Date of Examination: November 15, 2012 Time of Examination: 10:00 A.M. Name: M.S.

Age: 55 Sex: Male Address: Sinubong, Zamboanga City Civil status: Married Occupation: Factory worker Religion: Roman Catholic Source of Information, Reliability: Patient, 90-95% Chief Complaint: Fatigue

HISTORY OF PRESENT ILLNESS: 2 years PTA, the patient experienced on and off joint pain at the right toe and ankle, characterized as excruciating pain with a pain scale of 5/10. He took dexamethasone 8mg PRN which afforded temporary relief. 5 months PTA, the patient experienced facial swelling, truncal obesity and anorexia. Patient noted an increase in weight at this time. He also had joint swelling and pain on the same body parts with pain scale of 9/10, pinning in character and warm to touch. He took mefenamic acid, 500 mg and flanax, 550 mg/capsule but no relief was noted. He increased his intake of dexamethasone every 3 days. No consultation was done. 3 months PTA, patient had productive cough and the other signs and symptoms were still noted occasionally. He increased his frequency in taking dexamethasone 8mg to OD. 1 month PTA, the cough did not subside and characterized as productive, foul smelling with yellow-colored phlegm. There were accompanying signs and symptoms of dyspnea, orthopnea (uses 3 pillows) and night fever. He took paracetamol 500 mg which gave temporary relief. He consulted a physician and was instructed to take with Rifampicin and Isoniazid OD which he took for 2 weeks only. He also discontinued taking dexamethasone. 2 weeks PTA, follow-up consultation was done because of persistent signs and symptoms. He was prescribed with Azithromycin taken OD for 4 days and Cimecod forte syrup taken 1 tbsp, TID for 4 days for cough. 1 day PTA, the patient experienced severe fatigue with accompanying high fever and dyspnea which prompted him to seek medical consult. PAST MEDICAL HISTORY: The patient was hospitalized when he was 17 years old due to fractured left thigh secondary to fall. He was admitted for 17 hospital days. No other history of hospitalization noted. The patient has no childhood illnesses like chicken pox, measles and other infections. No congenital conditions were noted. He doesnt take any other medications for health maintenance except for those mentioned above. There were no history of allergies to foods, drugs, pollens and others.

PREPARED BY: MARIO T. TUMACMOL JR.

FAMILY HISTORY: No herido-familial diseases were noted on both sides of the family like hypertension, asthma, cardiovascular diseases, cancer, renal problems, mental illnesses and other conditions.

PERSONAL AND SOCIAL HISTORY: The patient lives with his wife and 3 children in Sinubong. He is very dedicated in his work as a factory worker in a Mega Sardines Company. He does not smoke. But he is a known alcoholic drinker (Kulafu) approximately 6x per month since he was a teenager. No other members of the family experienced the same manifestations. She is fond of eating balance diet composed of vegetables, fruits, fish and rice .He rarely eats meats. REVIEW OF SYSTEMS: General: (+) fatigue, (+) weakness, (+) weight loss Integumentary. (-) rashes, (-) urticaria, (-) pruritus HEENT: Head: (-) dizziness, (-) lightheadedness, (-)headaches Eyes: (-) double vision, (-) pain, (-) excessive tearing, (-) blindness Ears: (-) ear aches, (-) tinnitus, (-) hearing loss Nose: (-) nasal pain, (-) nasal stuffiness, (-) epistaxis Mouth and Throat: (-) dysphagia Neck: (-) stiffness of the neck Pulmonary: (-) coryza, (+) dyspnea, (+) tachypnea,(+) respiratory distress Cardiovascular: (-) palpitations, (-) chest pain, (+) tachycardia Gastrointestinal: (+) anorexia, (-) nausea, (-) diarrhea, (-) constipation, (-) melena, (-) hematemesis Genitourinary: (-) frequency of urination, (-) urgency, (-) hesitancy, (-) burning or pain sensation on urination

PREPARED BY: MARIO T. TUMACMOL JR.

Musculoskeletal: (+) joint pain at right knee and toe, (-) fracture, (+) weakness both upper and lower extremities Neurologic: (-) syncope, (-) seizures, (-) paralysis, (-)numbness Hematologic : (-) easy bruising, (+) easy fatigability noted

PHYSICAL EXAMINATION

GENERAL APPEARANCE: Patient is conscious, coherent,sitting on a wheel chair and appears to be weak-looking. He is oriented to time, place and people. He is in respiratory distress and coughs frequently. He is febrile and has significant weight loss of approximately 5-10% in a period of 1 week.

