Cushing's Syndrome: Symptoms - Focus on moonface, central obesity, thin skin and fatigue.

Cushing’s Syndrome

It is basically high levels of cortisol or adrenocorticotropic hormone (which leads to high cortisol).
The reasons for the manifestations of the many symptoms relate directly to the actions of these hormones.

Overall symptoms

Most people with Cushing syndrome will have:
• Upper body obesity (above the waist) and thin arms and legs
• Round, red, full face (moon face)
• Slow growth rate in children

Skin changes that are often seen:
• Acne or skin infections
• Purple marks (1/2 inch or more wide) called striae on the skin of the abdomen, thighs, and breasts
• Thin skin with easy bruising

Muscle and bone changes include:
• Backache, which occurs with routine activities
• Bone pain or tenderness
• Collection of fat between the shoulders (buffalo hump)
• Thinning of the bones, which leads to rib and spine fractures
• Weak muscles

Women with Cushing syndrome often have:
• Excess hair growth on the face, neck, chest, abdomen, and thighs
• Menstrual cycle becomes irregular or stops

Men may have:
• Decreased fertility
• Decreased or no desire for sex
• Impotence

Other symptoms that may occur with this disease:
• Mental changes, such as depression, anxiety, or changes in behavior
• Fatigue
• Headache
• High blood pressure
• Increased thirst and urination

So how does excess cortisol cause the symptoms “moonface”, central obesity, thin skin and severe fatigue?

Cortisol counteracts insulin, contributing to hyperglycemia via stimulation of hepatic gluconeogenesis and inhibition of the peripheral utilization of glucose by decreasing the translocation of glucose transporters to the cell membrane, especially GLUT4. However cortisol increases glycogen synthesis (glycogenesis) in the liver. Cortisol also acts as an anti-diuretic hormone

Moonface
The reason why fat tends to accumulate where it does is not known, but perhaps it is because there are more stress hormone receptors in the face and body, which are more sensitive to insulin, where skeletal muscle is less sensitive to insulin. Another reason is due to increased mobilization of fat in extremities and deposition in the trunk.

Central obesity
It is generally suggested that stress-induced cortisol weight is usually gained around the waistline, because fat cells in that area are more sensitive to cortisol. The fat cells in your abdomen are richer in stress hormone receptors, are particularly sensitive to high insulin, and are very effective at storing energy – more so than fat cells you would find in other areas of the body.

Thin skin
In laboratory rats, cortisol-induced collagen loss in the skin is ten times greater than any other tissue. It is probable that increasing copper availability for immune purposes is the reason many copper enzymes are stimulated to an extent which is often 50% of their total potential by cortisol. This includes lysyl oxidase, an enzyme which is used to cross link collagen and elastin.

Severe fatigue
This is due to increased catabolism of protein for gluconeogenesis and decreased synthesis of protein (except for in the liver). This leads to muscle weakness and thus fatigue. As the effects of insulin are also reduced, glucose is not being effectively taken into cells, especially skeletal muscle which can also contribute to feeling fatigued.

SS and DD of GERD

Gastroesophageal Reflux Disease [GERD]

DDx
• Peptic ulcer disease, gastritis, nonulcer dyspepsia, or cholelithiasis
• Angina pectoris - chest pain
• Infectious esophagitis: Candida, herpes simplex virus, cytomegalovirus
• Pill-induced esophagitis - dysphagia, odynophagia
• Esophageal motility disorders, eg, achalasia, esophageal spasm, scleroderma
• Radiation esophagitis - dysphagia, odynophagia
• Zollinger-Ellison syndrome (gastrinoma) - heartburn, dysphagia
Typical Presentation
Heartburn - often occurs 30–60 minutes after meals and upon reclining/ relief from taking antacids or baking soda, symptom is dominant, the diagnosis is established with a high degree of reliability.
Concomitant nausea, vomiting or early satiety – Gastroparesis is suspected.
Overall, a clinical diagnosis of gastroesophageal reflux has a sensitivity of 80% but a specificity of only 70%.
Regurgitation - the spontaneous reflux of sour or bitter gastric contents into the mouth.
Dysphagia or Odynophagia - occurs in one-third of patients and may be due to erosive esophagitis, abnormal esophageal peristalsis, or the development of an esophageal stricture.
It is necessary to undergo gastroscopy if find weight loss, anemia, family history of Upper GI cancer, GI bleed or advanced age.
Atypical Presentation
• Asthma – microaspiration causes initiation of asthma, adult onset asthma KIV.
• Otitis Media – children, with effusion results hearing loss
• Chronic cough
• Chronic laryngitis
• Sore throat
• Chest pain
In the absence of heartburn or regurgitation, atypical symptoms are unlikely to be related to gastroesophageal reflux.
Physical examination and laboratory data are normal in uncomplicated disease.

