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)

Acromegalic hand

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

Mandibular prognathism

Wide spaces between teeth

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