VITAL SIGNS: Temperature: 37.8C Pulse Rate: 108 bpm Respiratory Rate: 31 cpm Blood Pressure: 150/80 mmHg SKIN: Patients skin is warm to touch, dry and with obvious thinning. There was no cyanosis, jaundice noted. Patient is slightly pale. No rashes and lesions seen. HEENT: Head: Hairs are thick, resilient, evenly distributed with no signs of infection or infestations. Scalp without lesions. Head is regular in contour. Eyes: The patient has anicteric sclerae with pale palpebral conjunctivae. His pupils have 4 mm diameter that constrict to 2 mm, equally round, reactive to light. No discharges were seen. No ptosis and nystagmus seen. No sunken eyeballs noted. Ears: No discharges, lesions, tenderness and swelling noted. Nose: No nasal flaring. Nasal septum is in midline. No polyps and discharges seen. Mouth and Throat: Patient has moist, pinkish lips and buccal mucosa. No ulcerations, mouth sores and bleeding gums seen. Tongue is midline with some dental caries. No difficulty of swallowing experienced noted. Tonsils are not inflamed.

PREPARED BY: MARIO T. TUMACMOL JR.

NECK: He has symmetrical and supple neck. No lesion and masses noted upon palpation. Trachea is in midline. No neck tenderness. No lympadenopathies. CHEST AND LUNGS: Inspection: There is symmetrical chest expansion. No chest indrawing, no chest retractions or use of accessory muscles. No lesions and scars noted. Palpation: Decreased tactile fremitus tactile fremitus on both lung fields. Percussion: Presence of dullness upon percussion on both lower lung fields. Auscultation: Decreased breath sounds and crackles noted on both lung bases. CARDIOVASCULAR: Patient has adynamic precordium with sinus tachycardia. PMI is located at 5 intercostals space, right midclavicular line. S1 is louder than S2. No heaves and trills heard and palpated.
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ABDOMEN: Inspection: No abdominal distention, no organomegaly seen. Auscultation: Normoactive bowel sounds heard on all quadrants. Percussion: Tympanitic abdomen heard on all quadrants. Palpation: (-) Tenderness upon palpation, (-) mass. GENITOURINARY: Not examined MUSCULOSKELETAL: There were no joint deformities. Knee and toe joints are tender. EXTREMITIES: CRT <2 seconds, no clubbing. NEUROLOGIC: Mental Status: Alert and cooperative. Oriented to time, place and person, motor and sensory intact and no signs of neurological problems

PREPARED BY: MARIO T. TUMACMOL JR.

SALIENT POINTS: HISTORY AND ROS Age: 55 Occupation: factory worker Chief complaint: fatigue Dexamethasone intake for 3 months Facial swelling Truncal obesity Anorexia Weight gain 5 months PTA Productive cough Dyspnea Orthopnea Prescribed with rifampicin and isoniazid od taken for 2 week Fractured left thigh secondary to fall at 17 years old Known alcoholic drinker approximately 6x per month. (+) fatigue (+) weakness (+) weight loss 1 week PTA (+) dyspnea (+) tachypnea (+) respiratory distress (+) tachycardia (+)weakness both upper and lower extremities (+) joint pain at right knee and toe (+) easy fatigability noted PHYSICAL EXAMINATION Appears to be weak-looking In respiratory distress and coughs frequently Febrile and has significant weight loss of approximately 5-10% in a period of 1 week Temperature: 37.8c Pulse rate: 108 bpm Respiratory rate: 31 cpm Blood pressure: 150/80 mmh Skin is warm to touch, dry and with obvious thinning Patient is slightly pale Pale palpebral conjunctivae Palpation: decreased tactile fremitus on both lung fields. Percussion: presence of dullness upon percussion on both lower lung fields. Auscultation: decreased breath sounds and crackles noted on both lung bases. Tachycardia Knee and toe joints are tender.

CLINICAL IMPRESSION: CAP-MR with Hypertension JNC-Stage 1 secondary to Cushings Syndrome secondary to chronic use of glucocorticoids.

PREPARED BY: MARIO T. TUMACMOL JR.

