
Hypothalamic hamartomas Gelastic seizures
Intracranial neoplasms
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Precocious Puberty
Gonadotropin-independent Increased gonadal steroids No HPG axis involvement McCune-Albright syndrome
Café-au-lait Polyostotic fibrous dysplasia Precocious puberty
Gonadal or adrenal neoplasms Rare
Familial male-limited precocious puberty
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Question 9
During the hospital discharge examination of a term female neonate, you palpate a 1-cm mass beneath her right nipple. There is no erythema at the site and no discharge from either nipple. The mass is nontender and freely mobile. The genitalia appear mildly swollen but are otherwise normal.
Of the following, the MOST appropriate treatment is
A. Excisional biopsyB. Fine-needle aspiration of the massC. IM gonadotropin-releasing hormoneD. Oral cephalexinE. Reassurance of the parents
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Premature Thelarche
Breast tissue development Uni or bilateral May regress or persist
Diagnosis of exclusion No other signs of pubertal
development Exogenous estrogen
1-2y Self-limited Normal in neonates
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Premature Pubarche
Pubic hair <8y in girls; <9.5y boys
Axillary hair, body odor, acne
Due to Premature adrenal
pubertal maturation PCOS
Late onset CAH Tumor - rare
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Delayed Puberty
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Delayed Puberty
Constitutional Delay Normal variant
Central Kallmann Syndrome
Hypothalamic hypogonadism Acquired
Trauma, neoplasm, infiltrative disorders, hyperprolactinemia, chronic illness - anorexia, CF, sickle cell
Gonadal Turner, Klinefelter Trauma, chemotherapy, radiation
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Delayed Puberty
Other Androgen insensitivity
Inguinal or labial mass Primary amenorrhea
17-hydroxylase deficiency Cannot produce sex steroids
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Turner Syndrome
XO Short stature Gonadal failure
Streak ovaries Other
Cubitus valgus, shieldlike chest, webbed neck
Cardiac Renal
Mosaic
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Klinefelter Syndrome
47, XXY
Small, firm testes
Gynecomastia
Neurobehavioral difficulties
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You will get more diabetes than you ever dream of on Purple team!
Diabetes
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Hypoglycemia
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Hypoglycemia
Signs and symptoms ANS, Epinephrine, CNS
glucopenia Fasting vs. Stress vs.
Iatrogenic
Hyperinsulinism Most common cause in
neonates Mutations of enzymes,
iatrogenic, adenoma Beckwith-Wiedemann
Macrosomia, macroglossia, omphalocele, hemihypertrophy and embryonal tumor
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Hypoglycemia
Ketotic hypoglycemia Common cause of childhood hypoglycemia 18 months to 5 years Resolves by 8 to 9 years
Other Hypopituitarism, GSD, disorders of
gluconeogenesis
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Obesity
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Question 10
You care for a 17-year-old boy who is overweight. He has gained 44 lb (20 kg) in the last year, especially in his abdominal area. On examination today, his blood pressure is 158/90 mm Hg using a large, appropriately sized cuff. His mother has a similar body habitus and is being treated for type 2 DM. Of the following, the MOST likely abnormalities to expect in this patient if his presentation continues into adulthood is
A. High triglycerides and low HDLB. Hypoglycemia from insulin sensitivityC. Low concentrations of C-reactive protein in the bloodD. Low fibrinogen concentration with bleeding diathesesE. Low triglycerides and low LDL
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Obesity
Look for causes of secondary obesity Endocrine Genetic CNS
Metabolic Syndrome Obesity Insulin resistance Dyslipidemia HTN Increased risk of developing Type 2 DM and
CV disease Look for PCOS
Hyperandrogenism, irregular menses, chronic anovulation