• Pediatric Cushing features (obesity +purple stretch

marks in the abdomen +HTN), Initial management?

• A Head CT
• B Adrenal scintigraphy
• C Adrenal MRI
• D Early morning and evening serum cortisol
• Pediatric Cushing features (obesity +purple stretch
marks in the abdomen +HTN), Initial management?
• A Head CT
• B Adrenal scintigraphy
• C Adrenal MRI
• D Early morning and evening serum cortisol
• Intital testing for cushing sybdrome
• -Late night salivary cortisol
• -24 hours urine collection free cortisol
• -Late night dexamtahosepone test
• Earliest sign of puberty in male is:
• a) Appearance of pubic hair
• b) Increase testicular size
• c) Increase penis size
• d) Increase prostate size
• Earliest sign of puberty in male is:
• a) Appearance of pubic hair
• b) Increase testicular size
• c) Increase penis size
• d) Increase prostate size
• Earliest sign of puberty in males: testicular enlargement
• Earliest sign of puberty in female: breast enlargement
• 9 years came to your clinic and found breast is
Tanner stage 2
• What you will do
• A-US
• B-Bone age
• C-Hormonal test
• D-reassurance
• 9 years came to your clinic and found breast is
Tanner stage 2
• What you will do
• A-US
• B-Bone age
• C-Hormonal test
• D-reassurance
• 6 years old girl came with breast enlargement and
pubic hair
• Most common cause
• A-Hypothyroidism
• B-Central
• C-Ovarian
• D-Adrenal
• 6 years old girl came with breast enlargement and
pubic hair
• Most common cause
• A-Hypothyroidism
• B-Central
• C-Ovarian
• D-Adrenal
• Precocious puberty is when a child's body begins
changing into that of an adult (puberty) too soon.
• Puberty that begins before age 8 in girls and before
age 9 in boys is considered precocious puberty.
• Precocious puberty can
• Cause psychological stress for the family
• Cause advanced and early closure of growth plat and
final height will be short
• Most common cause of precious puber in boys and
girls is central idiopathic
• However boys tend to have higher incidence of brain
pathology than girls but idiopathic still the most
common in both genders
• Precocious puberty
• Need first FSH and LH
• If LH is high then this is central and neeed MRI
• If normal or low then do GnRH stimulation test
• After GnRH stimulation test measure LH
• If high this this this central

• if LH is normal or low this this peripheral

QUESTION 61
• 5 years old with testicular enlargement and pubic
hair, bone age 7 years
• What should you do first
• A-MRI brain
• B-Ultrasound ovary
• C-GnRH stimulation test
• D-DHEAS
• 5 years old with testicular enlargement and pubic
hair, bone age 7 years
• What should you do first
• A-MRI brain
• B-Ultrasound ovary
• C-GnRH stimulation test
• D-DHEAS
• 6 years old boy with pubic hair , bone age 6 years , normal
testicular size 2 cm , Serum DEAS slightly high
• Most likely cause
• A-Brain tumor
• B-Premature benign pubarche
• C-Congenital adrenal hyperplasia
• D-Testicular tumor
• 6 years old boy with pubic hair , bone age 6 years ,
testicular size 2 cm , Serum DEAS slightly high
• Most likely cause
• A-Brain tumor
• B-Premature benign pubarche
• C-Congenital adrenal hyperplasia
• D-Testicular tumor
• Isolated benign pubarch
• Only pubic hair
• Normal or slightly advance bone age
• No other sexual characters
• Serum DHEAS slightly high
• Need observation
• Increase tesicular size at puberty : testicles more than
2.5 cm in length and more than 5 ml in volume
• 2 years old her mother noticed development of the
breast no other sign of puberty
• A. precocious puberty
• B. premature puberty
• C. premature breast development
• D-Turner syndrome
• 2 years old her mother noticed development of the
breast no other sign of puberty
• A. precocious puberty
• B. premature puberty
• C. premature breast development
• D-Turner syndrome
• Girl with enlarged breast with no other secondary
sexual characteristics and normal bone age: benign
premature thelarche
• Need reassurance and follow up

