Cushing’s syndrome focussed examination

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.

Introduction

• 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)

General

• 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?

General inspection

• Central adiposity
• Intra-scapular fat pad
• Hirsutism
• 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

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)

Neck

• 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)

To complete

• 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!

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

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