Acromegaly focussed examination

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)

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

Test yourself with some questions!

What are some potential causes of acromegaly?

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How would you investigate for acromegaly?

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What is the surgical management of acromegaly?

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Can you discuss different medical managements available and their mechanism of action?

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Which additional investigations are required in monitoring patients with acromegaly?

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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 P and Salenave S (Acromegaly. Orphanet Journal of Rare Diseases 3:17 doi:10.1186/1750-1172-3-17), licensed under the Creative Commons Attribution 2.0 Generic license (https://creativecommons.org/licenses/by/2.0/deed.en). Sourced from: https://commons.wikimedia.org/wiki/File:Acromegaly_prognathism.JPEG