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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the clinical presentation of Cushing's syndrome and the physiologic consequences of cortisol excess

  • Describe the pharmacologic and nonpharmacologic management of patients with Cushing's syndrome

  • Recommend strategies to prevent the development of Cushing's syndrome associated with exogenous glucocorticoid administration

  • Recommend therapy-monitoring parameters for patients with Cushing's syndrome

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PATIENT PRESENTATION

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Chief Complaint

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"Doctor, something is wrong with me. I'm gaining so much weight and I'm always so tired and weak."

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History of Present Illness

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JT is a 48-year-old female who presents to her primary care physician's (PCP) office with complaints of increasing fatigue and muscle weakness over the last 3 months. She states that she feels so tired and weak some mornings that she is not able to get herself out of bed. She also reports having gained about 10 lb (~4.5 kg) over the last 3 months and has been experiencing menstrual irregularity since then. She is not pregnant and not currently attempting to become pregnant. JT was diagnosed with RA 2 years ago, at which point she was placed on hydroxychloroquine 400 mg daily and celecoxib 200 mg daily to relieve joint pain and stiffness. Within the last year, she had been experiencing more flare-ups of her RA. Hydroxychloroquine and celecoxib were discontinued and she was placed on prednisone approximately 4 months ago. Since being diagnosed with RA, the patient also reports having episodes of depressed mood. Her depression had been well controlled on sertraline 50 mg PO daily, but she reports increasing number of depressive episodes recently.

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Past Medical History

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RA × 2 years

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Depression × 1½ years

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HTN × 1 year

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Dyslipidemia × 1 year

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Family History

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Mother is alive at age 72 with type 2 DM; father is alive at age 75 with type 2 DM and HTN. She has one sister, who is healthy.

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Social History

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Married and lives with husband. Has a healthy 19-year-old son in college. Works as an assistant manager at a local grocery store

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Tobacco/Alcohol/Substance Use

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(−) Alcohol, tobacco, or illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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No known drug/food allergies/intolerances/ADEs

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Medications (Current)

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Prednisone 10 mg PO q am

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Sertraline 50 mg PO q am

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Lisinopril/HCTZ 20 mg/12.5 mg PO q am

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Atorvastatin 20 mg PO q am

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Review of Systems

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(+) Fatigue and frequent body aches with muscle weakness in major muscle groups; (+) pain in joints of hands, ankles, and knees; reports weight gain in her abdomen, face, and around her neck and shoulders; ...

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