,

,

"




) ( NET

Hypogonadism & Gynecomastia

'

1-5
5-7
7-12
12-16

'
'

'
'
"
"
'
'
'

16-18
18-20
20-26
26-29
29-35
35-38
38-40

"

40-43

"
2003 -

Diaebtes Melitus
.
4 :
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.


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-
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. " thyroid -
cartilage " . .
.isthmus .recurrent laryngeal nerves-
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( . .
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.
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T3- " de-iodinase`5
) ( . 20% T3- " .
. "
. ) ,(TRH
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TSH ,
)" (Na-I symporter .
TSH .
" ,T3 .de-iodinase-
:


(Free T4 (FT4 -.

. -
.
(Total T3 (TT3 T3 . -.

TSH .

TSH.
.
. ,
" .
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,TBTA .TBG-
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TBG TT4.
--- ) T4 (FT4-
-- --- --- TT4 , FT4 ".
TGB TT4.
.
FT4
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) TSH TSH-(.
TSH :
TSH ?

- ? .TRH test TRH .

25 ," .
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TRH - . ,
.
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.TRH-
) ,(
TRH .
- TSH
. ) TRH- (TSH
.
,
" .
:
. .

anti-microsomal .(anti-thyroid peroxidase (TPO

o
.anti-thyroglobulin
o

10


: , .

" bioassay ) ( " .

: .

:(SHBG (sex hormone binding globulin .

.
: ,

.
:
.
pertechetate
.
, .
.
. isthmus-
. .
Hot nodule - .
. "
.
.
Cold nodule ,,
. .
.
(Multi-Nodular Goiter (MNG CT-
) , , '( .
.CT- .retrosternal thyroid
" .(RAIU (Radio Active Iodine Uptake
24- .
) ,TSH
, (.
-
. . rapid
,turnover
, 24 . .

:
)
( , .
.

- :
.21
Diffuse toxic goiter .Graves
Toxic adenoma .
- toxic MNG .
11


- .
TSHoma TSH
.
Hydotiforn mole / choriocarcinoma HCG
TSH- " HCG .
, .HCG
.
: Graves` disease
3 :
.diffuse toxic goiter
.1
.optalmopathy
.2
.dermopathy
.3
TSH receptor cross-reaction
. .
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HLA .
, pernicious anemia ,
: TSH
.
TSH ) TSH , TSH
(.
- .
:
Goiter , .

.
.
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sclera- .
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) (.

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.GAG .
.
,
.
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Dermopathy . GAG . .

.pre-tibial myxedema
.27
.
" ) (.
) "
(.

12


:
) FT4, TT3), TSH ,

.
TSH .

) alkaline phosphatase(.

) (.

:
clone - .
clone .
.
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Thionamides .
.a
2 .
.
Iodine . , 10
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.
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Lithium .
.c
.
.2
: .
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30% ,
. " ) .
(
) (.
.
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.
. :
:
,
o

.reccurent laryngeal- .
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o

,
.
30% . 30% ,
30% , . 40% .
:
PTU 3 MMI MMI- .
. .
PTU T4 T3- .
- . MMI
" , .

13


PTU MMI- . , MMI-
- .PTU
: PTU- 3 TT3
T4 T3- 24 . T3-
. FT4 "
T4 . T4 -
PTU.
)
( PTU .

:
DD .32
:
.

.
.

) ( .

: , .
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CNS .CLL
:
)( .33
.
carpal tunnel syndrome , .
) (.
) ( ,

) ( , )-
(.
.
:
FT4 TSH ,.
TSH .TRH .
FT4 TSH ,/.
, TRH .
:
) Levothyroxine( . .
T3 T4 .well-being
, "."go low, go slow
: Myxedema coma
extreme hypothyroidism .
.39
,accidental hypothermia "
) .(50% " " .

14


FT4 : TT3 , TSH ,.
.
.CO2
" , percipitating factor ,
:
.
T4 T3.
.
: Subacute thyroiditis
, .
- .decervant
.41
) (.
, CRP-.
:
--- --- -.
.1
-.
.2
-.
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:
).(NSAIDs

.
, .
, .
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# " .
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20 .60

30-20 )
(.
.

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).(T4

, , .

15


" .

.
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:
:

cacitonin.
o
-
o
.

o
. ,
.
: .

.
, .15%
: ) ( .

.
: , .

.FN
:

, .
: Thyroid scan
:
.
.
.
.
,( Pertechnetate (Tc99m, TcO4 , ) (trapping"
" 20 .
.
5" .goiter - goiter-
) ( . .
Hot nodule . ,
, . )
( .
TSH .
Cold nodule . 15%
colloid cyst- ,MNG , , ,,
.
:
: US .

