EndocrinologyEndocrinology

CalciumCalcium

An otherwise healthy 6-week infant presents with a An otherwise healthy 6-week infant presents with a generalized seizure. She is exclusively breast fed. The generalized seizure. She is exclusively breast fed. The child is somewhat sleepy with a non focal examination.child is somewhat sleepy with a non focal examination.Lab dataLab data::Glucose Glucose 88 mg/dL 88 mg/dLSodium Sodium 141 mEq/L141 mEq/LCalcium Calcium 5.1 mg/dL5.1 mg/dLPhosphorus Phosphorus 9.1 mg/dL9.1 mg/dLMagnesiumMagnesium 2.1 mg/dL2.1 mg/dL

The most likely diagnosis is:The most likely diagnosis is:

a)a) Pseudohypoparathyroidism Pseudohypoparathyroidism

b)b) HypoparathyroidismHypoparathyroidism

c)c) Vitamin D deficiencyVitamin D deficiency

d)d) Albright’s hereditary osteodystrophyAlbright’s hereditary osteodystrophy

Actions of PTHActions of PTH

1.1.

2.2.

CaCa POPO44

NET EFFECTNET EFFECT

25 OH Vit D25 OH Vit D

1,25 (OH)1,25 (OH)22 Vit D Vit D

1 hydroxylase

3.3.

Gut

An otherwise healthy 6-week infant presents with a An otherwise healthy 6-week infant presents with a generalized seizure. She is exclusively breast fed. The generalized seizure. She is exclusively breast fed. The child is somewhat sleepy with a non focal examination.child is somewhat sleepy with a non focal examination.Lab dataLab data::Glucose Glucose 88 mg/dL 88 mg/dLSodium Sodium 141 mEq/L141 mEq/LCalcium Calcium 5.1 mg/dL5.1 mg/dLPhosphorus Phosphorus 9.1 mg/dL9.1 mg/dLMagnesiumMagnesium 2.1 mg/dL2.1 mg/dL

The most likely diagnosis is:The most likely diagnosis is:

a)a) Pseudohypoparathyroidism Pseudohypoparathyroidism

b)b) HypoparathyroidismHypoparathyroidism

c)c) Vitamin D deficiencyVitamin D deficiency

d)d) Albright’s hereditary osteodystrophyAlbright’s hereditary osteodystrophy

An otherwise healthy 6-week infant presents with a An otherwise healthy 6-week infant presents with a generalized seizure. She is exclusively breast fed. The generalized seizure. She is exclusively breast fed. The child is somewhat sleepy with a non focal child is somewhat sleepy with a non focal examination.examination.Lab dataLab data::Glucose Glucose 88 mg/dL 88 mg/dLSodium Sodium 141 mEq/L141 mEq/LCalcium Calcium 5.1 mg/dL5.1 mg/dLPhosphorus Phosphorus 9.1 mg/dL9.1 mg/dLMagnesiumMagnesium 2.1 mg/dL2.1 mg/dL

What is an important diagnostic consideration What is an important diagnostic consideration (i.e. what else is the child at risk for)(i.e. what else is the child at risk for)

DiGeorge syndrome – thymic aplasia, congenital heart DiGeorge syndrome – thymic aplasia, congenital heart

disease, immune deficiency disease, immune deficiency

Biochemical changes in ricketsBiochemical changes in rickets

Ca PO4 Bone Urine

NMinimalchanges

N RicketsAminoaciduriaPhosphaturia

Stage 1

Stage 2

Initial

Ca:PO4:Alk Phos:

9.7 3.12514

2 ½ weeks

9.8 3.52185

4 months

10.5 6.5 518

A. Normal Normal Low

B. Low Low Low

C. Low Increased Increased

D. Low Normal Normal

E. Normal Low Increased

CALCIUM PHOS ALK PHOS

Which is consistent with vitamin D deficiency rickets?

