[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has complained of weight gain.  Please examine them and discuss your findings with the examiners.”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/149509868″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”8″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”2″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has Cushing syndrome.

The clinical signs exhibited in this video include:

  • Central obesity;
  • Abdominal striae;
  • “Moon face” appearance.

In this particular patient the features were caused by long-term prednisolone for sarcoidosis.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Cushing’s Syndrome

Cushing’s syndrome is a PACES favourite, in large part due to the unfortunate commonality of the condition and the wide clinical spectrum of disease.

Clinical features:

  • Cardiovascular
    • Hypertension
  • Gastrointestinal
    • Central obesity or rapid weight gain
  • Reproductive / endocrine
    • Reduced libido
    • Amennorhoea/dysmennorhhoea
    • Infertility/subfertility
  • Dermatological
    • Facial plethora
    • Hirsutism
    • Thin skin
    • Bruising
  • Psychological
    • Depression
    • Emotional difficulties
  • Musculoskeletal
    • Proximal muscle atrophy
    • Osteopenia leading to osteoporosis
  • Renal
    • Renal tract calculi

The clinical features on bold are the key features of Cushing’s compared to the others which are found commonly in many other endocrine and non-endocrine related conditions.

The most common cause is iatrogenic from long term glucocorticoid exogenous use, for conditions such as inflammatory bowel disease and chronic obstructive pulmonary disease or for immunosuppression in transplantation.

Non-iatrogenic causes are limited:

  • Cushing’s disease due to excess adrenocorticotrophic hormone (ACTH) secretion which is the most common cause and from a pituitary adenoma
  • Ectopic secretion of ACTH from small cell lung cancer or carcinoid (the latter is often indistinguishable from Cushing’s disease)
  • Adrenal adenomas (carcinoma >> hyperplasia) secreting cortisol.

The history will give the clearest of indications as to whether the cause is iatrogenic or not, and this highlights the need to take a proper medication history and include past medications.

If the history does not indicate an iatrogenic cause, then further investigations need to be carried out to determine which one of the above, non-iatrogenic causes it is. The primary and most sensitive test is the dexamethasone suppression test, for which all the causes of Cushing’s syndrome will result in failure to suppress.

Management includes treating the complications of the condition, such as insulin and other medications such as metformin for diabetes and anti-hypertensives as well as bisphosphonates for osteoporosis. For Cushing’s disease, surgical trans-sphenoidal hypophysectomy is still the treatment of choice for cure.

If iatrogenic aim for reduction and if possible removal of glucorticoids and replacement with alternative therapies.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has Cushing syndrome.  He is obese with a moon face and has abdominal striae.  I would like to proceed by taking a thorough history.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]