• If there is advanced bone age or other sexual

character like pubic hair or menses then need
investigation
• 4 years old girl with breast enlargement and bone age
6 years
• You should do
• A-MRI brain
• B-Pelvis ultrasound
• C-Abdominal X ray
• D-CT brain
• 4 years old girl with breast enlargement and bone age
6 years
• You should do
• A-MRI brain
• B-Pelvis ultrasound
• C-Abdominal X ray
• D-CT brain
• All Males with precocious pubery and all girls under
6 years and precocious puberty should have MRI
• 7 years old has pubic hair, developed breast ,ask
about which kind of puberty?
• central precocious puberty •
• ovarian tumor •
• central lesion •
• gonadotropin adenoma
• 7 years old has pubic hair, developed breast ,ask
about which kind of puberty?
• • central precocious puberty •
• ovarian tumor •
• central lesion •
• gonadotropin adenoma
• Which of a following is a cause of precocious
puberty
• A-Addison disease
• B-Hyperthyroidism
• C-Congenital adrenal hyperplasia
• D-DM
• E-Turner syndrome
• Which of a following is a cause of precocious
puberty
• A-Addison disease
• B-Hyperthyroidism
• C-Congenital adrenal hyperplasia
• D-DM
• E-Turner syndrome
• 1 7-year girl with pubic hair growth, what is the best
investigation?
• A FSH
• B CT Scan
• C LH
• D The pelvic US
• 1 7-year girl with pubic hair growth, what is the best
investigation?
• A FSH
• B CT Scan
• C LH
• D The pelvic US
• Isolated Premature pubarche is a benign condition
• Needs follow up
• Pelvis US can be done to look for psosible adrenal
mass
• A 9-months-old female infant presented with
bilateral breast enlargement. What is the most
appropriate investigation?
• A Breast Ultrasound
• B Pelvic Ultrasound
• C CT for chest
• D-CT brain
• A 9-months-old female infant presented with
bilateral breast enlargement. What is the most
appropriate investigation?
• A Breast Ultrasound
• B Pelvic Ultrasound
• C CT for chest
• D-CT brain
• Iolated breast development can sometimes associated
with ovarian follicular cyst (exaggerated thelrache)
• Usually no need for surgery
• Isolated breast enlargement with normal bone age
• Isolated pubic hair and normal bone age

