A 49-year-old man comes to the office due to a 3-month history of fatigue. He also reports diffuse joint pain, finger swelling, and difficulty gripping objects with his right hand. The patient has poorly controlled hypertension despite compliance with medications, a low-salt diet, and regular exercise. Temperature is 36.7 C (98 F), blood pressure is 146/98 mm Hg, pulse is 90/min, and respirations are 14/min. On examination, facial features appear coarse and differ significantly from those on his driver's license photograph taken 3 years ago. The palms are sweaty and have a doughy feel. The skin is oily. Multiple skin tags are noted, particularly on the neck. Tapping the ventral aspect of the right wrist produces shooting pain on the lateral side of the right hand. Which of the following is the best next step in evaluating this patient?

Question

A 49-year-old man comes to the office due to a 3-month history of fatigue.  He also reports diffuse joint pain, finger swelling, and difficulty gripping objects with his right hand.  The patient has poorly controlled hypertension despite compliance with medications, a low-salt diet, and regular exercise.  Temperature is 36.7 C (98 F), blood pressure is 146/98 mm Hg, pulse is 90/min, and respirations are 14/min.  On examination, facial features appear coarse and differ significantly from those on his driver's license photograph taken 3 years ago.  The palms are sweaty and have a doughy feel.  The skin is oily.  Multiple skin tags are noted, particularly on the neck.  Tapping the ventral aspect of the right wrist produces shooting pain on the lateral side of the right hand.  Which of the following is the best next step in evaluating this patient?

Quizplus · Accepted Answer

11ec25c8_d39b_9b55_bc81_25303cb18f67_MD0003_00 This patient's presentation (ie, coarse facial features, arthralgias, uncontrolled hypertension, enlargement of the digits, carpal tunnel syndrome) is consistent with acromegaly. This condition is caused by excessive growth hormone (GH) secretion, usually due to a pituitary somatotroph adenoma. Other common features include jaw malocclusion, hyperhidrosis, cardiomyopathy, macroglossia, and pituitary mass effect symptoms (eg, headache, visual field defects). carpal tunnel syndrome acromegaly GH stimulates hepatic insulin-like growth factor-1 (IGF-1) secretion, which mediates most of the clinical manifestations of acromegaly. IGF-1 levels in patients with acromegaly are consistently elevated throughout the day and are useful as an initial test, in contrast to GH, which fluctuates widely and has low sensitivity and specificity (Choice A). insulin-like growth factor-1 (IGF-1) Treatment can alleviate many of the physiologic effects (eg, hyperglycemia) of acromegaly, although skeletal and joint abnormalities are largely irreversible. Initial treatment for most patients includes transsphenoidal resection of the pituitary adenoma. For patients with residual or unresectable tumors, medical therapy is indicated; options include somatostatin analogues (eg, octreotide) or growth hormone receptor antagonists (eg, pegvisomant). (Choice B) In normal individuals, administration of glucose rapidly suppresses GH secretion, whereas in patients with acromegaly, GH is not suppressed and may paradoxically increase. Measurement of GH in an oral glucose suppression test can confirm the diagnosis of acromegaly; this test is especially useful in patients with equivocal IGF-1 levels but is not recommended as the initial diagnostic test. (Choice D) Once acromegaly is confirmed, patients should undergo MRI of the head to identify a pituitary mass. However, incidental pituitary lesions are common in normal patients and can be misleading. As a general rule in endocrinology, imaging is performed after the biochemical diagnosis of a disorder is made. (Choice E) Thyrotropin-releasing hormone administration suppresses GH secretion in normal individuals but stimulates secretion in many patients with acromegaly. However, this test has poor sensitivity and is not routinely performed. Educational objective: Acromegaly is caused by excessive secretion of growth hormone (GH), usually due to a pituitary somatotroph adenoma. Insulin-like growth factor-1 mediates most of the effects of GH and is the preferred initial test in suspected acromegaly. GH is not as sensitive or specific due to wide fluctuations in circulating levels. Initial treatment for most patients includes transsphenoidal resection of the pituitary adenoma. References: Acromegaly: an Endocrine Society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/25356808)

A 49-Year-Old Man Comes to the Office Due to a 3-Month