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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
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