Cholecystitis Role Play: History Taking

History:

PAIN: sharp, cramping, dull,
WHEN: come and go, acute
WHERE: begin at epigastric, then localized at right hyppchondrium; radiate to the back or below the right scapula
Aggregating factors: Breathing deeply , after meal (esp: large meal or high fat meal)
Associated symptoms: Chills


GIT system review:

Abdominal pain AS ABOVE
Appetite YES
Weight NO
Nausea YES
Vomiting YES
Vomiting blood (haematemesis) NO
Heartburn NO
Difficulty swallowing (dysphagia) NO
Bloating (Abdominal fullness) YES (at RUQ)
Change in bowel habit NO
Blood in stools/ bowel motion NO
Black-tar like stools (malaena) YES
Fevers YES (above 38’c)
Jaundice YES
Itch NO
Overseas travel NO


References:
http://www.nlm.nih.gov/medlineplus/ency/article/000264.htm
http://emedicine.medscape.com/article/171886-overview
http://www.mayoclinic.com/health/cholecystitis/DS01153/DSECTION=symptoms

Sign & Symptoms of Pneumonia

Symptoms of pneumonia caused by bacteria in otherwise healthy people (younger than 65) usually come on suddenly. They often start during or after an upper respiratory infection, such as influenza or a cold, and may include:

• Cough, often producing mucus (sputum) from the lungs. Mucus may be rusty or green or tinged with blood.
• Fever which may be less common in older adults.
• Shaking, "teeth-chattering" chills (one time only or many times).
• Fast, often shallow, breathing and the feeling of being short of breath.
• Chest wall pain that is often made worse by coughing or breathing in.
• Fast heartbeat.
• Feeling very tired (fatigue) or feeling very weak (malaise).
• Nausea and vomiting.
• Diarrhea

Clinical signs of pneumonia are characteristic and are referred to clinically as consolidation :

• Expansion : reduced on the affected side
• Vocal fremitus : increased on the affected side (in other chest disease this sign is of very little use!)
• Percussion : dull
• Breath sounds : bronchial breath sounds
• Additional sounds : medium, late or pan-inspiratory crackles
• Vocal resonance : increased
• Pleural rub : may be present

Sign and Symptoms of Sleep Apnea

Sign and Symptoms of Sleep Apnea

Signs:

1. Abnormal heart rhythm and increase blood pressure (caused by decrease oxygen levels in blood.)

2. Prolonged sleep apnea leads to heart failure and malfunction of the lungs

Symptoms:

1. Snore: loudest when sleep on the back and lessen when sleep on the side. (Prominent in Obstructive Sleep Apnea)

2. Observed episodes of breathing cessation during sleep (choking and gasping)

3. Abrupt awakenings accompanied by shortness of breath

4. Breathing become slow and shallow

5. Excessive daytime sleepiness especially when inactive (hypersomnia).

6. Morning headache

7. Memory and learning problems and not able to concentrate

8. Feeling irritable, depressed, or having mood swings or personality changes

9. Sex drives reduced.

10. Urination at night

11. A dry throat when you wake up

12. Difficulty staying asleep (insomnia)

p/s: partners or family members will notice these before the patient.

In children

1. Hyperactivity, poor school performance, and aggressiveness

2. Unusual sleeping positions, bedwetting, and may breathe through their mouths instead of their noses during the day.

References:

http://www.mayoclinic.com/health/sleep-apnea/DS00148/METHOD=print

http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Signs.html

The Merick Manual of Medical Information

Classical Signs & Symptoms of Aortic Stenosis

***Quick review!!!
Symptoms: What the patient present with upon consultation.
Signs: What the doctor get from patient upon examination.

Symptoms
Symptoms and heart problems in aortic stenosis are related to the degree of narrowing of the aortic valve area. Patients with mild aortic valve narrowing may experience no symptoms. When the narrowing becomes significant (usually greater that 50% reduction in valve area), the pressure in the left ventricle increases and a pressure difference can be measured between the left ventricle and the aorta.

In 4% of the patients with aortic stenosis, the first symptom is sudden death, usually during strenuous exertion.

The major symptoms of aortic stenosis are:
• chest pain (angina)-usually 1st symptom. The pain is described as pressure below the breast bone brought on by exertion and relieved by rest. The thickened heart muscle must pump against high pressure to push blood through the narrowed aortic valve. This increases heart muscle oxygen demand in excess of the supply delivered in the blood, causing chest pain.
• fainting (syncope)- usually associated with exertion or excitement. These conditions cause relaxation of the body's blood vessels (vasodilation), lowering blood pressure. In aortic stenosis, the heart is unable to increase output to compensate for the drop in blood pressure. Therefore, blood flow to the brain is decreased, causing fainting. Fainting can also occur when cardiac output is decreased by an irregular heart beat (arrhythmia). Without effective treatment, the average life expectancy is less than three years after the onset of chest pain or syncope symptoms.
• shortness of breath (dyspnoe)- reflects the heart muscle's failure to compensate for the extreme pressure load of aortic stenosis. Shortness of breath is caused by increased pressure in the blood vessels of the lung due to the increased pressure required to fill the left ventricle. Initially, shortness of breath occurs only during activity. As the disease progresses, shortness of breath occurs at rest. Patients can find it difficult to lie flat without becoming short of breath (orthopnea). Without treatment, the average life expectancy after the onset of heart failure due to aortic stenosis is between six to 24 months.


Classical Clinical Signs
• Small and delayed pulse-absence of this finding, particularly in an elderly patient with noncompliant vasculature, does not exclude severe aortic stenosis.

• Systolic murmur-may be most easily audible in the ‘mitral area’. This may cause a mistaken diagnosis of ischaemic mitral regurgitation in a patient with severe aortic stenosis and angina. The absence of a murmur over the right clavicle can help to exclude aortic stenosis.

• Soft or absent second heart sound

• Hypotension