Examination of a Cushing's

Updates: 12th Jan 2009 (Point forms are updated from Jeffrey's tips) Special thanks!

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 is able to ellicit the causes 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 (usually paper thin in Cushing's). Remember, exogenous steroids administration may cause skin thinning.

    • the skin thickness in normal person is 1.8mm

  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.

    • Do not forget temporalis deposition of fat giving the characteristic moon facies

  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 patient if there's any pain felt, as this can be a sign of osteoporosis as a result of exogenous steroids.

    • Spine tenderness have a tendency to affect weight bearing spines i.e lumbar. Alternately, you can palpate downwards from thoracolumbar junction as this may save you some time instead of palpating from cervical spine.

  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)

    • Striaes can also be found in inner thigh and axilla.
    • In the abdomen, you may also want to elicit hepatomegaly due to fat deposition in the liver or due to increased in workload of the liver to metabolise the excessive steroids.

  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)

    • in the legs, pedal edema can be a sign of mineralocorticoid excess, so be aware!

  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.

5 referrals:

Jeff said...

in the abdomen, you may also want to elicit hepatomegaly due to fat deposition in the liver or due to increased in workload of the liver to metabolise the excessive steroids.

Striaes can also be found in inner thigh and axilla.

the skin thickness in normal person is 1.8mm...so unless the skin pinched is paper thin, its normal.

Spine tenderness,in my opinion affects the weight bearing spine i.e lumbar. There's no need to palpate from cervical right down to sacrum bcuz it will cause u time especially when you're not used to the technique. I personally start palpating from the thoracolumbar junction downwards.

in the leg, signs of mineralocorticoid excess to be aware of is pedal edema.

Do not forget temporalis deposition of fat giving the characteristic moon facies/

judycolby said...

And don't forget that many Cushing's patients have only a very few of the classical symptoms but do have many other issues not mentioned - GI problems, depression, reversed sleep pattern, etc.

SOwens said...

The one thing that we have learned, having tried to get cured or diagnosed with Cushing's for 7 years, is that the text book cases of Cushing's are not the normal. Having Cushing's sucks because our symptoms fit into other things. Like stress, anxiety, poor diet/exercise, and the list goes on.

The problem with diagnosis is that doctors will want to run a test or two and then call it stress. The Cushing's community knows that a few tests can not rule out Cushing's. Most doctors think it does. Many of us stay sick until we either find a doctor who knows what they are doing or we get so sick no one can miss it.

Cushing's isn't rare. It is just rarely diagnosed. It is a life altering and life ending/shortening disease if left untreated. Finding a good team of doctors is deciding factor of getting a diagnosis or getting worse.

skinnyminny8 said...

? Heard rare to get a visual field defect as pituitary tumours in Cushings Disease are very small.

Anonymous said...

dun forget the lymph nodes as well (lung CA-ectopic)