Cushings

Question 1

What hormone is affected in cushings?

Answer 1

Cortisol

ACTH

Question 2

What investigations do you want for cushings?

Answer 2

1. Overnight dexamethasone suppression test or 24hr urinary cortisol
2. 48hr dexamethasone suppression test. If abnormal:
3. Localise legion - plasma ACTH, High dose dexamethasone suppression test (some response suggests cushings disease)
4. Imaging - MRI pituitary, CT chest and pelvis

Question 3

Cushing’s exam: general

Answer 3

Central obesity

Skinny legs

Question 4

Cushing’s exam: hands

Answer 4

Clubbing
BM pricks
Thin skin

Question 5

Cushing’s exam: arms

Answer 5

Bruising
BP
Proximal myopathy - shrug shoulders against resistance

Question 6

Cushing’s exam: face

Answer 6

Moon fancies
Plethora
Acne
Hirtusism
Visual fields - at end

Question 7

Cushing’s exam: Chest/back

Answer 7

Gynaecomastia
Buffalo hump
Suprascapular fat pad
Kyphosis

Question 8

Cushing’s exam: abdo

Answer 8

Purple striae
Central obesity
Lipodystrophy

Question 9

Cushing’s exam: legs

Answer 9

Proximal myopathy - stand up with arms crossed

Bruising

Question 10

Cushing’s syndrome (also side effects of steroids)

Answer 10

CVS - HTN, fluid retention
Endocrine -DM
Neuro - peripheral neuropathy 
GI - fatty liver, pancreatitis
MSK - osteoporosis
General features:
Moon faces 
Central obesity 
Striae
Buffalo hump
Thin skin
Easy bruising
Acne
Hirtuism
Gynaecomastia
Proximal muscle wasting

Question 11

Causes of Cushing’s syndrome

Answer 11

High ACTH:

• cushings disease - pituitary adenomyosis
• ectopic ATCH - SCLC

Low ACTH (excess cortisol)

• adrenal adenoma/carcinoma
• steroid use

Question 12

Concluding a Cushing’s exam

Answer 12

Is the pt on steroids? No:
Look for cause: see Ix
Assess visual fields
Other tests: urine and BM - DM, bone scan, U&E - hypoK