PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.


Thursday, August 24, 2006

Cushing's Syndrome


I would be keen to examine this lady's blood pressure and dipstick the urine for evidence of overt glycosuria and proteinuria. I also would like to complete my examination by checking the visual fields and performing a funduscopy to look for evidence of retinopathy and papilloedema. A history of steroid usage is of prudent importance in this patient.

This lady has Cushing's syndrome as evidenced by the presence of moon-face associated with hirsutism and acne. There are buffalo hump and truncal obesity as well. There is thinning of the skin with localised bruises especially over the cubital fossae of both arms. However there is no purplish striae noted on the abdomen and inner thighs. There is no oral thrush. Patient has proximal weakness. The back is straight with no features of kyphoscoliosis.

Questions:
1. What are the causes of Cushing's syndrome?
Outline: Pituitary-driven, adrenal and ectopic or iatrogenic sources.

2. How would you investigate to determine the cause?
I would screen the patient by doing a 24hr urinary free cortisol first and overnight dexamethasone suppression test. A high dose dexamethasone suppression test is then needed to localise the source of excess cortisol. An elevated ACTH level would isolate the source to either from pituitary or ectopic source.

3. What are the other tests to determine the source of ACTH (to distinguish primary from ectopic)?
CRH and inferior petrosal sinus sampling. An MR of the pituitary gland is helpful as well.

4. How would you manage Cushing's syndrome?
Outline: If possible, the underlying source of excess cortisol should be removed. In cases where the source cannot be removed, I would manage the complications which may arise from Cushing's syndrome.

5. What is Nelson's syndrome?
(A reminder: In real exam situation, you are unlikely to get so far. If you do, then there are 2 extreme possibilities, ie, either you score tremendously..or you failed badly!)
The bell has already rang! The answer is in the book :)

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5 Comments:

At 8/24/2006 10:14:00 PM, Blogger Axonopathic said...

Courtesy of wuchereria, who post this blog together with me:)

 
At 8/25/2006 08:31:00 AM, Blogger eMRCPian said...

Thanks, axonopathic.
Most of the time, Cushing's syndrome in PACES is due to iatrogenic cause. Any signs to suggest gout, RA, asthma, fibrosing alveolitis, SLE, nephrotic syndrome....

 
At 8/25/2006 05:47:00 PM, Blogger saramin said...

she does not seem to have acne; the hirsutism seem to be "?racial" (mainly in her forehead, her chin is clear). We are used to see Cushingoid faces of westerens; this is difficult to us to see an Asian with Cushing's syn. (no plethoa can be seen , and the telangiectasiae would be easily missed)!
Dr. O Amin

 
At 8/25/2006 09:46:00 PM, Blogger Axonopathic said...

Definitely, emrcpian. I look hard for the possible etiologies that you've mentioned but I'd found none.

To saramin: She does have acne if look closely enough. Sorry the original picture file has been resized to suit this blog. Thanks for the great tip!

 
At 8/31/2006 10:08:00 AM, Blogger vagus said...

actually, a high dose dex suppression, when used (not all think this is a reliable enougn test), might be more helpful in determining the source of ACTH in an established ACTH-dependent Cushing's (ie ectopic which has little response versus cushing's dz, which may still partially suppress). it's not really used to localize the source of excess cortisol.

 

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