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!

Here’s how an acromegaly OSCE station would work

1. Acromegaly focussed exam
2. There’s lots more focussed examinations to try

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