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
• 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)

Cushing’s facial appearance

Telangiectasia

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!

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/