Acromegaly Exam

By Dr. Julie Gilmour

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Prior to Exam

  • Hand hygiene, introduce self, informed consent, exposure & draping.

General Inspection

  • Ascertain height, weight & BMI
    • If GH excess prior to epiphyseal fusion = gigantism

Hands

  • Inspection of hands:
    • Wide spade-like hand shape (due to soft tissue and bone swelling)
    • Enlarged thenar and hypothenar eminences
    • Palms – increased sweating and warmth
    • Skin thickening
  • Measures diameter of middle phalanx of middle finger on both hands
    • Done for serial monitoring (middle phalanx less likely to be affected by physical activity)
    • Hand volume (immerse to wrist crease in a graduated flask with water)
  • Examine for changes of OA (premature)
    • Heberden’s nodes (marginal osteophyte at the distal interphalangeal joint)
    • Squared thumb
  • Examine for carpel tunnel syndrome
    • Highest specificity
      • Hypoalgesia (decreased sensitivity to pain) in median nerve territory
      • Classic or probable Katz hand diagram result
      • Weak thumb abduction strength – tests abductor pollicis brevis
    • Other tests – Phalen’s test (hold for 60 sec in prayer sign), Tinel’s test & inspect for thenar atrophy

Arm

  • Measures BP – HTN
  • Examines upper arm strength (ie. deltoid) for evidence of proximal myopathy
  • Palpate behind medial epicondyle for ulnar nerve thickening
  • General facial inspection
    • Coarse facial features
    • Acne
    • Frontal bossing (due to expansion of frontal sinus)
  • Eyes
    • Assesses visual fields – bitemporal hemianopia if pituitary tumor
    • Assesses EOM & visual acuity (see pituitary cranial n examination for details)
    • Fundoscopy examination
      • optic atrophy – due to CN 2 compression
      • papilloedema – due to increased ICP
      • angioid streaks – due to degeneration & fibrosis of Bruch’s membrane. Red/brown/grey streaks that are 3-5x the diameter of the retinal vein and emanate from the optic disc (Extra)
      • Examine for HTN & DM retinopathy changes
  • Mouth
  • Macroglossia
  • Separated teeth
  • Jaw – square and protrudes (prognathism) – secondary to lengthening of mandibular arm
  • Hoarse voice (sonorous low pitched, not really hoarse )- due to soft tissue enlargement of the larynx and pharynx ; hoarse if vocal cord polyps develop
  • Hirsutism in women

Neck

  • Thyroid – examine for diffuse enlargement or multinodular goiter
  • Enlarged neck circumference seen with OSA (collar size > 17 inches in men & 16 inches in women) – due to enlargement of larynx
  • Kyphosis of thoracic spine
  • Skin tags
  • Acathosis Nigricans

Chest

  • Cardiac Exam
    • Palpate carotid pulse – irregular pulse due to arrhythmia (ie. AF)
    • Palpation – apex heaving/sustained due to LVH
    • Auscultation – increased incidence of valvular heart disease (AR, MR), S4
    • Examine for evidence of heart failure – due to diastolic dysfunction and LVH
      • JVP (elevated), auscultate lung bases (crackles), pedal edema, ascites
      • Examine for pulmonary HTN – seen with OSA
      • Palpable P2, RV heave, elevated JVP, TR
  • Examines for gynaecomastia and breast masses in men
  • Examines for nipple discharge – if pit. tumor co-secreting prolactin

Abdomen

  • Palpate for internal organ enlargement
    • Spleen
      • Percussion – Castell’s method (percuss lowest intercostal space in anterior axillary line = + if dull on insp), Traube’s space, Nixon method
      • Palpation – supine & two handed in RLD position
    • Liver – Percuss total liver span (N < 13cm), palpate for hepatomegaly
    • Kidneys – bimanual method (balloting)
  • Testicular exam for atrophy (seen if associated gonadotropin deficiency or co-secreting pituitary tumor – prolactin & GH)

Lower limbs

  • Examine for OA
    • Knees – crepitus on passive movement, bony enlargement, varus deformity, pain
    • Hip – restriction of internal rotation, abduction & extension, pain
  • Examine for proximal myopathy (eg. Quadriceps strength bilaterally)
  • Heel pad thickness (measure by radiologic assessment- useful for serial followup)
  • Examine for common peroneal nerve entrapment (L4-S1)
    • Foot drop (unable to dorsiflex/evert, high steppage gait) and decreased sensation over dorsum of foot & lateral shin. Normal reflexes.

To finish

  • Extension of the physical examination
    • Glucometer – check BS (associated with DM)
    • Urinalysis – for glycosuria
  • Recommends colonoscopy – at diagnosis (Endocrine Society, 2014)
    • Q 5 years if previous polyp, persistently elevated IGF-1 or positive FHx for colon cancer
    • Q 10 years if no polyp and normal IGF-1
    • Risk of polyp increased but true risk of ca. is unknown

References: Endocrine Society Acromegaly Guidelines, 2015 • Clinical Examination 6th ed: Talley & O’Connor, 2010