An 11-year-old girl with a normal medical history is referred by her pediatrician to the pediatric endocrinology clinic due to progressive lip enlargement for the past 4 years, which led to being bullied at school. The upper and lower lips have been increasing in size symmetrically. The lip swelling is painless, persistent, and not associated with weather or food consumption. There is no history of trauma, voice change, or difficulty swallowing.

She denies chest pain, palpitation, tremors, syncope, anxiety, tingling, or muscle spasms. She also denies headaches or sweating. There is no history of high blood pressure. She has regular bowel movements and denies abdominal pain or distention. There is no family history of similar symptoms or medical conditions.

Her physical examination reveals a thin girl (height, 60 in [153 cm] [64th percentile]; weight, 75 lb [34 kg] [17th percentile]; BMI, 14.5 [4th percentile]; and arm span, 63 in [160...

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