Cushing’s Exam

By Julie Gilmour

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Prior to Exam

  • Hand hygiene, introduce self, informed consent, exposure & draping

General Inspection

  • Ascertain height, weight & BMI
    • Central obesity is common with thin limbs (lemon on stick appearance)
  • Inspect skin for obvious bruising (due to loss perivascular supporting tissue)
  • Assess mental status – can develop psychosis &/or depression
  • Assess cognition – MMSE or MOCHA – can have memory problems

Hands

  • Skin thickness < 1.8mm on dorsum of hand (best done with calipers)

Arm

  • Measures BP – HTN
  • Examine skin for excess pigmentation over extensor surfaces (high ACTH in Cushing’s disease or ectopic (usually not seen as symptoms develop rapidly))
  • Examine for proximal myopathy (eg. Deltoid, Biceps, Triceps)
  • General Facial Inspection
    • Moon-like facies
    • Plethora
    • Acne
    • Hirsutism (may indicate adrenal carcinoma with high DHEA or ACTH-dependent)
    • Telangiectasia
  • Eyes
    • Examine visual fields, EOM and visual acuity (Cushing’s disease)
    • Examine for HTN and DM retinopathy changes
    • Cataracts

Neck

  • Look at back of neck for dorsal fat pad (fat deposition over interscapular area)
  • Examine for supraclavicular fat pads
  • Examine for acanthosis nigricans

Chest & Back

  • Cardiovascular exam
    • Increased risk for CAD – examine for signs of CHF
  • Gynaecomastia in male
  • Examine for osteoporosis & vertebral fracture
  • Infrascapular fat pads (usually also enlarged, are glucocorticoid sensitive like the fat pads around neck)
  • Chest examination (possible malignancy if ectopic ACTH suspected)

Abdomen

  • Central obesity
  • Violaceous striae (exposure of vascular subcutaneous tissue due to disruption of collagen in dermis), may be > 1cm wide
  • Palpate for hepatomegaly – due to fat deposition
  • Palpate for adrenal masses (large adrenal carcinoma)
  • Genital exam:
    • Examine for clitoromegaly (virilization of female, if high DHEA)

Lower limbs

  • Examine for proximal myopathy
    • Examine muscle bulk and power in proximal muscles (quadriceps) – ie. squat, stand from sitting, arise from seated position
  • Pedal edema (especially in ectopic ACTH)
  • Examine for evidence of poor wound healing

To finish

  • Extension of physical examination
    • Urine dipstick for glycosuria

References: Clinical Examination 6th ed: Talley & O’Connor, 2010 • Endocrine Society Cushing’s Guidelines