Patient’s Particulars :
Name : Mrs...
Age : 74 years old
Sex : Female
Address : Tg. Agas, Muar, Johor
Occupation : Housewife

R/N : 11614

Bed / Ward : 25/9
Date of Admission : 7/5/06
Date of Discharge : 10/5/06
Date of Examination : 9/5/06
 
Chief Complaints :
Weakness and easily bruising of legs and hands – few months
Abdominal distension  - 1/52
Giddiness – 3/7
 
History of presenting illness :
Patient is a known case of rheumatoid arthritis for 2-3 years and is on medication.
 
Patient is complaining the weakness and easily bruising of both her upper and lower limbs for few months. It is gradual in onset and currently, it is becoming worse where even upon pressing the forearms when the nurse search for veins and upon pressing the ECG leads also, her body get bruised. It is also associated with easily get wounded where upon scratching the skin though gently done, the skin easily gets peel off leaving a wound. The weakness claimed to be associated with the muscle wasting of her limbs. There is no history of taking any traditional medication nor history of taking any hormonal medication.
 
 
There is also history of gradual onset of abdominal distension for 1 week. It becomes gradually worsen. There are no aggravating and relieving factor for it. There are also history of loss of appetite for quite sometimes that patient cannot remember the duration and loss of weight that patient unable to quantify. There is alteration of her bowel habit where patient sometimes had constipation for about 3-4 days but no diarrhea. This problem had started few months back. There is no alteration in stool colour and consistency. Micturition is normal. There are no pain, fever and vomiting. There is no history of jaundice.
 
Patient also complaints of giddiness for 3 days. It is gradual in onset and progressively worsen. It is aggravated by a change in body posture and relieved by closing the eyes.It is associated with mild blurring of vision and dull-aching pain in the neck.There are no nausea, fever and vomiting.
 
Patient was brought to the hospital by her daughter on 7/5/06. Currently, patients giddiness is improving but the bruising, weakness and abdominal distension condition remains the same.
 
 
Past Medical History :
-         Rheumatoid arthritis for 2-3 years which is on regular medication.
-         No history of hypertension, diabetes mellitus, pulmonary tuberculosis, asthma and any heart disease.
-         There were history of admission to the hospital for few times due to chest infection.
-         There is history of right index finger amputation due to infection which was done last year.
 
Treatment History :
On medication for her rheumatoid arthritis condition but unable to get the drugs name.
 
Personal History :
-         Patient eats mixed diet.
-         Patient is not a smoker and do not consume alcohol.
-         Sleep is fine and not disturbed.
-         Bladder habits : 3-4X/daytime and 2X/night
 
Family History :
There is no significant family history in family members like hypertension, diabetes mellitus, asthma, pulmonary tuberculosis as well as rheumatoid arthritis.
 
Treatment History  :
1)      T. Metoprolol 100gm BD
2)      I.V Unasyn 375mg TDS
3)      T. Claritromycin 500mg BD
 
Menstrual History :   Not taken
 
Social History :
-         Patient is married with 3 children.
-         Stays at single-storey village house.
-         Stays with her husband who is just a common village worker.
 
Activities of Daily Living :
Comprehension : Good
Ambulations : Previously need assistance. Currently, more bed-ridden.
Dressing : Able to dress herself with some assistance.
Eating : Able to eat by herself without assistance.
Toiletting : Currently, she is on diaper.
 
General Physical Examination :
-         Patient is alert, conscious and cooperative.
-         Moderately built and mildly nourished.
-         Short stature.
-         Patient is sitting comfortably without assistance on the bed.
-         Generally, the cushingoid’s appearance are present like moon-face, thick neck, telangiectasia/plethora at the cheek but no acne, buffalo hump, supraclavicular fat pads, hyperpigmentation around the neck and upper part of the chest, multiple ecchymoses/bruising of both lower limbs, centripetal obesity, skin atrophy (thinning) and wasting of both upper and lower limbs muscle.
-         There is pallor at the lower palpebral conjunctiva and palms of hand.
-         There is wound due to scratching at the right arm and left leg (sheen area)
-         No icterus, cyanosis, clubbing, oedema and lymphadenopathy.
-         No flapping tremors.
-         Vital signs :-
a)      Pulse rate : 77 beats/min, regular, normal volume, no vessels wall thickening
b)      Blood pressure : 140/70mmHg taken in the right arm in supine position
c)      Respiratory rate : 20 breaths/min
d)      Temperature : Afebrile
 
