A 37 year old homeless man presents to the GP clinic for the first time in his life. He is strikingly tall and has coarse and thickened skin on his palms and soles of his feet. He has come in because he can no longer stand the headaches that have become increasingly worse over the years. He often feels fatigued on the street. He also experiences joint pain and stiffness, especially in his knees and hips, which he attributes to the cold.

Upon examination, the patient's skin feels warm to the touch, and he is visibly sweating during the examination.

Which of the following is the most likely underlying cause of this condition?

Options:
explanation: In this case, the patient's tall stature, coarse and thickened skin, enlarged hands and feet, joint pain, headaches, and excessive sweating are all consistent with the clinical features of acromegaly. Acromegaly results from the excessive production of GH from the pituitary gland, typically due to a pituitary adenoma. This condition leads to the overgrowth of bones and tissues and is associated with various systemic symptoms and complications. By contrast, the raised thyroid stimulating hormone seen in hyperthyroidism would not explain the joint pain and stiffness, coarse skin, and excessive growth.
name: Raised thyroid stimulating hormone
label: d
answer: no
explanation: In this case, the patient's tall stature, coarse and thickened skin, enlarged hands and feet, joint pain, headaches, and excessive sweating are all consistent with the clinical features of acromegaly. Acromegaly results from the excessive production of GH from the pituitary gland, typically due to a pituitary adenoma. This condition leads to the overgrowth of bones and tissues and is associated with various systemic symptoms and complications. By contrast, excessive cortisol leads to symptoms such as weight gain, central obesity, easy bruising, hypertension, and mood disturbances. It does not fit with the clinical picture in this vignette.
name: Cortisol
label: e
answer: no
explanation: This is the correct answer. In this case, the patient's tall stature, coarse and thickened skin, enlarged hands and feet, joint pain, headaches, and excessive sweating are all consistent with the clinical features of acromegaly. Acromegaly results from the excessive production of GH from pituitary gland, typically due to a pituitary adenoma. This condition leads to the overgrowth of bones and tissues and is associated with various systemic symptoms and complications.
name: Raised growth hormone (GH)
label: a
answer: yes
explanation: In this case, the patient's tall stature, coarse and thickened skin, enlarged hands and feet, joint pain, headaches, and excessive sweating are all consistent with the clinical features of acromegaly. Acromegaly results from the excessive production of GH from the pituitary gland, typically due to a pituitary adenoma. This condition leads to the overgrowth of bones and tissues and is associated with various systemic symptoms and complications. By contrast, elevated testosterone levels are related to symptoms of hyperandrogenism such as hirsutism, acne and obesity. It does not fit with the clinical picture in this vignette.
name: Raised testosterone
label: c
answer: no
explanation: In this case, the patient's tall stature, coarse and thickened skin, enlarged hands and feet, joint pain, headaches, and excessive sweating are all consistent with the clinical features of acromegaly. Acromegaly results from the excessive production of GH from the pituitary gland, typically due to a pituitary adenoma. When GH enters the blood, it then signals the liver to produce IGF-I, causing bones and tissues to grow. Since this question is asking for the underlying cause, the answer should be GH, not IGF-1.
name: Raised insulin-like growth factor I (IGF-I)
label: b
answer: no

Correct answer: a