To Detect the Undetected

I think the most satisfying thing in doing medicine is to get to the diagnosis, and especially some rare ones, get a taste and u'll be addicted to it. An example is one of the cases I saw last week, a 68 yo man was electively admitted for revision of his left TKR (total knee replacement). He had TKR done to his both knees 3 yrs ago and now presented with failed implant bilaterally. His known comorbid was only HPT for 20 yrs which was under regular f/up in GHKL.
Seems to be a straightforward case.
But my first glance on him tells me somethin's not right. This man seems to have some subtle features of acromegaly. Further history revealed a gradual increase in shoe/body size in past 10 yrs, and with the typical spade-like hands/ macroglossia with spaced teeth etc, pretty suggestive of it. BP on admission was 200/110mmHg, with bilateral pedal edema. CVS has soft systolic murmur.
So I continued to work on it. CXR revealed a massive cardiomegaly, and the skull Xray, yup the enlarged sella turcica. CT showed pituitary macroadenoma at last..this guy really has acromegaly! Explained the bilateral knee OA (probably also the failed implants), cardiomyopathy and the poorly controlled HPT. This diagnosis has been missed in the past 10 years!