BASIS:

HISTORY AND ROS Chief complaint: fatigue Dexamethasone intake for 3 months Facial swelling Truncal obesity Weight gain 5 months PTA Productive cough Dyspnea Orthopnea Known alcoholic drinker approximately 6x per month. (+) fatigue (+) weakness (+) weight loss 1 week PTA (+) dyspnea (+) tachypnea (+) respiratory distress (+) tachycardia (+)weakness both upper and lower extremities (+) joint pain at right knee and toe (+) easy fatigability noted

PHYSICAL EXAMINATION Appears to be weak-looking In respiratory distress and coughs frequently Febrile and has significant weight loss of approximately 5-10% in a period of 1 week Temperature: 37.8c Pulse rate: 108 bpm Respiratory rate: 31 cpm Blood pressure: 150/80 mmh Skin is warm to touch, dry and with obvious thinning Patient is slightly pale Pale palpebral conjunctivae Palpation: decreased tactile fremitus on both lung fields. Percussion: presence of dullness upon percussion on both lower lung fields. Auscultation: decreased breath sounds and crackles noted on both lung bases. Tachycardia Knee and toe joints are tender.

PREPARED BY: MARIO T. TUMACMOL JR.

DIFFERENTIAL DIAGNOSES DIFFERENTIAL DIAGNOSES RULE IN 55 years old (+) easy fatigability noted decreased tactile fremitus on both lung fields. (+) Cough presence of dullness upon percussion on both lower lung fields. decreased breath sounds and crackles noted on both lung bases. Productive cough Dyspnea Orthopnea Weight loss Hypercortisolism Facial swelling Truncal obesity RULE OUT

Small Cell Lung cancer

No history of smoking To be ruled out bronchial biopsy.

by

Tuberculosis

(+) easy fatigability noted decreased tactile fremitus on both lung fields. (+) Cough presence of dullness upon percussion on both lower lung fields. decreased breath sounds and crackles noted on both lung bases. Productive cough Dyspnea Orthopnea Night sweats Weight loss History of intake of Rifampicin and Isoniazid.

No family member with the same signs and symptoms To be ruled out by sputum smear and chest x-ray.

Iron Deficiency Anemia

(+) easy fatigability noted Patient is slightly pale Pale palpebral conjunctivae

Bronchiectasis

55 years old

No hemoptysis

PREPARED BY: MARIO T. TUMACMOL JR.

(+) Cough yellow sputum Fever: 37.8c Foul breath (+) easy fatigability noted decreased tactile fremitus on both lung fields. presence of dullness upon percussion on both lower lung fields. decreased breath sounds and crackles noted on both lung bases. Productive cough Dyspnea Orthopnea

PARACLINICALS 1. CBC - used as a broad screening test to determine an individual's general health status. It helps to diagnose various conditions, such as anemia, infection, inflammation, bleeding disorder or leukemia. 2. Chest x-ray - A chest radiograph is frequently used in diagnosis of pneumonia and other pulmonary diseases. It is used also to assess the integrity of the heart. 3. Echocardiogram, a non-invasive test that uses sound waves to create a moving image of the heart and to measure its size and shape. 4. CT scan an imaging modality to study pituitary adenomas and adrenal adenoma.

5. MRI - MRI is the imaging modality of choice to study pituitary adenomas and adrenal adenoma.

PREPARED BY: MARIO T. TUMACMOL JR.

MANAGEMENT Goal: To reduce the cortisol secretion to normal. To reduce the serum cortisol level to normal. To reduce the risk of comorbidities associated with hypercortisolism.

ENDOGENOUS CUSHING SYNDROME Treatment of choice for is resection of the causative tumor. surgical

EXOGENOUS CUSHING SYNDROME

Primary therapy for Cushing disease is transsphenoidal surgery. Primary therapy for adrenal tumors is adrenalectomy. Pituitary radiation may be useful if surgery fails for Cushing disease. Ketoconazole is probably the most popular and effective of these agents for long-term use and usually is the agent of choice for cushings syndrome. Hormone replacement - Patients with endogenous Cushing syndrome who undergo resection of pituitary, adrenal, or ectopic tumors should receive stress doses of glucocorticoid in the intraoperative and immediate postoperative period.

The treatment for exogenous Cushing syndrome is gradual withdrawal of glucocorticoid.

REFERENCES: 1. 2. 3. 4. Guyton and Hall, Textbook of Medical Physiology, 11 ed. th Harrison's Principles Of Internal Medicine, 18 ed. http://emedicine.medscape.com/article/117365-treatment#a1128 http://emedicine.medscape.com/article/124718-overview
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PREPARED BY: MARIO T. TUMACMOL JR.