Choose correct answerChoose correct answer

A.A. Vitamin D deficiency ricketsVitamin D deficiency rickets

B.B. Renal osteodystrophy (renal rickets)Renal osteodystrophy (renal rickets)

C.C. BothBoth

D.D. NeitherNeither

1. Increased phosphate level

2. Increased PTH level

3. Increased creatinine level

B

C

B

THYROIDTHYROID

A 15 day infant has an abnormal newborn thyroid screen result: The baby was born on 5/27/07. His newborn screening tests, performed on 5/29/07 revealed:

  Normal rangeTSH 37 IU/ml < 20T4 10.1 g/dl 9-19

This child:a) Has congenital hypothyroidism and should be referred

to a congenital hypothyroidism treatment centerb) Will likely develop mental retardation if untreated c) Likely does not have any thyroid abnormalityd) Has an altered hypothalamic set-point for T4e) Should be started on thyroxine replacement

immediately 

Venipuncture: (1/25/01) Normal rangeTSH 488 IU/ml (0.3-5.5)T4 1.2 g/dl (4.5-12.5)

You are contacted by your state Neonatal Thyroid Screening Program. Baby X was born on 1/4/01. His newborn screening tests, performed on 1/6/01 revealed:

 Initial filter paper Normal rangeTSH >200 IU/ml < 20T4 2.1 g/dl 9-19

 

Congenital hypothyroidismCongenital hypothyroidism

Thyroid dysgenesis/agenesisThyroid dysgenesis/agenesis Prevalence 1 in 4,000 [Whites 1 in 2,000; Blacks Prevalence 1 in 4,000 [Whites 1 in 2,000; Blacks

1 in 32,000]1 in 32,000] 2:1 female to male ratio2:1 female to male ratio Clinical features include:Clinical features include:

hypotonia, enlarged posterior fontanelle, hypotonia, enlarged posterior fontanelle, umbilical hernia, indirect hyperbilirubinemiaumbilical hernia, indirect hyperbilirubinemia

Laboratory findings:Laboratory findings: Very high TSH and low T4 Very high TSH and low T4 Therapy: Thyroxine – keep TSH in normal rangeTherapy: Thyroxine – keep TSH in normal range

6 month female with congenital hypothyroidism

..following 4 months therapy

A baby who was born with gastroschisis has an A baby who was born with gastroschisis has an abnormal newborn thyroid screen at 3 days which abnormal newborn thyroid screen at 3 days which revealed a low T4 and normal TSH. revealed a low T4 and normal TSH.

Repeat venipuncture showed:Repeat venipuncture showed:T4 T4 2.1 2.1 μμg/dL g/dL (4.5-12.5) (4.5-12.5) TSH TSH 2.3 2.3 μμIU/mL IU/mL (0.3-5.0)(0.3-5.0)

The most likely diagnosis is:The most likely diagnosis is:

a)a) Hypothyroidism due to dysgenesis of the thyroid glandHypothyroidism due to dysgenesis of the thyroid gland

b)b) Central hypothyroidismCentral hypothyroidism

c)c) TBG deficiencyTBG deficiency

d)d) Hypothyroidism from excess iodine exposure Hypothyroidism from excess iodine exposure

e)e) Normal thyroid function (as the TSH is normal)Normal thyroid function (as the TSH is normal)

Central hypothyroidism - rareCentral hypothyroidism - rare

TBG deficiencyTBG deficiency1:28001:2800

vs.vs.

Thyroxine (T4)Thyroxine (T4)

Major product secreted by the thyroid Major product secreted by the thyroid Circulates boundCirculates bound to thyroid binding proteins to thyroid binding proteins

- thyroid binding globulin (TBG)- thyroid binding globulin (TBG) Only a Only a tiny fraction (< 0.1%) is freetiny fraction (< 0.1%) is free and diffuses into tissues and diffuses into tissues When we When we measuremeasure T4, we measure the T4 that is T4, we measure the T4 that is bound to bound to

proteinprotein The level of The level of T4T4 is therefore largely is therefore largely dependentdependent on the on the

amount of TBGamount of TBG Changes in T4Changes in T4 may reflect may reflect TBG variationTBG variation rather than rather than

underlying pathologyunderlying pathology

TBG TBG deficiencydeficiency

Central Central hypothyroidismhypothyroidism

Free T4 Low Normal

TBG level Normal Low

T3RU Low High

17 year old female who complains of easy fatigability. Her mother developed Graves’ disease at the same age.  

Thyroid function: Normal rangeTSH: 3.7 IU/ml 0.3-5.5T4: 13.4 g/dl 4.5-12 

17 year old female who complains of easy fatigability. Her mother developed Graves’ disease at the same age.  

