Acromegaly OSCE Examination

1. Introduction
2. General Inspection
3. Hand Examination
4. Arms and Blood Pressure
5. Facial Examination
6. Visual Fields and Eyes
7. Neck Examination
8. Cardiovascular and Respiratory Assessment
9. Lower Limbs and Joints
10. Completing the Examination
11. Quiz

Wash your hands and don personal protective equipment if appropriate.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient's details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Briefly explain the examination and obtain consent, for example: "I would like to look at your hands and face, check your vision, and examine your pulse and blood pressure. Is that alright?"

Ask the patient if they are in any pain anywhere before you begin, as joint pain is common in acromegaly.

Position the patient seated on the edge of the bed or in a chair, and ensure their hands, forearms and face are exposed and accessible.

Begin by standing back and observing the patient from the end of the bed. The diagnosis of acromegaly is frequently apparent from the general inspection alone, so take time to build an overall impression before touching the patient.

Look for the characteristic coarsening of the facial features, large hands and feet, and an increase in overall body size. Patients often report that their rings no longer fit and that they have had to buy larger shoes or gloves, which is a useful clue to the gradual soft-tissue overgrowth.

Note the patient's height and habitus. Acromegaly developing in adulthood does not increase height, but if excess growth hormone was present before the epiphyses fused (in childhood) the patient would have gigantism and be unusually tall.

If the patient is mobile, watch how they walk. A broad-based, rolling gait may be seen, reflecting the degenerative joint disease and any varus (bow-legged) deformity that the acromegalic arthropathy causes at the knees.

Scan the bedside for clues such as a blood glucose monitor or insulin (suggesting associated diabetes mellitus), a visual field chart, or walking aids (reflecting the arthropathy that acromegaly causes). A deepened or husky voice may also be noticeable when the patient speaks, caused by thickening of the vocal cords and enlargement of the laryngeal soft tissues and sinuses.

Inspect the hands first. In acromegaly the hands are typically large, broad and "spade-like", with thickened, doughy soft tissue and an increase in the size of the fingers. This is due to overgrowth of soft tissue, cartilage and bone driven by GH and IGF-1, rather than any swelling of the joints themselves. A simple way to gauge the degree of acral enlargement is to hold your own hand against the patient's, palm to palm, and compare the overall span; the patient's hand often noticeably overlaps your own.

Assess the skin thickness by gently pinching the skin over the third metacarpophalangeal joint and comparing it with the equivalent skin on your own hand. Excessively thick skin supports the diagnosis and reflects the generalised soft-tissue expansion seen throughout the body. The skin may also feel oily and sweaty, as acromegaly increases the activity of sweat and sebaceous glands, producing hyperhidrosis.

Inspect the fingertips for capillary blood glucose testing marks. Excess growth hormone is a counter-regulatory (anti-insulin) hormone, so it promotes insulin resistance and around one in three patients develops diabetes mellitus or impaired glucose tolerance.

Image - An unaffected hand on the left compared with an enlarged acromegalic hand on the right, showing widened fingers and thickened soft tissue

Creative commons source by Philippe Chanson and Sylvie Salenave [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

Acromegaly is a common cause of carpal tunnel syndrome. The soft-tissue overgrowth within the wrist compresses the median nerve as it passes through the carpal tunnel, producing pain, tingling and numbness in the thumb, index, middle and radial half of the ring finger. Look for wasting of the thenar eminence (the muscle bulk at the base of the thumb) as a sign of long-standing median nerve compression.

Two bedside tests can provoke the symptoms of carpal tunnel syndrome:

• Tinel's test – tap firmly over the carpal tunnel on the palmar aspect of the wrist. A positive test reproduces tingling or paraesthesia in the median nerve distribution.
• Phalen's test – ask the patient to hold their wrists in full flexion (back-to-back) for around 60 seconds. A positive test again reproduces the median nerve symptoms.

Finally, palpate the radial pulse, assessing the rate and rhythm. A normal rate is 60–100 bpm. This begins to assess the cardiovascular complications of acromegaly, which are an important cause of excess mortality in these patients.

Move up the arms and inspect the axillae and skin. Acromegaly is associated with multiple skin tags (acrochordons), which are small benign outgrowths of skin that are particularly common in the axillae and neck. They are clinically relevant because their presence has been linked with an increased risk of colonic polyps, part of the recognised association between acromegaly and colorectal neoplasia.

While inspecting the axillae and neck, also look for acanthosis nigricans – velvety, thickened, darkened skin in the flexures. This is a marker of the insulin resistance that growth hormone produces, and ties in with the impaired glucose handling seen in many patients.

You may also note proximal muscle weakness, as a chronic myopathy can develop in long-standing disease. A quick bedside screen is to ask the patient to stand from a seated position with their arms folded across their chest; difficulty doing so without pushing up on the arms of the chair suggests proximal weakness.

Offer to measure the blood pressure. Hypertension is common in acromegaly and arises from a combination of sodium and fluid retention (growth hormone has an anti-natriuretic effect on the kidney) and increased vascular tone. Hypertension contributes substantially to the cardiovascular morbidity of the condition, so its identification is an important part of the examination.

Inspect the face carefully, as it carries some of the most recognisable features of acromegaly. Look for coarse facial features overall, with thickened skin and accentuated facial creases.

Specific features to look for include:

• Frontal bossing – prominence of the forehead and brow caused by overgrowth of the frontal bones and the underlying frontal sinuses.
• Prognathism – protrusion of the lower jaw (mandible) due to bony overgrowth, often producing an underbite (malocclusion) where the lower teeth sit in front of the upper teeth.
• Interdental separation – widening of the gaps between the teeth, as the jaw enlarges but the number of teeth stays the same.
• Enlarged nose and lips – broadening of the nose and thickening of the lips from soft-tissue overgrowth.

Ask the patient to open their mouth and inspect the tongue for macroglossia (an enlarged tongue). This is significant beyond appearance: enlargement of the tongue and the soft tissues of the upper airway predisposes patients to obstructive sleep apnoea, a very common and important complication of acromegaly.

If you have not already done so, note any deepening of the voice, which results from thickening of the vocal cords and enlargement of the laryngeal cartilages and paranasal sinuses.

Image - The coarse facial features of acromegaly, including frontal bossing, an enlarged nose and prominent jaw, caused by bony and soft-tissue overgrowth

Creative commons source by Philippe Chanson and Sylvie Salenave [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

Image - Prognathism in acromegaly, with protrusion of the lower jaw produced by overgrowth of the mandible

Creative commons source by Philippe Chanson and Sylvie Salenave [CC BY 2.0 (https://creativecommons.org/licenses/by/2.0)]

Preview the Acromegaly OSCE Examination quiz