A Case of Acromegaly

I saw Mr. J for the first time a week ago.
I was floored as I stepped into the room.
Acromegaly, it seemed clear to me.
A condition of increased growth hormone by a pituitary tumor.
He exhibited most of the striking features, including large hands and feet, prominent forehead and jaw with some coarsening of features, large nose and tongue. He also had numerous skin tags, and colon polyps, which was the reason his gastroenterologist sent him to me.
I had his IGF-1 levels drawn, amongst other labs. I did caution him I expected to find that elevated and the next step when confirmed would be a pituitary MRI, cardiac echo (as part of the pre-op evaluation as some of these patients will have cardiomyopathy- a good thing to know before you embark on surgery) and a neurosurgical consult. My resident though didn't seem impressed- he thought the patient looked not-too-abnormal.
I wasn't the least bit surprised when his levels came back 5x above normal.
The thing was, he was initially a bit upset that his family doctor whom he has been seeing for years, did not pick this up.
The truth is, this is usually the case, I told him. The changes are so slow and so subtle, that often the people who have known you the longest are the ones who are least likely to notice the clinical picture. Even Mr. J himself who wasn't sure why his gastroenterologist sent him to me. He and his wife denied all the usual questions I asked him, including change in shoe size, ring, etc. He thought he looked pretty normal. Simply because of the extremely slow progression.
I remember what Dr. Y said in fellowship:
"This is the kind of disease a doctor new to the patient is most likely to detect, not someone who has known the patient for years."
So true.
One helpful tip I gave my resident who was working with me that day. I asked Mr. J if he had any older pictures. He pulled out a 9-year old government ID and we compared it to his present phenotype. And with that, my young trainee doctor was convinced.