Thyroid function: Normal rangeTSH: 3.7 IU/ml 0.3-5.5T4: 13.4 g/dl 4.5-12 Which of the following medication could explain the thyroid

function abnormality

a) INHb) Ortho Tri-Cylenc) Retinoid acidd) Ciprofloxacine) Doxycycline

Conditions that cause alterations in TBGConditions that cause alterations in TBG

Increased TBGIncreased TBG Decreased TBGDecreased TBGInfancy Familial deficiencyEstrogen Androgenic steroid treatment - OC Pill Glucocorticoids (large dose) - pregnancy Nephrotic syndromeFamilial excess AcromegalyHepatitisTamoxifen treatment

A 12-yr female has diffuse enlargement of the A 12-yr female has diffuse enlargement of the thyroid. She is asymptomatic. Her disorder is thyroid. She is asymptomatic. Her disorder is most likely associated with which of the following most likely associated with which of the following pathological processespathological processes

a) Infectiousb) Inflammatoryc) Autoimmuned) Toxic (drug)e) Neoplastic

Normal thyroid

Hashimoto thyroiditis

DCDC 16 year 7 month Growth failure x 1 1/2 years

LabsLabs:

TSH: 1008 µIU/ ml (0.3-5.0)T4: <1.0 µg/dl (4-12)

Antithyro Ab. 232 U/ml (0-1)A-perox Ab. 592 IU/ml (<0.3)

Prolactin: 29 ng/ml (2-18)

Cholesterol: 406 mg/dl (100-170)

DCDC

Start of thyroxineStart of thyroxine

BackgroundBackground: Autoimmune destruction of the thyroid Family history in 30-40% Lymphocytic infiltration

ClinicalClinical: Growth failure, constipation, goiter, dry skin, weight gain, slow recoil of DTR

LaboratoryLaboratory: High TSH Anti-thyroglobulin and anti-peroxidase antibodies

TherapyTherapy: Thyroxine

Hashimoto thyroiditisHashimoto thyroiditis

15 year old female with a history of easy fatigability. Found to have an elevated pulse rate at recent MD visit 

Thyroid function: Normal rangeTSH < 0.1 IU/ml 0.3-5.5T4 14.8 g/dl 4.5-12T3 580 ng/dl 90-190

Restlessness, poor attention spanEye changes

Goiter

Tachycardia, wide pulse pressure

Increased GFR- polyuria

DiarrheaMenstrual abnormalities

Myopathy

Antithyroid medication (Methimazole or Propylthiouracil [PTU]) Pros : 25% remission rate every 2 years

Cons: Drug induced side effects - skin rashes, agranulocytosis, lupus-like reaction

Radioactive iodine (131I)Pros : Easy. Essentially free of side effectsCons: Long term hypothyroidism

Surgery

Blockers if markedly hyperthyroid

Therapy for Graves diseaseTherapy for Graves disease::

Sexual differentiationSexual differentiation

Ambiguous genitalia is found in a newborn.Ambiguous genitalia is found in a newborn. The baby is noted to be hyperpigmented. The baby is noted to be hyperpigmented. Ultrasound demonstrates the presence of a Ultrasound demonstrates the presence of a uterus. The most useful test to aid in the uterus. The most useful test to aid in the diagnosis of this medical condition isdiagnosis of this medical condition is::

a)a) TestosteroneTestosterone

b)b) 17-hydroxyprogesterone17-hydroxyprogesterone

c)c) Serum sodium and potassiumSerum sodium and potassium

d)d) DHEASDHEAS

e)e) DHEAS/androstenedione ratioDHEAS/androstenedione ratio

Cholesterol

Pregnenolone

Progesterone

DOCA

Corticosterone

ALDOSTERONE

17 (OH) pregnenolone DHEA

17 (OH) progesterone Androstenedione

Compound S

CORTISOL

TESTOSTERONE

Desmolase

3--HSD 3--HSD 3--HSD

17-OH

17-OH

21-OH 21-OH

11-OH 11-OH

If she has salt wasting congenital adrenal If she has salt wasting congenital adrenal hyperplasia, which abnormalities are likely to hyperplasia, which abnormalities are likely to develop. True or False for eachdevelop. True or False for each

a)a) Increased serum potassiumIncreased serum potassium

b)b) Decreased serum sodiumDecreased serum sodium

c)c) Decreased bicarbonateDecreased bicarbonate

d)d) Decreased plasma cortisolDecreased plasma cortisol

e)e) Increased plasma renin activityIncreased plasma renin activity

T

T

T

T

T

A 1-year male infant has non palpable testes. A 1-year male infant has non palpable testes. Of the following, the most appropriate next step Of the following, the most appropriate next step would bewould be

a) Schedule a re-examination in 18 monthsb) Refer the patient for an exploratory laparotomyc) Begin therapy with LHRHd) Measure the plasma testosterone after

stimulation with HCGe) Begin therapy with testosterone enanthate, 50

mg IM monthly for 3 months.

