A 45-year-old female complains of recent weight gain, amenorrhea for 3 months, and bruising. No current medications. Medical and surgical history positive for cholecystectomy at age 41
On review of systems, patient reveals hair growth on face, acne, and easy bruisability. Vital signs: afebrile, pulse 80, 12 resps/min, BP 148/92. Physical examination shows abdominal obesity and striae over abdomen. Which of the following question is most helpful toward a differential diagnosis?
A. Have you used corticosteroids in the last month?
B. How much weight have you gained in the last 3 months?
C. Have you had any bleeding episodes, such as nosebleeds or gums bleeding?
D. Is cancer in the family history?
ANS: A
Cushing's disease is caused by excess cortisol and corticosteroid hormones, either endogenous or exogenous. Endogenous causes of cortisol hypersecretion include pituitary adenomas; other malignancies, such as small cell lung cancer; and adrenal tumors. Exogenous causes are related to the administration of steroids for the management of other chronic diseases. A thorough medical history will alert the practitioner to chronic diseases or medications that may be causing or contributing to the cushingoid signs and symptoms. Although weakness can be profound because of the muscle wasting that occurs, it is generally not the first symptom that will bring the patient to the office. For women, it may be oligomenorrhea or amenorrhea and hirsutism, and for men, impotence. Patients develop a "moon face" and "buffalo hump" with central obesity and thin extremities. Hypertension and osteoporosis develop over time. Purple striae around the thighs, breasts, and abdomen are characteristic of Cushing's; they are prone to easy bruisability, acne, and skin infections with poor wound healing. Patients complain of excessive thirst and polyuria owing to glucose intolerance, and they are prone to renal calculi. Changes in mental health are common and range from mood swings to psychosis.
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