11/13/24, 6\:59 PM Guide | Cushing's examination

Cushing's examination

Table of contents

Background

Cushing’s syndrome is a hormonal disorder that results from prolonged exposure to high levels of glucocorticoids.
The most common cause of Cushing’s syndrome is exogenous glucocorticoid use (e.g. prednisolone).
Endogenous Cushing’s syndrome can be classi
independent causes.

ACTH-dependent

In ACTH-dependent Cushing's syndrome, high ACTH levels stimulate the adrenal glands to produce glucocorticoids.
80% of ACTH-dependent Cushing’s syndrome is due to pituitary adenomas (also known as Cushing’s disease).
Less commonly, it is caused by ectopic ACTH production from bronchogenic (small cell lung cancer) or neuroendocrine
tumours.
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ACTH-independent

In ACTH-independent Cushing's syndrome, excess glucocorticoid secretion from the adrenal glands occurs despite low ACTH
levels.
This is often due to adrenal adenomas and, less commonly, bilateral adrenal hyperplasia or adrenal carcinoma.
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Clinical features of Cushing's syndrome

Clinical features of Cushing's syndrome include\:
Truncal obesity
Bu
Supraclavicular fat pads
Moon facies
Proximal muscle wasting
Bruising
Peripheral oedema
Acne
Headaches, visual
Cushing’s syndrome can cause various complications, including hypertension, osteoporosis, diabetes mellitus, cataracts and
myopathy.
Speci
Hyperpigmentation (skin and oral mucosa)
In exogenous Cushing's syndrome (due to treatment with glucocorticoids), there may be clinical features of the underlying
disease process being treated (e.g. COPD, rheumatoid arthritis, organ transplantation).

Introduction

Wash your hands and don PPE if appropriate.
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Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle.
Adequately expose the patient’s chest for the examination (o
appropriate, inform patients they do not need to remove their bra). Exposure of the patient’s lower legs is also helpful to assess
for oedema and skin thinning.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Signi
part of the assessment.

Clinical signs

Perform a brief general inspection of the patient, looking for clinical signs suggestive of Cushing’s syndrome\:
Facial plethora\: facial fullness (moon facies) and rounding of the face
Dorsocervical fat pad ('bu
Thinning of the skin and easy bruising
Weight gain and central obesity

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Medical equipment\: note any oxygen delivery devices and ECG leads.
Mobility aids\: items such as walking aids give an indication of the patient’s current mobility status.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their
physiological parameters have changed over time.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications.

Hands

Inspection

The following signs may be seen on close inspection of the hands\:
Finger pricks\:
Reduced skin fold thickness\: due to skin thinning
Pigmentation (excess ACTH / Cushing’s disease)
Signs of arthritis (e.g. joint swelling or deformities)\: a potential reason for long-term exogenous glucocorticoid use

Arms

Inspect the arms

Bruising
Cushing's syndrome causes skin thinning and makes patients more susceptible to bruising.
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Pulses and blood pressure

Radial pulse
Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Blood pressure
causes hypertension.
Oblood pressure guide for more details). Cushing's syndrome commonly
A comprehensive blood pressure assessment should also include lying and standing blood pressure.
In an OSCE station, you are unlikely to have to carry out a thorough blood pressure assessment due to time restraints, however,
you should demonstrate that you have an awareness of what this would involve.

Face

General appearance

Inspect the general appearance face for features associated with Cushing's syndrome\:
Facial plethora\: facial fullness and rounding of the face (moon facies) (Figure 1)
Facial acne
Hirsutism (Figure 2)
Buttersystemic lupus erythematosus (a possible reason for long-term exogenous glucocorticoid use)
Figure 1. Moon facies

Mouth

Inspect the inside of the mouth for the following\:
Oral thrush (candidiasis)
Buccal pigmentation (excess ACTH / Cushing’s disease)

Visual

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Assess for bitemporal hemianopia (found in Cushing’s disease due to compression of the optic chiasm by a pituitary
adenoma).
This method of visual
You need to position yourself, the patient, and the target correctly (see details below)
You need to have normal visual
Visual
1. Sit directly opposite the patient, at a distance of around 1 metre.
2. Ask the patient to cover one eye with their hand.
3. If the patient covers their right eye, you should cover your left eye (mirroring the patient).
4. Ask the patient to focus on part of your face (e.g. nose) and not move their head or eyes during the assessment. You should
do the same and focus your gaze on the patient’s face.
5. As a screen for central visual
assessment can be completed with an Amsler chart.
6. Position the hatpin (or another visual target) at an equal distance between you and the patient (this is essential for the
assessment to work).
7. Assess the patient’s peripheral visual
and slowly move the target towards the centre, asking the patient to report when they
target but the patient cannot, this would suggest the patient has a reduced visual
8. Repeat this process for each visual
9. Document your
Assess the patient's peripheral visual

