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Acromegaly focussed examination

The OSCE instructions may be non-specific, for example: ‘Examine this patient’s endocrine status.’ This could be Cushing’s syndrome, acromegaly or hypothyroidism. Approach this situation by asking a few generic questions (if allowed) and by doing a general inspection to determine which condition you think is present. Then proceed with the relevant focussed examination to elicit other signs.

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent

Generic questions (acromegaly is usually obvious so ask questions to elicit symptoms you cannot examine for)

  • What did you notice first when you developed this condition?
  • Have you noticed a change in your appearance?

Determining if there is active acromegaly

  • Do you notice excessive sweating?
  • Do you have high blood pressure?

Other symptoms – work down body

  • Headaches 
  • Visual problems
  • Pins and needles
  • Back ache
  • Muscle weakness
  • Change in shoe size

General inspection

  • Increased size of feet, hands, head
  • Mildly hirsute
  • Kyphosis

Arms

  • Inspect and palpate with patient’s hands on pillow
    • Dorsum: large, spade-shaped, with signs of osteoarthritis 
    • Palms: sweaty, doughy/boggy texture to palms, capillary glucose stick marks on finger pulps (secondary diabetes)
    • Signs of carpal tunnel syndrome (release scar or loss of thenar eminence and/or loss of sensation in median nerve distribution)
  • Blood pressure (hypertension)

Face

  • General: coarse facial features, acne, enlarged nose and ears, macrognathia (large mandible), look for hypophysectomy scar under upper lip
  • Eyes: visual fields (bitemporal hemianopia in pituitary adenoma), prominent supra-orbital ridges
  • Mouth: prognathism (protrusion of mandible), splaying of teeth, macroglossia and ridges from teeth on sides of tongue

Neck

  • Thyroid goitre (increased thyroid vascularity)
  • JVP (cardiomyopathy)

Chest

  • Inspect: multiple skin tags
  • Acanthosis nigricans in axillae
  • Signs of cardiomyopathy (palpate apex, auscultate heart for murmurs/added sounds and lung bases for pulmonary oedema)

Limbs

  • Pedal oedema (cardiomyopathy)
  • Proximal myopathy (check resisted shoulder abduction, then ask patient to stand up with arms crossed)
  • Gait: rolling gait with bowed legs

To complete

  • Thank patient 
  • ‘To compete my examination, I would measure the blood pressure, perform thyroid and cardiovascular examinations and formally assess visual fields.’
  • Summarise and suggest further investigations you would consider after a full history, for example:
    • Insulin-like growth factor-1 
    • Growth hormone response to oral glucose tolerance test
    • MRI pituitary

Test yourself with some questions!

Picture references

Face acromegaly photos: 2008 Chanson and Salenave (Acromegaly. Orphanet Journal of Rare Diseases 3:17), licensed under the Creative Commons Attribution 2.0 Generic license

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