" : , ,

" .

16


) ( . - 16%
" . .
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14%- .
) 92% 1%-( 8% .FN
,
.
:
, , . -
, !!!
: ,35 2" .
, , . - .
.
" , .
FNA, 80% ,
20% " ) (.
, 77%
" US . ,
" . 80% ,
" .
,
. , ...

:
:
Differentiated

Papillary
o
Follicular
o
Hurtle
o
Medullary

Anaplastic

, ,papillary .
. anaplastic thyroid carcinoma 95%
5.
) papillary (follicular- .
follicular ,papillary- .
?
.

45 .

!
.

17


) (20 , ,
) ( .
, low risk 20
. high risk .30-60%
:
- .

replacememnt TSH-

, TSH- growth factor.

:
,near total thyroidectomy
,
. .
low risk ,lobectomy & isthmectomy
isthmus- .
.
: low risk
lobectomy & isthmectomy 4 "
. .
TSH . T4 .
3.5 - T4- - TSH-
.
TSH-
.
." -
TSH- .
, , ,
) ( .
. ,
.
: low risk
" .
: high risk
.
4 . , T4 - .
TSH- .
remnant " . :
,
"
. , ablation .
1%- 24 ,
. ,
.
, .
- CT- .

18


.
, -
.
- 50-60%- "
.CT /
,
. , "
.

: 1#
, , ." pulse pressure .
) ( TSH . T3- .
. -

RAIU- ,
) ( . TSH
) (.
)
( . .
.50
)( .
) (.
.-
) ( .
-.
TT3 TBG ,
. -.
, - .
.
: 2#
1 " ,
. " PTU .
, .
, .
(1) :
(2) . (3) .
. ,
3 (4) . reccurent laryngeal -
." , .

. "

19


. 10mCi
. 30mCi .
TT3 TT4 " T3 ) .(T3 toxicosis
.
RAIU - turnover
, . - .
,
. , MNG RAIU-
.
: 3#
patchy
, . 20%
. ,
, " .US
" L-T4 .

- . T4 .
) subclinical hypothyroidism TSH - TSH
.(TRH
"
TSH- " .,
- . , - )
.(50 -
. .gr 50
.
.
: 4#
, )
( . .
.
. .
cox2 .subacute thyroiditis -
, proton pump inhibitor
, ) (.
" ) ( . "
. .
"
) . " PTU T3
, (.
self-limited
. .
.
- . 10% - .
.
: 5#
20



.cold nodule 20% .
.

.
FNA 92%
.95%- 5% FN .
.
.
) (70% 30% FP
.
: 6#
.
"

.
.
delivery dose- 20mCi
60mCi
. .
: 7#
. 30%
.40%-
.
.
" ,
) (.

"
" 2% " . ,
) 20% 50 "( .
".
" ) ( ."
) ( , ) ( .
" . 3 "
, .
. -
. renal vein -
IVC- . .
, . .
" . 3 .

21


.
".

:
0.1% ".
- .paraganglioma
" "tumor 10% ,- , .
20%- .
- , , ,-.
.10%
.
,
.
.organ of Zuckerkandle
.celiac trunk- -
, ) (.
:
MEN-II 2 A ,.B-

.Von Hipple-Lindau

NF1 : . .

Familial non-syndromic .

. .
: MEN type 2
A ) ,(40% (MTC (100%-90 -
) .(50% .
RAT .10
- )
( . -.
B ) MTC- (A )
( . RAT -
) protooncogen ( )
(.
: Von Hipple-Lindau disease
) 1:30,000 (.
3 : ) )renal cell carcinoma (60% ,(20% hemangioma-
) .(hemangioblastoma
.
) anticipation (.
70% ) 70% (.
.
.
:
.

22


.
.11
:
" ,

".
Orthostatic hypotension .

:
.
24 . 70%- .
. " 85%
.
VMA .
, .
" .
" "

,re-uptake . )
(MIBG ) "(.
CT - - )
( " .CT
.
:
" .
" - .

2 " .
" .
# " .
, . , "
- .

:
: --- " ---
I --- ACE I --- II
--- ".

".
, .
-
" . .
.
.
.Conn`s syndrome

23


.
:
) (.

/ 70 .
:
:" IV .
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. ) (
.
" : .
.2
.
:
.
- .
,spironolactone
. .triamterene

.
- .

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3 :
.15%
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.75%
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.10%
.3
.
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) ( .
. "
.

