Case Study 2 : James, a 32 year old Asian male makes a doctor's visit for a regular checkup. Unable to find a babysitter last minute, James brings along his 4 year old daughter, Cindy. The doctor notices that besides being relatively small for a 4 year old, Cindy's fingers seem a little bit like a baby's and somewhat chubby. There are no other physical or behavioral signs of concern. The doctor asks James if he has any concerns about Cindy, and James mentions that indeed Cindy is one of the smaller kids at her daycare center, but that she is active, gets along well with her friends, eats well, and is generally well behaved with no problems of communication. The doctor and James agre that Cindy is most likely healthy and fine, and that Cindy might "catch up" in height afte a "growth spurt". About two years later, James brings Cindy back to the doctor, still worried about Cindy's lack of growth, and this time, with new concerns about Cindy's emotional state, what he describes as "lazy eyes", and perceived difficulties in math and reading. Moreover, James informs the doctor that just about a week ago, Cindy had experienced mild vaginal bleeding. During this visit, the doctor also notices that Cindy has a slight but noticeable midline diastema. The doctor refers Cindy to a pediatrician this time, and a thorough examination reveals the following