Acromegaly

 

Thank you for asking me to examine Harry who presented with changes in his facial appearance.

 

My findings were suggestive of acromegaly complicated by __

 

I will discuss my findings in further detail with commentary on associated features and complications.

 

Mention first the general inspection features that point towards acromegaly (hands and face), then go into more detail in a systematic order in the order you examined so that you don’t miss thing.

 

On general inspection, the patient had morphological features suggestive of acromegaly.

• The patient had large hands with broad palms and spade-like fingers. On inspection of the face, there were prominent supraorbital ridges, an enlarged nose and lips, and prognathism (enlargement of the lower jaw) with splaying of the teeth, consistent with acromegaly. 

 

On further examination of the hands.

• The skin over the dorsum of the hands was thickened. There was/was not increased sweating.

• There were/were not osteoarthritic changes in the hands.

• There were no finger pin-pricks suggestive of diabetes.

• Phalen’s test for carpal tunnel syndrome was negative/positive

 

There was/was not evidence of proximal myopathy (in the arms and legs).

 

In the axilla, there were skin tags (molluscum fibrosum), and acanthosis nigrans.

 

In the face:

• There was prominent supraorbital ridges and enlarged features as discussed

• There was macroglossia, and hirsutism (in women).

• There was/was not scar to suggest previous pituitary surgery.

• There was a deep, resonant voice.

 

On examination of the eyes:

• On visual field testing, there was a bitemporal hemianopia. On fundoscopy, there was optic atrophy, papilloedema and angioid streaks. There was/was not opthalmoplegia.

 

In the neck:

• There was no goiter. (May be diffuse, or multi-nodular)

 

In the chest:

• There was/was not gynaecomastia (in males).

 

There were/were not signs of cardiomegaly and congestive cardiac failure.

 

In the legs:

• There were/were not osteoarthritic changes in the hands, and legs, or evidence of pseudogout. There was/was not heel pad thickening. Look for foot drop from common peroneal nerve entrapment

 

In the abdomen:

• There was/was not organomegaly

 

I would have liked to have:

• Taken the blood pressure was ___.

• More complete assessment of joints for OA

 

In summary, Harry had morphological features of acromegaly with/without associated features of visual field loss, nerve entrapment, cardiac sequelae, arthropathy, proximal myopathy, or diabetes.

 

I would proceed from here by:

• Confirming my diagnosis with insulin-like growth factor-1 plasma level, (+/- a glucose growth hormone suppression test), and an MRI to visualize any pituitary tumour

• Screen for diabetes with a HbA1c

• Based on symptoms, consider a:

  • TTE - cardiomegaly

  • Sleep study - OSA

  • Colonoscopy - bowel cancer

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How do you assess disease activity?

• Skin tag number

• Sweating

• Glycosuria

• Increasing visual loss or cranial nerve plasies

• Enlarging goitre

• Hypertension

• Symptoms of headache, increasing ring size, shoe size or dentures