Sunday, January 11, 2009

Medical PBL: Examination of a Cushing's

MaryO'Note: This doctor from Malaysia hopes that everyone should recognize a Cushing's patient!  We Cushies have always say that we could recognize another sufferer but it would sure be nice if doctors could recognize this disease this easily!

Should we go to Malaysia for easier, faster diagnosis?

From http://medicalpblukm.blogspot.com/2009/01/examination-of-cushings.html

By now, I hope that everyone should be able to recognize a Cushingnoid patient even before you examine a patient. Therefore, it is more of a showmanship for a short case of a patient with Cushing's syndrome/disease.


As Cushing's has clear cut characteristics, it is nice if a medical student can be able to find out the cause and the complications of Cushing's along the examination. There ius no need for a thorough examination of a particular body system as you'll be needing to go through almost the whole body. Below is a rough guide which welcomes comments and criticism to improve it.

  1. Hands - Inspect the hands for any deformities, vasculitic lesion or pulp atrophy which may be suggestive of autoimmune origin such as rheumatoid arthritis and SLE. Therefore, you should also run your fingers briefly along the small joints of the hands to palpate for the joins for signs of any swelling or tenderness. Have a light pinch at the skin of the dorsum part of the hand, yours and the patient's to compare the skin thickness. Remember, exogenous steroids administration may cause skin thinning.
  2. Forearms - Inspect for any bruises which may be suggestive of side effects of steroids or complication of Cushing's syndrome.
  3. Facial - Look out for any plethoric features, malar rash or acnes. These are suggestive of Cushing's as well. Discoid rash is almost a pathogmonic feature especially if it is also found at the back of the ears.
  4. Hair - Stroke the patient's hair (Inform the patient before doing this!!) to examine for alopecia (more hair may fall off or patches of baldness can be seen).
  5. Eyes - Examine the eyes for any signs of cataract. This may not require fundoscopy as sometimes it can be severe enough that it can be seen by the naked eyes. You may use two pentorches (one below the face pointing upwards and the other having a quick flash at the eye). This can be due to side effect of Cushing's or a diabetic patient. Remeber, Cushingnoid can be diabetic as well.
  6. Oral - Examine the oral cavity at the mucous membrane for any ulcers. This can be a sign of SLE. Superimposed thrush can be present too, which may be a diabetic sign.
  7. Upper torso - inspect and feel the supraclavicular fossa and interscapular area for fat pads. These are the signs of a Cushing's: Buffalo hump and supraclavicular fat. Also, try to elicit tenderness along the vertebra spine by gently pressing from the cervical spine downwards to sacral spine. Ask the aptient if there's any pain felt, as this can be a sign of osteoporosis as a result of exogenous steroids.
  8. Abdomen - Inspect for purple striae on the abdomen as a sign of Cushing's. Remember that adequate exposure is the key in finding the purples striaes. Medical students tend to miss the sign as they had not lower the pants enough to expose the lower part of the abdomen. Try to palpate for any adrenal masses. (Adrenal adenoma)
  9. Legs - You may look for bruises and skin thinning here as well. However, if there is positive findings on the forearm, most likely there will be findings on the legs. It is nice to show to the examiner that you are observant, but some examiners may not mind if you missed this. (Correct me if I'm wrong)
  10. Proximal myopathy - In a patient with Cushing's, there tend to have proximal myopathy. Test both upper limb's muscle for shoulder abduction and adduction (you may use the chicken wing manouever) as well as the flexion and extension of the arm.
  11. Tell the examiner that you would like to end the examination by:
    • getting the patient to squat to confirm for proximal myopathy.
    • measure the patient's blood pressure
    • (optional) - test the urine for glucose
    • (optional) - check the visual fields ( possible pituitary tumor, adenoma,etc)
    • (optional) - examine the fundus for optic atrophy, papiloedema, signs of hypertensive or diabetic retinopathy
So, if there's any mistakes here, do correct me. I'm more than willing to share the differences as well.
Here's a brief rundown of the causes of Cushing's syndrome:
  • exogenous steroids
  • pituitary adenoma
  • adrenal adenoma
  • adrenal carcinoma
  • ectopic ACTH (small cell carcinoma of the lungs)
Some extra stuff for you to ponder:
  1. Classification (Types) of Cushing's syndrome
  2. Investigations for Cushing's syndrome
  3. Management for the Cushing's according to the causes.