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The OSCE instructions may be non-specific, for example: ‘Examine this patient’s endocrine status.’ This could be Cushing’s syndrome, acromegaly or hypothyroidism. Approach this situation by asking a few generic questions (if allowed) and by doing a general inspection to determine which condition you think is present. Then proceed with the relevant focussed examination to elicit other signs.
- Wash hands
- Introduce self
- Ask Patient’s name, DOB and what they like to be called
- Explain examination and obtain consent
Generic questions (may be required to differentiate between Cushing’s syndrome and hypothyroidism)
- What did you notice first when you developed this condition?
- Do you have any long-term conditions requiring you to take steroids?
- Have you noticed changes in your appearance?
Work down body
- Have you noticed mood changes?
- Do you get intolerant of heat or cold?
- Have you had any change in your periods?
- Central adiposity
- Intra-scapular fat pad
- Osteoporosis effects, e.g. kyphosis
- Around bed: inhalers, nebulisers, oxygen (may be used in COPD or interstitial lung disease)
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
- Poor wound healing
- 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)
- Intrascapular fat pad
- Supraclavicular fat pads
Chest and abdomen
- Skin thinning
- Classical purple 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)
- Thank patient
- ‘To complete my examination, I would measure blood pressure, dipstick test urine for glucose, 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/low dose dexamethasone suppression test
Now try some questions!
Outline the physiological mechanism controlling cortisol release
How does Cushing’s syndrome present?
Please list some causes of Cushing’s syndrome
What is the difference between Cushing’s syndrome and Cushing’s disease?
What investigations are required to localise the cause of cortisol excess?
Discuss the different management options available for Cushing’s syndrome
Here’s how a Cushing’s OSCE station would work
Learn more here…
There’s more learning on Cushing’s syndrome here!