) (.
) ( :
.

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) 24( :

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" "

NE .angiotensin2 , " .
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.(CRH (cortisol RH
.ACTH .
.
" " -.
:
.

Cyrcadian rhythm )6

( . ) 12-11(.
. ,
.
)
(.

)- ( :
- 90%.
:
) (80% .

, , .

, .

, .

- ) , , (.
.

:
: .

CRH .ACTH-
25


,

.
) ( ,
. .
.
:
, , , ,.

" shock

.
- .

: Autoimmune Addison`s disease

5 .
:
3-2 .
5-3.
.
,pernicious anemia
) (
, , ) ( .1
.
) (40% .
HLA ).(B8, DR3, DR4
,
" .T
:
.
.

, , .

.
, MSH (melanocyte

.(SH , .
" " 110- .

- ) , , ,

.(...
,

.
.Postural hypotension

:
)-(

.
.

.
,

. .

26


, ) (

) " ,

(.
. "

- -.
.

.
.

:
, .
- ACTH test . ACTH

.
.nmol/lit 550
ACTH

.
ACTH- .
, ACTH ) (
.ACTH- ) (
.ACTH-
:
CRH test CRH ACTH .

ACTH.

Metyrapone test .

: Addisonian crisis
? ) , ,(.
.
?
) , ,( . . " .
!!! .
.
.
:
IV .
" . .
.
:
) "( .
4-3 .
" ) fludrocortisone (.
: , ," ,.
.
,
.

27

) ( :
"
.
:
: ACTH
.1
.ACTH
.a
.ACTH
.b
: ACTH
.2
.
.a
100% ..
.b
Pituitary Cushing ACTH
. CRH
.
) .feedback setpoint elevation
() . " (.
Ectopic ACTH ACTH
. -.
, , .
Adrenal tumor CRH) ACTH-
(.
:
) ( .

.bufallo hump

.moon face

).(plethora

Striae , " striae ) .

(.
, .

".

, .

, ,.

- .

ACTH )(

.
:
:
" . dexamethasone -

) (.
.ACTH-

28


ACTH " .

" .

:
24 :

1% , )
.(CBG
.
.
.
" : 12 -

. ,
. .
. .FP
] [ ! 25
:
.1 .
.
.2 ) (screening-
. .
) ( :
ACTH . non-ACTH dependant
. ACTH
.ACTH-dependant- " .
MRI .
. . . .
: IPSS inferior petrosal sinus sampling
MRI ,50%
.
.
" "
. .IPSS
,
. " ,
) CRH CRH- (.
. ACTH-
) .(2 ACTH- .
,
.
.
) (
:
:
: ) ( .

" .
, , .

29


: .

) ( .
- .
: .

" : .

, .
:
.

.
.

" .

) small cell
, (.
:
.
:
Metyrapone .
Ketoconazole - .

) , (.

- 1 :
, .
.
?
.

.
:

, , , ,,
, , .
, , .
.
) (.
,

, . ? )
(.
? ? ?

? salt craving

? ) (.

. postural hypotension ,

30


. " 100/60
) " (.
? ?

.
:

- , .
- , , .
:
) (

) (.

Galactorea .

Orthoststic hypotension 3.

" . 20 -" ,
.
:
.
.
: " 250 .cortosyn

FN
- . "
.

-.
ACTH : ACTH .

) ( ACTH . -
.
, : )

( ) ( .
)
(.
: . ) ( . )

"( . )( . ) astrup
( . . IGF-1 ..GH-
anti-thyroid AB ,.

. .
. -.
ACTH test 400 ,450- ) .(<550 ACTH .
:
. :
, , .
TB
) .(CT
.
31


.
:
- , ,.
, 4 .20
, .
.
.mg 15 + 20
mg 5-7.5 * 1
mg/day 1.5
addisonian crisis .
" IV .
. .
" .
2 :
. ...
?
, .

- , ,

.
, " , ) (,

, ).(striae
- .2

, )( . )TG ,
( . .
.
: screening
24.
.1
.Overnight dexamethasone
.2
. : FP-
.

) ,( - cyt P450

" .
.

" .

: ) 12-11(

) ,(
"-" ,
-.
2" ) overnight- .(screening-
8" /.
, ,overnight- .
:
1 .
32


.
)" (
2 ." .
) ( . 8 -"
. ACTH -
, ) ACTH-dependant ACTH (.
.MRI .
.IPSS
." - .
" .MRI
) (
) ,( . " .
2 !
FP- .overnight-
2-" 8" .ACTH
3 :
.
,ACTH- .
" .
: ectopic ACTH tumor 4
ACTH .
)
( .
.
CT PET , octeoscan
.
3 " :
" :
" ) (.

