Case Study 52 - Cushing Syndrome

1. Of the vital signs listed above, which of them has to be of most concern to the
patient's PCP?

Of the vital signs listed above, the patient’s blood pressure (185/105) has to be of most
concern to the PCP.

2. Assuming that the patient has hypercortisolism, briefly explain the

pathophysiology of the abnormal vital sign noted in Question 1.

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Cortisol is a hormone that helps with the regulation of blood pressure but since the

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patient is producing an excessive amount, it is causing her blood pressure to be elevated.

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3. Is this patient technically underweight, overweight, obese, or is her wieght
considered healthy and normal?
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According to the patient’s height and weight, her BMI is 27.5 which categorizing her as
overweight.
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4. Assuming that M.K. has hypercortisolism, what are two possible causes of this
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patient’s persistent, dull head pain?

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The two possible causes of this patient’s persistent, dull head pain would be her high
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blood pressure and the possible tumor that is growing on her pituitary gland causing her brain to
expand and cause pressure/pain.
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5. What is the significance in the patient’s report that she is not taking any
medications other than a daily multivitamin pill and ibuprofen?

The significance in the patient's report that she is not taking any other medication is that
steroid medications, used to treat other diseases, are linked to the development of Cushing
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 Syndrome. But since the patient isn't taking any, they can rule it out and assume that her
Cushing Syndrome is pathological, caused by a pituitary tumor, adrenal gland tumors, etc.

6. Identify the nine abnormal laboratory test results in Table 52.1.

The nine abnormal laboratory test results include K+ (low) , glucose (high), plasma
ACTH (high), cortisol (high), urine free cortisol (high), pH arterial blood (high), testosterone
(high), Neutrophils (high), and Lymphocytes (low).

7. Why is serum glucose high?

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Serum glucose is elevated because hypercortisolism inhibits glucose uptake by the liver,

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muscle, and adipose tissue leading to an increase in blood glucose levels.

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8. Explain the pathophysiology that underlies polydipsia in this patient.
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The pathophysiology that underlies polydipsia in this patient is that polydipsia can be
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caused by high blood glucose in the bloodstream. Since the patient’s increase of cortisol is
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blocking the uptake of glucose, hyperglycemia in the patient is causing her to experience
excessive thirst.
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9. Do laboratory test results suggest that hypercortisolism in M.K. is ACTH-

dependent or ACTH-independent?
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The laboratory test results suggest that hypercortisolism in M.K. is ACTH- dependent,
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meaning she is making too much.

10. What is the significance of the serum K+ concentration and the pH of the arterial
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blood?

The significance of the K+ concentration and the pH of the arterial blood is that the
patient is experiencing metabolic alkalosis.

11. Note that hyperpigmentation of the skin and gingiva was a physical findings in this
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 patient. Is this clinical manifestation more characteristic of ACTH- dependent or
ACTH- independent Cushing syndrome?

This clinical manifestation is more characteristic of ACTH- dependent Cushing

Syndrome because the patient’s hyperpigmentation and gingiva is being caused by the increased
production of ACTH.

12. Which imaging techniques might be critical to establishing a specific cause of

hypercortisolism in this patient?

The imaging techniques that might be critical to establishing a specific cause of

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hypercortisolism in this patient include a CT scan of both the brain and the abdomen to help

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detect if there is a tumor on her pituitary gland or adrenal glands that are causing elevated

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ACTH levels. A chest x-ray can also help to see if there is an ACTH secreting pulmonary tumor
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that is causing hypercortisolism.
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13. What type of menstrual abnormality would be suspected in this patient and which
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abnormal laboratory test result is consistent with this type of abnormality?

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The type of menstrual abnormality that would be suspected in this patient is menstrual
irregularities by suppressing ovulation or her menstrual cycle may shut down completely.
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Testosterone is the abnormal laboratory value that is consistent with this type of abnormality.
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14. What is the treatment of choice for curing hypercortisolism in this patient?
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The treatment of choice for curing hypercortisolism in this patient is surgery in order to
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remove the tumor causing her elevated ACTH levels. Radiation therapy may also be suggested
if the tumor is not completed removed.

15. Patient Case Figure 52.1 shows that an enlarged sella turcica is a potential clinical
manifestation of Cushing syndrome/disease. Explain the association.

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 The pituitary gland sits on the sella turcica and if it is enlarged it can indicated that there
is a tumor growing on the pituitary gland. This is associated because pituitary tumors cause high
levels of cortisol that lead to the development of Cushing Syndrome.

16. Why is cardiac hypertrophy shown as a clinical manifestation of Cushing

syndrome in Patient Case Figure 52.1?

Cardiac hypertrophy is shown as a clinical manifestation of Cushing Syndrome because

many Cushing Syndrome patients tend to become overweight and have persistent hypertension,
so the heart is having to work harder in order to be able to supply the patients’ bodies with
enough blood flow.

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