Chapter 88: Cushing Syndrome: A Tale of Two Glands Level II

Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services (userservices@mheducation.com) for more information.

LEARNING OBJECTIVES

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

• 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.

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

PATIENT PRESENTATION

Chief Complaint

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

HPI

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 lb over 2 years) and depression with insomnia.

PMH

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

FH

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.

SH

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

Meds

Seasonique one tablet PO once daily as directed

Nasonex two sprays in each nostril once daily PRN allergic symptoms

Unisom SleepTabs 25 mg PO QHS PRN sleep

Advil 200 mg one to two tablets PO Q6H PRN headache

All

Sulfa—rash

ROS

(+) 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. LMP 7 weeks ago.

Physical Examination

Gen

WDWN obese, cushingoid-appearing white woman in NAD

VS

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

Skin

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

HEENT

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