History

9 day old male infant

1 day history of decrease feeding, vomiting and lethargy.

Examination

Ill appearing infant with poor respiratory effort

Vital signs: T 99 F HR 100/min BP 61/40 RR 24/min

Resp: Subcostal retractions but clear to auscultation

Cardiac: Regular rate and rhythm. Normal S1 and S2

Abdomen: Soft, non distended. Non tender. No HSM

Neuro: Lethargic. No focal deficit

Genitalia: Normal male. Bilateral descended testes

Laboratory data:Laboratory data:

WBC 16.7

Hb 16.4

Hct 49

Plt 537 K

Na 121

K 9.3

Cl 83

CO2 6.7

Glucose 163

BUN/Creat 33/0.2CSF:

Chemistry: Protein 74 Glucose 82

Microscopy: WBC 6 RBC 100

Emergency therapyEmergency therapy

Fluid resuscitation:Fluid resuscitation:20 ml/kg Normal saline20 ml/kg Normal saline

GlucocorticoidGlucocorticoid2 mg/kg Solucortef IV2 mg/kg Solucortef IV

Monitor EKGMonitor EKG

Modes of presentationModes of presentation

ClassicalClassical Simple virilizingSimple virilizing Virilizing with salt lossVirilizing with salt loss

““Non classical” / Late onsetNon classical” / Late onset

Therapy and evaluation of therapyTherapy and evaluation of therapy

Glucocorticoid (Hydrocortisone)Glucocorticoid (Hydrocortisone) Monitor growth, 17-OHP, urinary pregnanetriolMonitor growth, 17-OHP, urinary pregnanetriol

Fluorocortisol (Florinef 0.1 – 0.45 mg/day)Fluorocortisol (Florinef 0.1 – 0.45 mg/day) Blood pressure, plasma renin activity (PRA)Blood pressure, plasma renin activity (PRA)

Supplemental saltSupplemental salt Until introduction of infant foodUntil introduction of infant food

History

15 year female presents with primary amenorrhea

Breast development began at 10 years

Examination

Height: 5 ft 7 in Weight 130 lb

Tanner 5 breast development

Scant pubic hair

What is your diagnosis?

XY GenotypeXY Genotype

TestosteroneTestosterone

EstradiolEstradiol

Androgen

Receptor

Estrogen

Receptor

Arom

atase

Complete androgen insensitivityComplete androgen insensitivity

History

15 year female presents with primary amenorrhea

Breast development began at 10 years

Examination

Height: 5 ft 7 in Weight 130 lb

Tanner 5 breast development

Scant pubic hair

Which of the following clinical features is the most likely to give you the correct diagnosis

a) Blood pressure in all 4 extremities

b) Careful fundoscopic examination

c) Rectal examination

d) Measurement of blood pressure with postural change

e) Cubitus valgus and shield shaped chest

Complete androgen insensitivityComplete androgen insensitivity

XY genotypeXY genotype Non functioning androgen receptorNon functioning androgen receptor Sertoli cells – AMHSertoli cells – AMH

Regression of Mullerian structuresRegression of Mullerian structures

Leydig cells – testosteroneLeydig cells – testosterone No functioning receptorNo functioning receptor Therefore Wolffian regressionTherefore Wolffian regression

Testosterone converted to DHT Testosterone converted to DHT – No functioning receptorNo functioning receptor– Therefore normal female external genitaliaTherefore normal female external genitalia

Early PubertyEarly Puberty

The earliest sign of puberty in a male is: The earliest sign of puberty in a male is:

a) Enlargement of the penisb) Enlargement of the testesc) Growth accelerationd) Pubic hair growthe) Axillary hair growth

2 year old girl with breast development2 year old girl with breast development– No growth accelerationNo growth acceleration– No bone age advancementNo bone age advancement– No detectable estradiol, LH or FSHNo detectable estradiol, LH or FSH

The most likely diagnosis is:a) Ingestion of her mother’s OCPsb) Precocious pubertyc) Premature adrenarched) Premature thelarchee) McCune Albright Syndrome

