Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year 2 doctor working in General Practice. Your next patient is a 23-year-old gentleman complaining of changing shoes multiple times due to increasing feet size. Please take a history and perform a relevant examination.
Patient History:
Your name is Bob Smith – you are a 23-year-old master's student studying business.
You have noticed lately that you have been changing multiple pairs of shoes over the past few years because your feet are getting bigger. You thought you had already reached puberty and do not know why your feet just keep growing. You also noticed your hands are also getting bigger.
You also noticed that your hands are sometimes slightly sore when typing on keyboards – unsure if you have any numb or tingling sensation. You feel really tired and always do not feel energised after waking up in the morning. You are a big snorer. You sweat a lot, and while checking your body after a workout, you notice new skin tags on your torso.
No headache. No visual disturbances (bitemporal hemianopia). No change in appetite. No polyuria/ polydipsia. You also have reduced libido.
Ideas, Concerns, Expectations:
You think you might be having arthritis as your mother has pain in her hands too due to her arthritis. You are concerned about your growing hands and pain while typing as you type a lot in your job. You want to do well in your job for a big promotion. You want some analgesia and generally just want to find out what is going on!
Past Medical History:
Hypertension
Drug History:
Ramipril
Penicillin allergy – rash
Family History:
Multiple endocrine neoplasia type 1 (father), rheumatoid arthritis (mother)
Social History:
Live with parents + independent
Master student studying business.
Don't smoke.
Drink a couple of cans of lager once a week with the lads.
No recreational drug use.
Examination Findings:
Prominent forehead and brow (frontal bossing), separation of teeth, large hands and feet, macroglossia, large protruding jaw (prognathism). A few skin tags on the torso. Thickening of nose/ skin. Clammy and sweaty.
May show: displaced apex beat (enlarged heart), enlarged liver/ spleen during abdominal palpation, tinel’s test may be positive (carpal tunnel syndrome). If indicated, enlarged prostate + goitre/ cranial nerve palsies.
Differentials:
Acromegaly
Pseudo-acromegaly (similar physical appearance in the absence of elevated GH / IGF-1)
Investigations:
Bedside:
Observations (may show hypertension)
BM (may show high BM associated with diabetes in acromegaly)
ECG / Echocardiogram (left ventricular hypertrophic changes/ arrhythmias/ cardiomyopathy in acromegaly)
Bloods:
Insulin-like Growth Factor 1 (IGF-1) (raised in acromegaly) – long half-life + high sensitivity
Oral glucose tolerance test while measuring growth hormone (high glucose suppresses GH)
Prolactin (associated with hyperprolactinaemia in acromegaly) indicated if symptoms of galactorrhoea, amenorrhoea in females, reduced libido, infertility, erectile dysfunction
Phosphate/triglycerides (may be raised in acromegaly)
GHRH levels (elevated in ectopic releasing hormone secretion from neuroendocrine tumours)
Consider Cortisol / estradiol / testosterone + routine bloods (baseline)
Random serum growth hormone is not recommended due to secretion is episodic, and the half-life is short
Imaging:
MRI Brain for pituitary/ hypothalamus tumour
CT scan – to check for lung/ pancreatic/ adrenal/ ovarian tumours in ectopic GH/GHRH)
Consider CXR: may show enlarged heart + tumour location
Consider AXR: tumour location
If back pain – spine XR - vertebral fracture (low-quality bone despite high bone mass in acromegaly)
Octreoscan (tumour localisation for suspected ectopic sources)
PET Scan (tumour localisation)
If indicated, acromegaly is associated with thyroid cancer, consider USS thyroid + TFT
Screening:
Consider colonoscopy if indicated (colon cancer is associated with acromegaly). Regular colonoscopy screening should be started at the age of 40 – frequency depends on initial screening + activity of acromegaly.
Management: