Table of Contents
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