HISTORY. Ask if the patient has had recent changes in memory, attention span, or behavior. Discuss the patient's sleep-wake pattern, and evaluate the patient for sleep disturbances. Family members may comment on the patient's changed affect, short-term memory, emotional instability, and ability to concentrate.

Other signs include weakness, fatigue, back pain, general discomfort, difficulty completing activities of daily living, and changes in the urinary output. Be sure to question the patient about weight gain and changes in body proportions between the shoulders. Patients may also notice changes in their appetite and thirst. Other changes in appearance include hirsutism, oily skin, acne, purple striae, and poor wound healing. Women may have noted changes in menstruation, and both men and women may note changes in libido and in their feelings about themselves.

PHYSICAL EXAMINATION. Changes in fat metabolism lead to generalized obesity, a round ("moon") face, a hump in the interscapular area, and truncal obesity. Hyperpigmentation of skin and mucous membranes may be present as a result of increases in ACTH. Because of alterations in protein metabolism, loss of collagen support in the skin leaves the skin more fragile and easily bruised. Both males and females experience changes in secondary sexual characteristics and body hair distribution, along with an increase in acne. Some patients have peripheral edema from water and sodium retention. Muscle wasting, especially in extremities, leads to difficulty in getting up and down from a sitting position, difficulty in climbing stairs, or generalized weakness and fatigue. Note if the extremities are thin with atrophied muscles.

Auscultate the patient's blood pressure; most patients are hypertensive because of increased circulating volume or increased sensitivity of the arterioles to circulating catecholamines. Neck vein distension may be present.

258 Cushing's Syndrome

PSYCHOSOCIAL. A diagnosis of Cushing's syndrome can be devastating. Determine the patient's response to the disease and the effect the disease has had on the patient's sexuality, body image, and relationships with others.

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