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A previously healthy 16-year-old girl presents with a 1-month history of increasing sleepiness. Over the last week, she has fallen asleep even while eating, causing her family to fear that she will choke. Once asleep, she is almost impossible to wake up.

She also reports being increasingly hungry, eating things she never previously liked and eating at all hours of the day or evening. She has gained 40 pounds. Her one other complaint is that she has frequent hiccups, which can last for hours.

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Congratulations to Burt Langer, MD, of Villanova, PA, for sending in the first correct answer to last issue’s challenge. The correct answer was papillary thyroid carcinoma, the topic of the first article in this issue.