• All need reassurance and follow up

• Treatment for central precocious pubery
• GnRH analogue (depot)
• Treatment for peripheral precocious puberty
• Adrenal masses or testicular tumor:
• -Surgical
• -Medications: Anti estrogen: Tamoxifin
• Anti androgen: Mydroxyprogestrone acetate
• Ketoconazole
• For congenital adrenal hyperplasia : steroid , mineralcorticosteroid
• Mccune albright syndrome
• Hyperfunctioning of endocrine glands
• Precocious puberty
• Thyotoxocosis
• Café au lait spots
• Fibrous dysplasia
• 13 years old brought by her mother concerned about
her stature, patient is normal, on examination, no
signs of breast development and no pubic hair, what
is the cause?
• A- Celiac disease
• B-Kalman syndrome
• C-Consitutional
• D-Familial
• 13 years old boy brought by her mother concerned
about her stature, patient is normal, on examination,
no signs of breast development and no pubic hair,
what is the cause?
• A- Celiac disease
• B-Kalman syndrome
• C-Consitutional
• D-Familial
• Delayed puberty
• In girls no signs of puberty at age of 13 years and no
signs of puberty at age of 14
• Most common cause of delay puberty: constitutional
• Causes
• Systemic and chronic disease
• Malnutrition
• Central causes:
• Pituitary or CNS disease
• Periphral causes :
• Ovarian failure: Turner syndrome
• Testicular failure: Klenifilter syndrome
• 9 y/o child brought by his mom who’s concerned about
his short stature. His friends make fun of Him,
Investigations show bone age of 7 years and low insulin
like growth factor (IGF-1 Normal serum GH . How
would you treat him?
• A-GH deficiency
• B-Familial
• C-Constitutional
• D-Hypothyroidism
• 9 y/o child brought by his mom who’s concerned about
his short stature. His friends make fun of Him,
Investigations show bone age of 7 years and low insulin
like growth factor (IGF-1 Normal serum GH . How
would you treat him?
• A-GH deficiency
• B-Familial
• C-Constitutional
• D-Hypothyroidism
 Familial Consitituitonal GH deficiency
Final height Short Normal Short (if not
treated)
Growth velocity Normal Normal Low
Bone age Normal Delayed by1-2 Delayed by more
years tan 2 years
GH stimulation Normal Normal No response
test
IGF-1 Normal Low or normal Low
Puberty Normal Delayed Delayed if FSH
or LH affected
Family history Parents will be Common Sometimes
short
• 9 y/o child brought by his mom who’s concerned about
his short stature. His friends make fun of Him,
Investigations show bone age of 7 years and low insulin
like growth factor (IGF-1). How would you treat him?
• A-Reevaluate after 1
• B-Give growth hormone
• C-Do MRI
• D-Ask for celiac screen
• 9 y/o child brought by his mom who’s concerned about
his short stature. His friends make fun of Him,
Investigations show bone age of 7 years and low insulin
like growth factor (IGF-1). How would you treat him?
• A-Reevaluate after 1 year
• B-Give growth hormone
• C-Do MRI
• D-Ask for celiac screen
• 9 Years old boy brought to clinic with his parents
complaining that he is short. He appears healthy, less than
50% percentile for height on growth chart. His profile
revealed progressive increase in height, his labs was
normal, best indicator of his future height is?
• A. His weight vs height
• B-Parental height
• C-Parental weight
• D. Can't be expected
• 9 Years old boy brought to clinic with his parents
complaining that he is short. He appears healthy, less than
50% percentile for height on growth chart. His profile
revealed progressive increase in height, his labs was
normal, best indicator of his future height is?
• A. His weight vs height
• B-Parental height
• C. Parental weight
• D. Can't be expected
• 13 old boy came with his mother , his mother complain
about he is shorter compare to his classmates , he is 145
Mother is 155 , Father 174 , His bone age 10 years old ?
What is his expected height will be. ( mother + father (
+13 if boy or -13 if girl )) / 2
• A 139-145
• B 146-157
• C 158-169
• D 170-175
• 13 old boy came with his mother , his mother complain
about he is shorter compare to his classmates , he is 145
Mother is 155 , Father 174 , His bone age 10 years old ?
What is his expected height will be. ( mother + father (
+13 if boy or -13 if girl )) / 2
• A 139-145
• B 146-157
• C 158-169
• D 170-175
• A 4 years old girl , her mother height is 163 and
father height 172 cm
• Calculate mid parental height
• A-169
• B-165
• C-161
• D-157
• A 4 years old girl , her mother height is 163 and
father height 172 cm
• Calculate mid parental height
• A-169
• B-165
• C-161
• D-157
• 7 year old boy short for his age with bone age delay
but normal growth velocity... what should you do for
him?
• A Lab Work up
• B Reassure and tell parents he’ll catch up
• C Give GH
• D-Give sex hormones
• 7 year old boy short for his age with bone age delay
but normal growth velocity... what should you do for
him?
• A Lab Work up
• B Reassure and tell parents he’ll catch up
• C Give GH
• D-Give sex hormones
• 9-year-old brought by his mother, looks smaller than his
colleagues at school, she also looks small size. X-ray
shows his bone age is 7 , examination was normal except
he is below (5th?) centile for weight and height, Labs:
Normal growth hormone - Normal TSH T4 T3 - Normal
vitals - Normal insulinlike growth factor 2.
• a) Behavioral therapy for the child
• b) Familial
• c) Growth hormone deficiency
• D)Hypothyroidism
• 9-year-old brought by his mother, looks smaller than his
colleagues at school, she also looks small size. X-ray
shows his bone age is 7 , examination was normal except
he is below (5th?) centile for weight and height, Labs:
Normal growth hormone - Normal TSH T4 T3 - Normal
vitals - Normal insulinlike growth factor 2.
• a) Behavioral therapy for the child
• b) Familial
• c) Growth hormone deficiency
• D)Hypothyroidism
WHAT DOES THIS GROWTH
CURVE SHOW
What investigations you will ask for
•
ANSWERS
Constitutional delay of growth – had some delay then
catches up
• Usually the growth will catch up near puberty
• Can be familial (to say familial we have to know the
mother and fathers height )
• Investigation: bone age
WHAT DOES THIS GROWHT
CURVE SHOW
GIVE DIFFERNTIAL
DIAGNOSIS
¢Short stature
ANSWERS
¢Familial short stature
• In short stature:
• If the weight is affected more than the height then
most likely cause is malnutrition or chronic disease
followed by endocrine disease
• If the height is affected more than the weight then
likely cause is endocrine and turner syndrome (in
girls) followed by chronic diseases or malnutrition
• male with type hair and dark secrtum = tanner stage
• 1
• 2
• 3
• 4
• male with type hair and dark secrtum = tanner stage
• 1
• 2
• 3
• 4
• - 4 weeks old infant, mother happy he never
cries. on examination: Jaundice + Umbilical
hernia + Distended Abdomen + Coarse face
features + Bulging frontal fontanel. Diagnosis?
• A- Congenetal Hypthyroidism
• B- Gilbert's Syndrome
• C- Cerebral Palsy
• D- Rickets
• - 4 weeks old infant, mother happy he never
cries. on examination: Jaundice + Umbilical
hernia + Distended Abdomen + Coarse face
features + Bulging frontal fontanel. Diagnosis?
• A- Congenetal Hypthyroidism
• B- Gilbert's Syndrome
• C- Cerebral Palsy
• D- Rickets
• Congenital hypothyroidism
• Most common cause:
• Thyroid dysgenesis
• Can be caused by maternal antibodies (mother with
Hashimoto). Usually transient

