A 33-year-old man complains of a tingling sensation in his hands for several months which occasionally awakens him during sleep. The patient has noticed he has gained weight and no longer wears his wedding ring as it has become too tight. You notice the patient is sweating while speaking to you and has quite a large jaw, furrowed tongue and large hands. His blood pressure reading is 142/91 mmHg. The most appropriate investigation would be:

## **Core Concept**
The patient's symptoms suggest **acromegaly**, a disorder caused by excess growth hormone (GH) secretion, often due to a pituitary adenoma. This condition leads to characteristic physical changes and metabolic effects.

## **Why the Correct Answer is Right**
The clinical presentation of this patient—tingling sensation in hands, weight gain, large jaw (macrognathia), furrowed tongue (macroglossia), large hands, and sweating—is highly suggestive of acromegaly. The most appropriate investigation to confirm the diagnosis and assess the underlying cause is **MRI of the pituitary gland**. This imaging technique can help identify a pituitary adenoma, which is the most common cause of acromegaly.

## **Why Each Wrong Option is Incorrect**
- **Option A:** While a **glucose tolerance test** can be used to assess GH suppression and diagnose acromegaly, it does not directly investigate the cause, such as a pituitary adenoma.
- **Option B:** **Thyroid function tests** might show alterations due to the systemic effects of GH excess but are not diagnostic for acromegaly or its cause.
- **Option D:** **Hand X-ray** might show characteristic changes like tufting of terminal phalanges but does not investigate the underlying cause of acromegaly.

## **Clinical Pearl / High-Yield Fact**
A key clinical pearl is that acromegaly can lead to **carpal tunnel syndrome**, explaining the patient's tingling sensation. Also, remember that **GH excess** can lead to insulin resistance and diabetes mellitus, and **hypertension**, as seen in this patient.

## **Correct Answer:** . **MRI of the pituitary gland**

✓ Correct Answer: B. Glucose tolerance test