Consultation note
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Dr. ___________ has asked for consultation on this patient regarding regarding acromegaly.

Thank you for inviting us to see this patient.

Chief complaint: ___ year old male/female presents today for evaluation and treatment of Acromegaly. Patient admits to the following complaints:
headache, weakness, arthritis/arthralgia, increased ring/glove/shoe sizes; occasionally diplopia, mental status changes, vomiting; rarely nasal stuffiness, CSF rhinorrhea

My key findings of the ROS, Past Hx, Family Hx, and social Hx are:
ROS: Review of 12 systems was negative with exception of those things mentioned above in the HPI and weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Patient denies weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Past Medical History:

Past Surgical History:

Family History:

Social History:
Diet:
Exercise:
Smoking:
Recreational Drug use :
Education:
Occupation:
Lives with ____ where ____

Home Meds:

Allergies:

My key findings of this patient's Physical Exam are:
VITALS:
Pulse:
Blood Pressure:
Respirations:
Temperature:
Weight:
Height:
BMI:

GENERAL: sitting up/reclined in bed, awake, alert, and oriented, review old photographs, bony hypertrophy, protrusion of sternum, hypertension, osteoporosis, generalized visceromegaly (heart, lung, liver, spleen, kidney)
HEAD: normocephalic, atraumatic, no temporal wasting, negative chvostek sign, coarse face - thick skin folds (brows, nasolabial creases), enlarged nose, enlarged mandible (prognathism, spreading (splaying) of teeth, protracted jaw), thick lips, macroglossia, prominent orbital and frontal ridges (frontal bossing)
NOSE, MOUTH: lips and mucous membranes are moist, normal color of buccal mucosa
EYES: EOMI, PERLA, no proptosis, visual field defects (especially bitemporal hemianopsia or bitemporal superior quadrantanopsia)
NECK: supple, thyroid normal in size, thyroid small, thyroid low set, no thyromegaly or masses
RESPIRATORY: clear to ascultation bilaterally
CARDIOVASULAR: S1S2, no murmurs/rubs/gallops
GI: soft, non-tender, + bowel sounds
LYMPHATIC: no cervicoclavicular adenopathy appreciated
MUSCULOSKELETAL: moving all extremities
EXTREMITIES: no edema present, enlarged (bones in) hands (especially fingertips) and feet
NEUROLOGIC: monofilament sensed in all areas of the foot, vibratory sensation intact, fine/crude touch intact, pulses palpable, DTRs 2+, CN grossly intact
DERMATOLOGY: no xanthomas appreciated, no skin ulcers, no calluses, no onchyomycosis/dermatophyosis, no striae, skin thickening (e.g. heel pad), changes in pigmentation, hirsutism, acanthosis nigricans
PSYCHIATRY: patient answers questions appropriately, appropriate affectcoherent thoughts without flight of ideas

Labs:

Assessment:

Causes:
usually tumor (70% adenoma, carcinoma rare), may be hypothalamic
pituitary carcinoma as cause of acromegaly very rare, only 9 cases previously reported, 1 more case now reported (N Engl J Med 2001 Nov 29;345(22):1645)
also ectopic secretion by pancreatic endocrine tumors, carcinoids
case report of acromegaly caused by growth hormone secretion by non-Hodgkin's lymphoma can be found in N Engl J Med 2000 Jun 22;342(25):1871
use of human growth hormone to increase mass or for ergogenic effects
Complications:
10% diabetes mellitus, osteoporosis, hypertension, osteoarthritis, entrapment neuropathies
diabetes insipidus (impaired anti-diuretic hormone), increased prolactin
rostral extension into third ventricle leading to headache, nausea and vomiting
spontaneous pituitary apoplexy leading to hypopituitarism
Associated conditions:
multiple endocrine neoplasia (MEN) I

Diagnostic Plans:
GH: Increased growth hormone (GH) > 10 ng/mL measured in morning under basal conditions. Lack of normal suppressiblity of GH by glucose > 5 ng/mL 1 hour following PO glucose
not necessary if basal level > 30-50. Hypoglycemia is stimulation test in children with growth problems. TRH paradoxically stimulates GH.
Metabolic Profile: hyperglycemia (decreased glucose tolerance), hyperphosphatemia (increased reabsorption)
IGF-1: Increased somatomedin C (insulin-like growth factor I) * Best Screening test
Imaging studies:
MRI enlarged sella turcica, lateral skull x-ray
X-ray enlarged sinuses, cortical thickening, tufting of distal phalanges

Therapeutic Plans:
Surgery is treatement of choice, specifically transsphenoidal pituitary adenomectomy or transfrontal resection if large or suprasellar extension.

Medication:
Pegvisomant (Somavert), a growth hormone receptor antagonist, 40 mg subcutaneously loading dose then 10 mg subcutaneously once daily, adjust dose by 5 mg increments every 4-6 weeks based on IGF-1 levels, maximum 30 mg/day, monitor liver function tests. 112 patients with acromegaly randomized to pegvisomant 10 mg vs. 15 mg vs. 20 mg vs. placebo subcutaneously once daily for 12 weeks mean serum insulin-like growth factor I concentrations decreased by 26.7% vs. 50.1% vs. 62.5% vs. 4% (p < 0.001) and become normal in 54% vs. 81% vs. 89% vs. 10% (p < 0.001) patients treated with 15 mg or 20 mg had significant decreases in ring size, soft-tissue swelling, degree of excessive perspiration, and fatigue, Total symptom scores decreased in all pegvisomant groups (p < or = 0.05). Monitor liver function tests.
Octreotide SQ (analog of somatostatin) was shown to have antineoplastic effect in a study of surgical specimens after trial for 4 months vs. no treatment before surgical resection of growth hormone-producing pituitary tumor in 32 patients. Octreotide acetate for injectable suspension (Sandostatin LAR Depot) given IM once every month and indicated for acromegaly, use should be restricted to patients who have responded to and can tolerate subcutaneous octreotide. Octreotide 100 mcg subcutaneously every 8 hours (titrated up to 1500 mcg/day if needed) for mean 30 months improved symptoms in > 80% of 103 acromegalic patients in uncontrolled study, 24% developed gallstones but no cases of cholecystitis.
Bromocriptine (effective in 50% refractory cases)

Patient Education:
Return to Clinic:
We have discussed our diagnostic and treatment plans with the patients and family/friends that were present. All questions have been answered to the patient's satisfaction.

Thank you for inviting to see this consult!

Written by ___ _____________________ Time out_______