• Usually needs a massive dose of L-Thyroxine initially

• 2 months ld mother notice bulging tongue , dry
mouth, constipation , FH of autoimmune disease ,
TSH high 22 , T3 low T4 low what mx:
• A. Give 1 month levothyroxine.
• B. give life long levothyroxine.
• C. repeat in 1 month
• D-Do thyroid scan
• 2 month old mother notice bulging tongue , dry
mouth, constipation , FH of autoimmune disease ,
TSH high 22 , T3 low T4 low what mx:
• A. Give 1 month levothyroxine.
• B. give life long levothyroxine.
• C. repeat in 1 month
• D-Do thyroid can
• High TSH , LOW T3 and low T4 : primary hypothyoridism

• Low TSH , low T3 and Low T4 seondary hypothyroidism like

(ptituary)

• LOW TSH , High T3 and T4 primary hyperthyroidsim

• High TSH , high T3 and T4 secondry hypethyroisdim

(Pitituary) or thyroid hormone resistant
• TSH low , T3 low , T4 normal , rT3 high sick
euthyoid syndrome
• In a village there was high incidence of infants with
cretinism
• What should you do
• A-Iodinize the water
• B-Start the infants on L Thyoroxine
• C-Follow them up
• D-Refer to ministry of health
• In a village there was high incidence of infants with
cretinism
• What should you do
• A-Iodinize the water
• B-Start the infants on L Thyoroxine
• C-Follow them up
• D-Refer to ministry of health
• Child came to ER with DKA symptoms, Started IV
fluids, What to give next? His K normal Slightly
elevated bicarbonate High glucose??
• A Start IV insulin
• B Start KCL
• Start bicarbonate
• D-Give antibiotic
• Child came to ER with DKA symptoms, Started IV
fluids, What to give next? His K normal Slightly
elevated bicarbonate High glucose??
• A Start IV insulin
• B Start KCL
• Start bicarbonate
• D-Give antibiotic
• 12 years Child uncontrolled DM with ketones asking
about the initial treatment:
• A. Insulin
• B. IVF
• C-Potassium
• D-antibiotic
• 12 years Child uncontrolled DM with ketones asking
about the initial treatment:
• A. Insulin
• B. IVF
• C-Potassium
• D-antibiotic
• ABCDE
• Star fluid as an infusion 10 ml per kg of normal
salinovr 1 hour
• Then after 1 hour start IV regular insulin as
continuous infusion 0.1 IU per kg per hour and add
kcl 40 meq per L
• If glucose decrease to 250 mg /dl then shift IV fluid
to D5 half normal saline
• The deficit of dehydration should be given over 48
hours
• If glucose is below 250 mg /dl , blood gas is normal
and patients s continuous then start SC insulin then
after 30 minutes giv a meal then after 60 minutes
stop the insulin
• 10 years old boy diagnosed with type 1 diabetes, presented
to the emergency department with 3 days history of not
feeling well and losing weight. Investigations showed high
blood sugar and ketone in the urine. What is the cause of
this condition?
• A elevate renin
• B decrease renin
• C decrease Insulin
• D Glucagon
• 10 years old boy diagnosed with type 1 diabetes, presented
to the emergency department with 3 days history of not
feeling well and losing weight. Investigations showed high
blood sugar and ketone in the urine. What is the cause of
this condition?
• A elevate renin
• B decrease renin
• C decrease Insulin
• D Glucagon
• pt present with signs & symptoms of DKA. His
Glucose is 34 mml. What is the goal in this
management?
• A. Decrease glucose by 3 mml per hour
• B. Decrease glucose by 6 mml per hour
• C. the glucose level goal should be above 18 mmol
• D-Correct acidosis with bicarbonate
• pt present with signs & symptoms of DKA. His
Glucose is 34 mml. What is the goal in this
management?
• A. Decrease glucose by 3 mml per hour
• B. Decrease glucose by 6 mml per hour
• C. the glucose level goal should be above 18 mml
• D_Correct acidosis with bicarbonate
• Cerebral edema
• Is the most common complication in DKA
• When to do ophthalmology screening for child with
DM type I
• A-lmmediatly
• B-After one year
• C-After 3 years
• D-After 5 years
• When to do ophthalmology screening for child with
DM type I
• A-lmmediatly
• B-After one year
• C-After 3 years
• D-After 5 years
• A child with DM type 1
• When you should screen for celiac
• A-Annually
• B-Every 2 years
• C-Every 5 years
• D-Every 10 years
• A child with DM type 1
