[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“Please chat to this patient who feels generally unwell.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/144967896″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”8″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”2″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has obvious acromegaly.

The clinical signs exhibited in this video include:

  • Large spade-like hands;
  • Prognathism;
  • Frontal bossing of the skull;
  • A large nose and ears;
  • Skin tags on the anterior neck.

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Acromegaly is a life threatening condition that results from a hormonal disorder involving overproduction of growth hormone (GH), can be subtle in nature with symptoms preceding diagnosis by several years.

Under the influence of GHRH (hormone produced by hypothalamus), pituitary gland produces GH, which when released in bloodstream, stimulates the liver to produce IGF-1 (insulin-like growth factor). High levels of IGF-1 then lead to a reduction in GH production through negative feedback. IGF-1 also has an effect on lipid and glucose metabolism. An imbalance of these three (GHRH, GH and IGF-1) eventually causes Acromegaly. This imbalance may be due to:

  • GH-secreting pituitary adenomas or hyperplasia (most common)
  • Hypothalamic tumors
  • Non-endocrine tumors producing ectopic GHRH and GH

In acromegaly, a person will have:

  • Abnormally large hands, feet and face
  • Coarse facial features
  • Thick lips and eyelids
  • Jutting forehead and jaw
  • Widely spaced teeth
  • Profusely sweating
  • Swollen palms and soles (earliest signs)
  • Doughy-feeling skin with large pores
  • Oily skin and hyperpigmentation (skin changes cease with disease regression)
  • Hypertrichosis

Rest of the clinical features depend whether it’s GH/IGF-1 excess or local effects on intracranial tumor. Mass effects of tumor include visual field defects, headaches, damaged normal pituitary tissue and loss of end-organ hormones. GH/IGF- excess results in:

  • Soft tissue swelling
  • Extremities enlargement
  • Increase in ring and shoe size
  • Prognathism
  • Macroglossia
  • Hyperhidrosis
  • Facial feature coarsening

Investigations carried out to diagnose the condition involve measurement of GH and IGF-1, measurement of GH one hour after glucose administration (100g), immunoassays for IGF-1. IGF-1 is the most reliable indicator. Other investigations include:

  • CT scan
  • MRI
  • Radiography
  • TRH and GHRH levels
  • Surgical specimens from pituitary tumors for histologic findings.

Management aims at lowering GH and IGF-1 levels in blood to the normal level. Treatment options include:

  • Tumor removal
  • Pituitary irradiation (if surgery fails)
  • Medical therapy for persistent post-operative disease
  • Somatostatin analogues
  • Dopamine-receptor agonists
  • GH-receptor antagonists

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has obvious acromegaly.  She has large hands, prognathism, frontal bossing and a large nose and ears.  I would like to test her visual fields and arrange imaging of her pituitary gland.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]