Examination: Cushing's Syndrome

Examining a patient for signs of Cushing's Syndrome involves an general inspection of the patient, along with a systematic examination of the main organs involved in the disease

• The patient as a whole (for the 'gestalt' picture of Cushing's syndrome):
  • For central obesity
  • For stooped posture (due to osteoporotic damage)
• Generalised changes over the body, including:
  • Easy bruising
  • Striae
  • Thin skin
  • Classical central fat distribution

• Examine each of the following body parts separately: (as for the cardiovascular, respiratory and abdominal examinations, start with the hands)
  
  
  • Hands and arms for...
    • Bruising
    • Thin arms
    • Ask to measure blood pressure (would be raised)
    • Shoulder abduction power - reduced in proximal myopathy
    • Rheumatoid arthritis (suggesting an iatrogenic cause of the Cushingoid features)
  
  
  • Face for...
    • Rounded face (moon face)
    • Visible vessels on the cheeks suggesting thin skin
    • Greasy skin
    • Acne
    • Hirsutism
    • At this point you may wish to test Visual fields (looking for a bitemporal hemianopia that may be the result of an ACTH producing pituitary tumour pressing on the optic chiasm)
  
  
  • Shoulders for...
    • Supra-clavicular fat pads
    • Buffalo hump
  
  
  • Abdomen for...
    • Central obesity
    • Striae
    • Bruising
    • Renal transplant scars (patient may be on long term steroids which is causing the Cushing's syndrome)
  
  
  • Legs for...
    • Skin ulceration
    • Ask patient to get up from a sitting position without using hands to test for proximal myopathy
  
  
  • Spine for...
    • Spinal tenderness (may occur with osteoporosis if vertebral fractures)

• Do bedside tests:
  • Carry out a urine dipstick and check BM blood sugar at bedside (Diabetes Mellitus)
  • Check blood pressure if not already done (Hypertension)
• Inspect this patient's drug chart for any steroid use.
• Consider further investigations, such as a dexamethasone suppression test.

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