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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize and differentiate the signs, symptoms, and laboratory changes associated with the various forms of Cushing syndrome.

  • Recognize the biochemical, anatomic, and emotional changes that can occur with Cushing syndrome.

  • Recommend appropriate treatment regimens for patients with Cushing syndrome.

  • Suggest appropriate adjunctive pharmacotherapy to other healthcare providers for patients with Cushing disease.

  • Provide patient counseling on proper dosing, administration, and adverse effects of treatment for Cushing disease.

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PATIENT PRESENTATION

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Chief Complaint

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“I have been tired and weak lately, and I’ve noticed some swelling in my legs recently.”

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HPI

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Susan Taylor is a 31-year-old woman who presents to her family physician complaining of fatigue, weakness, and edema. She also reports weight gain (50 lbs over 2 years) and depression with insomnia.

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PMH

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Patient has been healthy with no other major medical illnesses, except seasonal allergic rhinitis. She had two healthy children by uncomplicated vaginal deliveries.

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FH

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Mother is alive at age 54 with type 2 DM; father is living at age 56 with HTN. She has two sisters: one is healthy and the other has depression.

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SH

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Patient does not smoke, and drinks occasionally. She is a photographer. Children are ages 6 and 3.

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Meds

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  • Lessina PO once daily as directed

  • Nasonex two sprays in each nostril once daily PRN allergic symptoms

  • Unisom SleepTabs PO Q HS PRN sleep

  • Advil one to two tablets PO Q 6 H PRN headache

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All

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Sulfa—rash

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ROS

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(+) For fatigue, weakness, occasional back pain, and weight gain; also reports episodes of sadness, depressed mood, and insomnia; skin bruises easily; occasional headache, blurred vision, and heartburn; no CP, wheezing, or SOB. Normal menstruation with regular periods.

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Physical Examination

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Gen
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WDWN obese, cushingoid-appearing white woman in NAD

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VS
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BP 165/86 mm Hg, HR 85 bpm, RR 14/min, T 37.0°C; Wt 82.1 kg, Ht 5′3″

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Skin
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Thin skin with some bruising and scratches; purple striae visible on abdomen

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HEENT
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Rounded face; moderate facial hair; PERRLA; EOMI; funduscopic exam shows normal retinal background, optic cup-to-disk ratios 0.4; visual fields appear to be grossly intact; OP moist and pink

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Neck/Lymph Nodes
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Supple; (+) JVD at 30° (7 cm); (–) bruits, adenopathy, or thyromegaly

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Chest
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CTA bilaterally

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Breasts
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No lumps or masses

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CV
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