• When you should screen for celiac
• A-Annually
• B-Every 2 years
• C-Every 5 years
• D-Every 10 years
• In generally
• Annular screening for urine microalbumin for
diabetic nephropathy after 5 years from diagnosis
• Annular screening for diabetic retinopathy for
diabetic nephropathy after 5 years from diagnosis
• Screening for celiac screen and hypothyroidism at the
time of diagnosis and at 2 years from diagnosis and
then at 5 years of diagnosis
• 15 years old and known typ1 DM for 10 years
• Which is the first sign of diabtic nephropahty
• A-Hematriua
• B-Elevated renal function
• C-Nephrotic syndrome
• D-Microalbuminuria
• E-Hypertension
• 15 years old and known typ1 DM for 10 years
• Which is the first sign of diabtic nephropahty
• A-Hematriua
• B-Elevated renal function
• C-Nephrotic syndrome
• D-Microalbuminuria
• E-Hypertension
• 7 years old boy with type 1 DM. You found that’s his weight
and height is decreasing in the last few months
• HbA1C 6 %
• Which is the likely cause?
• A-Poor controlled DM
• B-Hypothyroidism
• C-Celiac disease
• D-Growth hormone deficiency
• E-Inflammatory bowel disease
• 7 years old boy with type 1 DM. You found that’s his weight
and height is decreasing in the last few months
• HbA1C 6 %
• Which is the likely cause?
• A-Poor controlled DM
• B-Hypothyroidism
• C-Celiac disease
• D-Growth hormone deficiency
• E-Inflammatory bowel disease
• Type 1 DM commonly associated with
• Hypothyroidism (Hashimoto):
• Increase weight and decrease height
• Celiac disease :
• Decrease weight and height
• New recent diagnosed DM and started on insulin but you
notice that she is frequently hypoglycemic. Most
explanation:
• A-Infection
• B-Addison diseases
• C-Celiac disease
• D-Insulin reservoir in pancreas
• E-Heart failure
• New recent diagnosed DM and started on insulin but you
notice that she is frequently hypoglycemic. Most
explanation:
• A-Infection
• B-Addison diseases
• C-Celiac disease
• D-Insulin reservoir in pancreas
• E-Heart failure
• Honey moon period usually accur in 1st 6 months
after DM type 1 diagnosis
• Because there is insulin reservoir in pancreas patient
can have hypoglycmic attacks
• Treatment : decrease insulin dose
• 12 years old boy diagnosed with type 1 diabetes, he
has been compliant with insulin since the diagnosis 2
months ago What is this called?
• A Brittle disease
• B Smogey syndrome
• C Honey-moon syndrome
• D Dawn syndrome
• 12 years old boy diagnosed with type 1 diabetes, he
has been compliant with insulin since the diagnosis 2
months ago What is this called?
• A Brittle disease
• B Smogey syndrome
• C Honey-moon syndrome
• D Dawn syndrome
• 7 years old known type 1 DM. He is on mixed of regular
and NPH insulin BID. His blood sugar in the morning
always high
• What you will do
• A-Increase evening NPH insulin
• B-Increase evening regular insulin
• C-Check serum glucose at 2 AM
• D-Ask him not to eat dinner
• E-Add oral hypoglycemic agents
• 7 years old known type 1 DM. He is on mixed of regular
and NPH insulin BID. His blood sugar in the morning
always high
• What you will do
• A-Increase evening NPH insulin
• B-Increase evening regular insulin
• C-Check serum glucose at 2 AM
• D-Ask him not to eat dinner
• E-Add oral hypoglycemic agents
• A child known case of DM type 1
• He is frequently having hypoglycemia after exercise
• Best site for insulin injection before exercise
• A-Thigh
• B-Deltoid
• C-Abdomen
• D-Axilla
• A child known case of DM type 1
• He is frequently having hypoglycemia after exercise
• Best site for insulin injection before exercise
• A-Thigh
• B-Deltoid
• C-Abdomen
• D-Axilla
• 6 years old came with polyuria and weight loss, You
suspect DM. Which of the following is suggestive of type
1
• A-Obesity
• B-Presence of family history of DM
• C-Acanthosis nigricans
• D-Low C peptide
• E-Hypertension
• 6 years old came with polyuria and weight loss, You
suspect DM. Which of the following is suggestive of type
1
• A-Obesity
• B-Presence of family history of DM
• C-Acanthosis nigricans
• D-Low C peptide
• E-Hypertension
• Type 1 DM
• Normal weight
• Usually no family history
• Low C-peptide (low insulin)