/ .

".
.

:
.
.1
.
.2
.
.3
2 " .
.4
.
.5
Congenial adrenal hyperplasia
ACTH ) (DOC-11
" .

. -.

33


" :
) - (50%" " ,

,.
" - " .

" .

:
, ) VMA (.
.
:
, .
4 :
)" "incidentaloma (.
,,
, .
.
.
,UFC , ,
. .
. 4"
. . .
.

:
, " .
.
.
chiasm- , .
cavernous sinus- carotid artery- .
2 . oral -
.ectoderm . .
.ratke`s pauch
MRI .6-5
:
. .
, .
) ( .
, .
.
,
. .
) : (7
.

34



o
.
.
o
) (
o
) (
.

.
o

: 8
6 )TSH,
(ACTH, LH, FSH ) GH, prolactin (.
) (ADH-

: ADH
. - siganl peptide
, . SP -
." .
, .
, .
ADH . ,aquaporin
. , . ADH ---
--- --- --- cAMP
. " .
ADH ADH
, . ,
ADH-.
. ,collecting tubule - ADH-
. ADH
) 20 !(.
: ADH
ADH .
- .
."
.
" ),
, , ( . .ADH
ADH- " . "
.
,ADH .
. )
( ADH .
(Syndrome of Inappropriate ADH (SIADH
: ADH ADH ,
. .

35


:
ADH- . :
) (.
Euvalemia -.
Normokalemia .
- ?
ADH --- ---
.
--- --- GFR --- ---
) ( .
:
+
.
:
ADH !
:
-

) ADH () .
(ADH
ADH CNS-

- .ADH
:
.
2 : " )
( . .
.
)(
. .
Diabetes Insipidus : ADH
) , (diabetes melitus-
ADH .
.
:
polyuria 2 . , .
.
polydipsia .
- ) (.
:
.

, .

.Normokalemia

.
DD : diabetes insipidus
osmotic diuresis .

36

Psychogenic )" "(.

o
Central .
o
Secondary .
o

.
Diabetes insipidus .
DD : nephrogenic diabetes insipidus
, .
.
, .
.19
DD : central diabetes insipidus
:

- .

. , , "
.
Craniopahyngioma .retke`s pouch-
)

- , (.
.

.ADH

:
- water deprivation test .ADH
ADH .ADH
. ,- .
295 .ADH
.diabetes insiphidus
.ADH
.
:
ADH.
desmopressin ADH . DDAVP
.minerin IV ..SC
.PO ) (.

: Growth Hormone
" )
( .

37


,GH , ) " ( . GH -
) ( .
.
GH .
.
GH . GH ) .(REM
GH .
: GH
GH , .
2 (GRH (GH releasing hormone -
(somatostatin (SS . .
:
--- --- Ach , .GH-
.GH
- , GABA- .GRH
GH- .
IGF-1 IGF-1 . .
IGF-1 . )(.
IGF-1 GRH .GH
2 : . , ) GRH L-DOPA
.(GH ,
.GH ,GH
.GH
: . SS
GH . ) GH(.
: GH
" , 2 .
.
: GRH
)( . .GH
" GRH down-regulation- ,
) GH GRH ( . "
.SS
:
. , ,
.
" .
SS- .GH
: GH
) (:
IGF-1 independent : , ,
.1
, .
IGF-1 dependant : , ,
.2
, ) (.
GH deficiency
38


, ) ( , )
,(dwarfism
, .
,
. .
:
:
: ,GH , ) .(Laron dwarf

.
: . '

) (.
:

.
:
, .
.
:
GH : , , .species specific
. .
.
).(CJD
GH .
.
.
GH- . GH- .
) ( .IGF-1
:
giantism , acromegaly-.
) (.
GH.
) (GH
2% .GRH
.41
, " .
- GH antagonists . GH .
,
) .(dominant negative

: Prolactin
) .(aa 198 .GH-
.
.GH 2
. .

39


. ) secondary massenger- .(cAMP
.
:
. ) ,PRF - prolactin releasing factors
(TRH thyroid rleasing hormone . " PIF
((prolactin inhibiting factors , .,
" . ,
.
.
)
(.
" ) --- --- (.
.
) TRH - ( ,
, .
: Hyperprolactinemia
] [
--- --- --- GnRH .LH, FSH
, .
:
)- , (.
, ) (.
.
.
:
.

" .

, , , )

" (.
: .

.TRH

DD :
"
.macroprolactinemia

, .
.
. .