Benign Premature ThelarcheBenign Premature Thelarche

Isolated breast developmentIsolated breast development– 80% before age 2 80% before age 2 – Rarely after age 4Rarely after age 4Not associated with other signs of puberty Not associated with other signs of puberty (growth acceleration, advancement of bone age)(growth acceleration, advancement of bone age)Children go on to normal timing of puberty and Children go on to normal timing of puberty and normal fertilitynormal fertilityBenign processBenign processRoutine follow-up Routine follow-up

5 year female with 6 months of pubic hair growth. Very fine axillary hair as well as adult odor to sweat.No breast development

No exposure to androgens

Growth chart:Normal growth without growth acceleration

Most likely diagnosis:1. Precocious puberty2. Benign premature adrenarche3. Non-classical congenital adrenal hyperplasia4. Adrenal tumor5. Pinealoma

Benign Premature AdrenarcheBenign Premature Adrenarche

Production of adrenal androgens before true Production of adrenal androgens before true pubertal development beginspubertal development beginsPresents as isolated pubic hair in mid childhoodPresents as isolated pubic hair in mid childhood– No growth accelerationNo growth acceleration– No testicular enlargement in boysNo testicular enlargement in boysIf normal growth rate, routine follow-upIf normal growth rate, routine follow-upIf accelerated growth and/or bone age If accelerated growth and/or bone age advancement, screen for advancement, screen for – CAHCAH– Virilizing tumor (adrenal/gonadal)Virilizing tumor (adrenal/gonadal)

Choose correct answerChoose correct answer

A.A. Premature theralchePremature theralche

B.B. Premature adrenarchePremature adrenarche

C.C. BothBoth

D.D. NeitherNeither

1. Growth acceleration

2. Normal adolescent sexual development

3. Onset of gonadal function usually in 2-3 years

D

C

B

You suspect a 16 year female has Turner You suspect a 16 year female has Turner syndrome. The most definitive diagnostic test issyndrome. The most definitive diagnostic test is

a) Buccal smearb) Chromosome analysisc) Measuring her FSH and LHd) Determining her bone agee) Determining her testosterone level

5 year old girl with pubic hair and rapid growth. 5 year old girl with pubic hair and rapid growth. She has no breast developmentShe has no breast development

Possible sources of androgens:

1.Liver

2.Adrenal

3.Ovary

4.Pituitary

5.Pineal

T

F

F

F

T

5 year old girl with pubic hair and rapid growth. 5 year old girl with pubic hair and rapid growth. She has no breast developmentShe has no breast development

Which of the following should be considered Answer T or F for each:

a) Central precocious puberty

b) Congenital adrenal hyperplasia

c) McCune Albright syndrome

d) Benign premature adrenarche

e) Adrenal tumor

F

T

T

F

F

When does puberty occur?When does puberty occur?

Classic teachingClassic teaching– 8 -13 in girls 8 -13 in girls (menarche (menarche ~ ~ 2 years 2 years

after onset of after onset of puberty)puberty)

– 9 -14 in boys9 -14 in boys

Case:Breast development: 6 yearsMother had menarche: 9.5 years

WhyWhy

Reactivation of Reactivation of hypothalamic –hypothalamic –pituitary –gonadal pituitary –gonadal axisaxis

Gonadatropin dependent Gonadatropin dependent (central) precocious puberty(central) precocious puberty

Clock turns on earlyClock turns on earlyIdiopathicIdiopathic > 95 % girls> 95 % girls

~~ 50 % boys 50 % boys– Hypothalamic hamartoma (Gelastic seizures)Hypothalamic hamartoma (Gelastic seizures)– NF (optic glioma)NF (optic glioma)– Head traumaHead trauma– NeurosurgeryNeurosurgery– Anoxic injuryAnoxic injury– HydrocephalusHydrocephalus

TreatmentTreatment

WhyWhy– PsychosocialPsychosocial

– HeightHeight

WhatWhat– GnRH agonistGnRH agonist

Precocious puberty in the malePrecocious puberty in the male

Gonadotropins

Prepubertal Pubertal

Gonadotropin independentGonadotropin independent Central precociousCentral precociousprecocious pubertyprecocious puberty pubertypuberty

LH

GGLeydig cell

Precocious puberty in the malePrecocious puberty in the male

Gonadotropins

Prepubertal Pubertal

Gonadotropin independentGonadotropin independent Central precociousCentral precociousprecocious pubertyprecocious puberty pubertypuberty

HCG LH

**McCune Albright

syndrome

GG GG*

Familial malePrecocious puberty(testotoxicosis)

