Cushing’s syndrome focussed examination

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain examination and obtain consent

General inspection

• Central adiposity
• Intra-scapular fat pad
• Hirsutism
• Around bed: inhalers (may be used in COPD or interstitial lung disease), steroid tablets

Hands and arms

• Capillary glucose stick marks on finger pulps (secondary diabetes)
• Pigmentation (Cushing’s disease)
• Deforming polyarthritis (a reason for corticosteroid use)
• Thin skin and bruising

Face

• Inspection: cushingoid-like facial features (‘facial mooning’), facial plethora, hirsutism, acne, telangiectasia, butterfly rash (SLE)
• Inside mouth: oral thrush, buccal pigmentation (Cushing’s disease)
• Listen for hoarse voice
• Visual fields (bitemporal hemianopia in pituitary adenoma)

Cushing’s facial appearance

Telangiectasia

Neck

• Intrascapular fat pad
• Supraclavicular fat pads

Chest and abdomen

• Skin thinning
• Abdominal striae
• Lipodystrophy from insulin injections (secondary diabetes)
• Signs of any conditions requiring prolonged steroid use (e.g. organ transplant scars, hyperexpanded chest in COPD)
• Proximal myopathy (check resisted shoulder abduction, then ask patient to stand up with arms crossed)

To complete

• Thank patient
• ‘To complete my examination, I would measure blood pressure and formally assess visual fields.’ 
• Summarise and suggest further investigations you would do after a full history, for example:
  • 24 hour urinary free cortisol
  • Overnight dexamethasone suppression test

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Now try some questions!

Outline the physiological mechanism controlling cortisol release

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How does Cushing’s syndrome present?

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Please list some causes of Cushing’s syndrome

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What is the difference between Cushing’s syndrome and Cushing’s disease?

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What investigations are required to localise the cause of cortisol excess?

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Discuss the different management options available for Cushing’s syndrome

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Here’s how a Cushing’s OSCE station would work

1. Cushing’s disease focussed exam
2. Find more stations here

Picture references

Cushing’s facial appearance: 2012. Ozlem Celik, Mutlu Niyazoglu, Hikmet Soylu and Pinar Kadioglu. Iatrogenic Cushing’s syndrome with inhaled steroid plus antidepressant drugs. Multidiscip Respir Med. 2012; 7(1): 26. Licenced under Creative Commons Attribution 2.0 Generic license (http://creativecommons.org/licenses/by/2.0). Sourced from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3436715/