40

: # 1
- . . .
.1 .GH
:
?
MEN-I , .
? ) ( , )
( , )( , ,.
. , ,
50% .
,carpal tunnel syndrome " ) ( .
" " , .
) ( , , carpal tunnel syndrome .
, .
) bitemporal hemianopsia
( .
.
:
? GH- )(
) ,long bones ( . .
.
.frontal bossing

, ,.

) overbite (.

. .
.
.

, .thenar & hypothenar eminance -

) .(spade hand ) ( .
.
.sleep apnea ,

.skin tags -

) ,
-(.
, .

.11 :
GH .

GH -.

Osteoarthritis .

: .

:
' )(.

41


' )(.
: .GH
GH .
) ?(.
.
24 . ) ( .
" GH -
.
.3-2 .
IGF-1 GH . ,"
.GH-
) (.
- .
" .
, GH
.GH- ? . GH
.
" . .GH
GH- . .
98% " .
MRI ) ( . CT
.FN
MRI .
MRI- 2%- .
. GH
," CT .
) 20-
.(19
:
: .
) ,
( . , -
.GH-
, " )
(.
22 .
.
.

. .
.27

: # 2
.28
, .
.
42


- . .
.
MEN-I - .
:
.
GH .
:
) 5000 .(900
.GH .
DD :
.
.
)(.
, .
TRH ) .(TRH
) . (.
) (
" ) (.
.
.
CT - ,
.
:
- .32
, .
.
. .
:
3 , , .
.36
. ,
" 90%- . .
) (
) ( . ) -
(0 .
.37
.38
Bromocriptine ." , , " .
. 10% .
Carbegoline . " .
.

: # 3
.40
43


.
100 , .
.
.anterior pan hypopituitary
:
.
. .
.
) (.
GH .
, .
Bromocriptine .
MRI )(complete regression

) (NET
) 2-1(.
) (.
.multiple endocrine neoplasia (MEN) type 1
3 :
.1
.2 ) , , (.
.3 ) (
MEN-1 .
NET-
.3
. .
.
, .
)
(.
.
: Insulinoma
.
.
" ) (.
, .NET-
. ) diazoxide
" ( .somatostatin analogs
: Gastrinoma
. . ,
.

44


,
. , .jejunum -
)( " .
" .
: ) (.
" .H/K ATPase inhibitors
) (.
.
, fundus-
) () pernicious anemia ,
(.
: (Verner-Morison syndrome (VIPoma
VIPoma .pancreatic cholera
(VIP (vasointestinal intestinal peptide
. . .
" .
.11
)( .
, .NET
" .15
" :
) ( .16
,
.
.
, .18
.
, .
) (octreotide .SC
.rebound phenomena IM
) SC (.
,
.impaired glucose tolerance ,
: Carcionid tumor
) 10%(.
.28
" .
, .
" ) 5HIAA ( .
NET .29
.
. "
) (.
.
: , . ,
.
45


: Glucagonoma syndrome
.
, , , ,.
: .
)( )( .
" .
, .
,migratory necrotising erythema .

Hypogonadism & Gynecomastia

:
) --- (GnRH ) LH --- (FSH-.
LH .
FSH .
" " .
, , .
,
" .
.
.dihydrotestosteron 5
.
.undifferentiated gonad TDF
. TDF- .Y
.(AMH (anti mullerian hormone-
.
," .AMH .
" .
.
:
.

)( .
.
)( .
, .
.
.
:
, .
, .
) (bound .

46


50 .
.
. .
- .
borderline .
:
:
.

:
.

. .
:
. .

:
# .
:
.

asthenia .

.
.bone mass-

:
eunochoid habitus . .

, .
.

. .

. 30-25

" 6-4" . .
.

.
.
:
:
.

Cryptorchidism .

:
varicocele .

.
.mumps

) .(torsion

47

," .

:
.
1:1000 :.
47XXY .
X .
) .(euchonoid
.
.
.
: mumps
.
" .
- -.
" , !
.
:
:
isolsted idiopathic .

Kallman syndrome .

:
.mass effect- ) (
. .
:
.

" :

.
o
.
o
" .
o
. "
o
.
IM .transdermal
o

: Gynecomastia
.
, .
Pseudogynecomastia .
.
" ) ( -.
.skin retraction-
.
: / ,17 / .55

48


" -
.
2 .
" ) (.
:
persistant pubertal .

.
, ,.

-.

) ,( .

, , .,
" .
hCG .
:
.
.
80-50 .
: .
, LH
) ( , estradiol ) hCG (.

49