1. Gonadotropin independent PP2. Polyostotic Fibrous Dysplasia3. Café au lait macules

Leydig cell

This child may well develop1. Hypothyroidism2. Acoustic neuroma3. Precocious puberty4. Hypocalcemia and hyperphosphatemia5. Optic nerve hypoplasia

Growth disorders andGrowth disorders anddelayed pubertydelayed puberty

Delayed pubertyDelayed puberty

HypogonadismHypogonadism

HypergonadotropicHypogonadism (↑FSH, LH)

Primary gonadal failure- Chromosomal - iatrogenic (cancer therapy)- autoimmune oophoritis- galactosemia- test. biosynthetic defect

HypogonadotropicHypogonadism (FSH, LH)

Constitutionaldelay

Central Hypogonadism- Isolate gonad. def. - MPHD- Kallmann (anosmia)- Functional

A 15 yr boy has short stature and delayed A 15 yr boy has short stature and delayed puberty. He is now in early puberty (Tanner 2). puberty. He is now in early puberty (Tanner 2). His parents are of average stature. His height His parents are of average stature. His height and weight are just below 3and weight are just below 3rdrd percentile. percentile.

All of the following are likely except:All of the following are likely except:

a) A bone age of 12 ½ yearsb) Growth hormone deficiencyc) Adult height in the normal ranged) Acceleration of growth and sexual maturation

over the next 2 years.e) History of normal length and weight at birth

A 15 yr male has delayed puberty. He also has A 15 yr male has delayed puberty. He also has headaches, diplopia and increased urination. headaches, diplopia and increased urination. His height is < 3His height is < 3rdrd percentille percentille

Which of the following is the most likely Which of the following is the most likely diagnosis?diagnosis?

a) Diabetes mellitusb) Pinealomac) Cerebellar tumord) Craniopharyngiomae) Pituitary adenoma

A 14 yr male has tender gynecomastia (3 cm in A 14 yr male has tender gynecomastia (3 cm in diameter bilaterally). He is in early to mid diameter bilaterally). He is in early to mid puberty. In most cases the best management for puberty. In most cases the best management for this gynecomastia is:this gynecomastia is:

a) Treatment with an anti-estrogen (e.g. Tamoxifen)b) Treatment with an aromatase inhibitorc) Treatment with a dopamine agonist

(bromocryptine)d) Surgerye) Reassurance

MiscellaneousMiscellaneous

HypoglycemiaHypoglycemia

Decreased substrateDecreased substrate– Poor intakePoor intake– Defective glycogenolysis or gluconeogenesisDefective glycogenolysis or gluconeogenesis

Increase utilizationIncrease utilization– SepsisSepsis– HyperinsulinismHyperinsulinism

Absent counter regulatory hormonesAbsent counter regulatory hormones– GHGH– CortisolCortisol

Choose correct answerChoose correct answer

A.A. Hypoglycemia from hyperinsulinemiaHypoglycemia from hyperinsulinemia

B.B. Hypoglycemia from metabolic fuel depletionHypoglycemia from metabolic fuel depletion

C.C. BothBoth

D.D. NeitherNeither

1. Usually preceded by ketosis

2. Brisk respones to glucagon

3. Usually responds to oral glucose

B

A

B

Side effects of corticosteroids include all of the Side effects of corticosteroids include all of the following exceptfollowing except

a) hypertensionb) hypoglycemiac) decrease bone mineralizationd) myopathye) cataracts

What is the most likely diagnosis in this newborn infant?

1. Mother has SLE2. Anasarca from cardiac failure3. Systemic allergic reaction 4. Congenital nephrotic syndrome5. Turner syndrome

5 year old male with short stature

1. Turner syndrome2. VATER syndrome3. Albright’s hereditary osteodystrophy4. Noonan syndrome5. Goldenhar syndrome

A moderately obese adolescent female has A moderately obese adolescent female has irregular periods, hirsutism and acneirregular periods, hirsutism and acne

Of the following, which is the most likely Of the following, which is the most likely diagnosis?diagnosis?

a) Cushing syndromeb) Polycystic ovarian syndromec) Virilizing adrenal tumord) Non-classical CAHe) Hyperprolactinemia

Choose correct answerChoose correct answer

A.A. Diabetes mellitusDiabetes mellitus

B.B. Diabetes insipidusDiabetes insipidus

C.C. BothBoth

D.D. NeitherNeither

1. Osmolality of serum > 300 Osm/L

2. Osmolality of urine > 500 mOsm/L

3. Hypernatremia

C

A

B