Cushing's/addison's

Question 1

cushing’s syndrome - features

Answer 1

catabolic effects:
proximal myopathy - thin limbs
purple striae
bruising
osteoporosis - vertebral crush fractures (?tenderness)

glucocorticoid effects:
diabetes
central obesity

mineralocorticoid effects:
HTN
hypokalaemia

moon face
acne + hirsutism
supraclavicular fat pads

Question 2

cushing’s - examination

Answer 2

INSPECTION
truncal obesity + facial mooning
supraclavicular fat pads
kyphosis
evidence of a steroid-treated condition - asthma, AV fistula, RA

HANDS + ARMS
bruising + thinning on dorsum/forearm
skinfold thickness
BP
shoulder abduction - proximal myopathy

FACE
mooning
greasy skin, acne, hirsutism

ABDO
purple striae
renal transplant scars - steroids

LEGS
stand from seated armless
ulcers

EXTRAS
spinal tenderness
interscapular fat pad
dip urine/bedside BG

Question 3

cushing’s features - mnemonic

Answer 3

Spinal tenderness
Weight - central obesity
Easy bruising
Diabetes
Interscapular fat pad
Striae
HTN

Question 4

cushing’s syndrome - screening

Answer 4

low dose dexamethasone suppression test - no suppression of endogenous cortisol - most sensitive

24h urinary free cortisol - must stay at home as all urine
loss of diurnal rhythm - morning + evening increased cortisol (should just be morning - getting out of bed stressful)

Question 5

cushing’s syndrome - causes

Answer 5

steroids
pituitary adenoma (micro so may not be on MRI + don’t get bitemp hemi so hard to tell if adrenal or pituitary)
adrenal adenoma or carcinoma
ectopic ACTH syndrome - wasting as carcinoma, pigmentation, hypokalaemia

Question 6

cushing’s - distinguishing adrenal + pituitary disease

Answer 6

ACTH high in cushing's disease (pituitary)
ACTH low (suppressed) in adrenal cushing's syndrome

but ACTH assay hard - degrades in bottle

Question 7

adrenal insufficiency (addison’s) - features

Answer 7

nonspecific - fatigue, nausea, abdo pain, diarrhoea
dizziness - postural hypotension
pigmentation - hand creases, buccal mucosa, scars - high ACTH
hypoglycaemia - loss of a main insulin antagonist

Question 8

adrenal crisis - presentation, management, investigations

Answer 8

trigger - infection, trauma, sudden steroid withdrawal
coma + hypotension
immediate IV steroids, saline (na depletion) + abx
bloods - glucose FBC, U+E, cultures, cortisol
IV dextrose if hypoglycaemia

Question 9

addison’s - investigations

Answer 9

hypocortisolaemia - basal levels normal or low in morning
synacthen test - dynamic test of adrenal reserve
low Na + high K - esp adrenal crisis