Chest and back

Inspection

The following signs may be noted on close inspection of the chest and back\:
Dorsocervical fat pad\: increased subcutaneous fat on the back of the neck
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Supraclavicular fat pads (supraclavicular fullness)\: increased subcutaneous fat in the supraclavicular fossa
Kyphosis\: resulting from vertebral wedge fractures due to osteoporosis
Gynecomastia in males
Acne on the chest or the back

Abdomen

Inspection

The following signs may be seen on close inspection of the abdomen\:
Central obesity
Prominent purple striae (Figure 2)
Lipodystrophy from insulin injections (diabetes mellitus)
Organ transplantation scars (a possible reason for long-term exogenous glucocorticoid use)

Legs

Inspection

Bruising
Cushing's syndrome causes skin thinning and makes patients more susceptible to bruising.
Peripheral oedema
Cushing's syndrome can cause peripheral oedema.

Proximal myopathy

Cushing's syndrome can cause proximal muscle weakness.
To screen for proximal myopathy, ask the patient to stand from a sitting position with their arms crossed (to minimise their
ability to mask proximal muscle weakness). Make sure to stand close to the patient to prevent them from falling. An inability to
stand up suggests proximal muscle weakness.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
“ T o d a y I p e r f o r m e d a f o c u s e d C u s h i n g' s s y n d r o m e e x a m i n a t i o n o n a 7 6- y e a r-o l d w o m a n . p a t i e n t h a d f a c i a l p l e t h o r a.
”
“ T h e h a n d s a n d a r m s d e m o n s t r a t e d t h i n n i n g o f t h e s k i n , h y p e r p i g m e n t a t i o n o f t h e s k i n .
”
a n d b r u i s e s w e r e v i s i b l e o n t h e f o r e a r m s . “ O n i n s p e c t i o n o f t h e f a c e , t h e r e w a s f a c i a l p l e t h o r a a n d r o u n d i n g o f t h e f a c e .
"
“ A s s e s s m e n t o f t h e v i s u a l
”
“ O n i n s p e c t i o n o f t h e c h e s t a n d b a c k , a d o r s o c e r v i c a l f a t p a d w a s v i s i b l e .
"
“ O n i n s p e c t i o n o f t h e a b d o m e n , t h e r e w a s c e n t r a l o b e s i t y a n d p r o m i n e n t a b d o m i n a l s t r i a e .
"
O n g e n e r a l i n s p e c t i o n , t h e
T h e r e w a s n o
https\://app.geekymedics.com/osce-guides/clinical-examination/cushings-examination/ 5/611/13/24, 6\:59 PM Guide | Cushing's examination
“ T h e r e w a s n o e v i d e n c e o f p e r i p h e r a l o e d e m a.
”
“ T h e r e w a s n o p r o x i m a l m y o p a t h y e v i d e n t .
”
“ I n s u m m a r y, t h e s e
”
“ F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
”

Further assessments and investigations

Perform a full cardiovascular examination including measurement of blood pressure\: to identify cardiovascular
involvement, including hypertension.
Bedside capillary blood glucose and serum HbA1c\: to test for diabetes.
Urea and electrolytes\: Cushing's syndrome can cause hypokalemia.
Late-night salivary cortisol, 24-hour urinary free cortisol, or low-dose dexamethasone suppression test\: to con
diagnosis of Cushing's syndrome.
Plasma ACTH\: to help distinguish between ACTH-dependent and ACTH-independent Cushing's syndrome.
High-dose dexamethasone suppression test\: to distinguish between pituitary and ectopic ACTH production.
Imaging\: pituitary MRI (if suspected Cushing's disease), CT/MRI of adrenals (if suspected adrenal source), CT
thorax/abdomen/pelvis (if ectopic ACTH production is suspected).
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Reviewer

Dr Marissa O’Callaghan
Special Lecturer in Medicine & Medical Registrar
St Vincent’s University Hospital

References

1. Sharma ST, Nieman LK, Feelders RA. Cushing's syndrome\: epidemiology and developments in disease management. Clin
Epidemiol. 2015 Apr 17;7\:281-93.
2. Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing's syndrome\: an Endocrine Society clinical practice guideline.
J Clin Endocrinol Metab. 2008 May;93(5)\:1526-40.
3. Ishikura K, Takamura T, Takeshita Y, Nakagawa A, Imaizumi N, Misu H, Taji K, Kasahara K, Oshinoya Y, Suzuki S, Ooi A, Kaneko S.
Cushing's syndrome and big IGF-II associated hypoglycemia in a patient with adrenocortical carcinoma. BMJ Case Rep. 2010.
Epub 2010 Mar 30.
Image references
Figure 1. Ozlem Celik, Mutlu Niyazoglu, Hikmet Soylu and Pinar Kadioglu. M o o n F a c i e s . License\: [CC BY 2.5]
Figure 2. Ozlem Celik, Mutlu Niyazoglu, Hikmet Soylu and Pinar Kadioglu. H i r s u t i s m a n d a b d o m i n a l s t r i a e . License\: [CC BY
2.5]
Source\: geekymedics.com
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