• Type 2 DM
• Obese
• Positive family history
• Elevated C –peptide
• Associates with acanthosis nigricans
• Part of metabolic syndrome (HTN , hyperlipidemia , hyperuricemia)
• Pediatric patient brought by his parents. X ray
showed widening of the ends of his bones (growth
plates) Calcium (low) PTH (mildly high) Alkaline
phosphatase (very high) What does the patient have?
• A Hypophosphataemia
• B Primary hyperparathyroidism
• C Vit D deficiency rickets
• D Renal osteodystroph
• Pediatric patient brought by his parents. X ray
showed widening of the ends of his bones (growth
plates) Calcium (low) PTH (mildly high) Alkaline
phosphatase (very high) What does the patient have?
• A Hypophosphataemia
• B Primary hyperparathyroidism
• C Vit D deficiency rickets
• D Renal osteodystroph
• All types of rickets : normal or low calcium
• All types of rickets : low serum PO4 except renal
rickets (high PO4)
• All types of rickets associates with high PTH except
: Hypophosphatemia rickets ( normal PTH)
• All types of rickets associates with low serum
vitamin D except Vitamin D resistant rickets type 2 (
high serum vitamin D )
• Nutritional rickets
• Widening of epiphyseal plate
• Cupping and fraying of metaphysis

• Renal disease
• Bone cysts
• Bone resorption
• Sclerotic bones
• A 10 year girl with hyperthyroidism (graves)
• She failed medical therapy with Methimazole
• Best next step
• A-Surgery
• B-Beta blockers
• C-Radiation
• D-Laser
• A 10 year girl with hyperthyroidism (graves)
• She failed medical therapy with Methimazole
• Best next step
• A-Surgery
• B-Beta blockers
• C-Radiation
• D-Laser
• First step in graves disease
• Medication : Methimazole preferred
• If failed:
• In children below 5 years : surgery
• Between 5-10 years : radiation or surgery
• 10 years and above: radiation and if failed then
surgery