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

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)

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💡 Conditions

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

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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