Systemic Examination
 
A)  Abdominal Examination
 
a)      Inspection
-         Abdomen is grossly distended.
-         Marks of striae gravidarum seen.
-         Flanks are full
-         All quadrants moves with respiration.
-         No visible swelling
-         Umbilicus are centrally located and everted.
-         No scars, sinuses, and dilated veins.
-         No visible pulsation and peristalsis.
-         Hernial orifices are intact.
 
b)      Palpation
-         No local rise in temperature and no tenderness.
-         Liver is palpable. It is about 2 fingerbreath below the right costal margin. It moves with respiration, cannot get above the swelling, cannot insinuate the finger, edge is round, firm, non-tender, smooth surface and no pulsation. Liver dullness is at the right fifth intercostal space at the midclavicular line. Liver span is not measured but it is about 13cm.
-         Abdominal girth : 82cm
-         Spleen and kidneys are not palpable.
-         There is no other palpable mass in the abdomen.
 
c)      Percussion.
-         All quadrants are resonant
 
d)      Auscultation
-         Normal bowel sounds are heard
-         No bruit
-         No hepatic or spenic rub
 
e)      Would like to do per rectal examination.
f)        Genitalia areas is not examined.
 
B)  Central Nervous System
-   Higher mental functions are normal
-   No signs of psychiatric effects as depression etc.
-   No facial asymmetry
-   Other CNS examination are not done.
 
C)   Respiratory System
-   Normal vesicular breath sound heard.
-   Mildly decrease breath sound with bibasal crepitations heard at the infra mammary, infra-axillary and infrascapular areas.
 
D)   Cardiovascular system
-  Apex beat located at the left fifth intercostal space in midclavicular line.
-   S1 and S2 are heard in all areas
-   No murmurs
 
E)   Musculoskeletal System
-         Muscle bulk is not measured.
-         Muscle power both upper and lower limbs generally in grade 4.
            Local Examination of Hands
-         There are synovial thickening on both wrist joints with limited range of movement especially on extension.
-         The fingers of both hands are in normal range of movement.
-         Grips are moderately good.
-         Patient is able to hold cup, spoon, button her cloth and comb her hair with minimal assistance.
-         There is amputation of the right index finger.
 
F)       Fundoscopy
Immature cataract of both eyes.
 
Provisional Diagnosis
Iatrogenic Cushing’s syndrome, bilateral immature cataract and chronic rheumatoid arthritis.
 
Investigations
 
A)    7/5/06
1)      Full Blood Count
-         Haemoglobin : 10.0g/dL (Decrease)
-         Haematocrit  :  33.7%  (Decrease)
-         MCH  :  25.6pg (Decrease)
-         Platelet  :  415X10^3/UL (Increase)
-         WBC  :  10.4X10^3/UL
-         Neutrophils  :  75.7%
-         Mixed  :  5.8%
-         Lymphocyte  :  18.5%
-         RBC  :  3.9X10^6/UL
-         MCV  :  86.2fL
-         MCHC  :  29.7%
-         RDW-CV  :  17.5%
-         PDW  :  11.2fL
-         MPV  :  9.4fL
-         PLCR  :  19.6%
2)      Glucose (Random)  :  7.4 mmol/L
3)      Urea and electrolytes
-         Urea :  7.1 mmol/L
-         Sodium  :  134 mmol/L (Decrease)
-         Potassium  :  4.5 mmol/L
-         Chloride  :  103 mmol/L
4)      Arterial Blood Gas (ABG)
-         pH  :  7.376
-         pCO2  :  41.8mmHg
-         pO2  :  26.8mmHg (Decrease)
-         HCO3  :  22.2mmol/L
-         BE (B)  :  -1.2mmol/L
-         BE (ECF)  :  -1.3mmol/L
-         Oxygen saturation :  48.3%  (Decrease)
5)      Thyroid Function Test
-         Free T4 :  15.6
-         TSH  :  2.11mIU/L
6)      Coagulation profile
-         Prothrombin time :  10.1 sec
-         INR  :  0.89 sec
-         APTT :  22.8 sec
 
B)      8/5/06
1)      ESR  :  65mm/hours (Increase : 4.0-7.0)
2)      Liver Function Tests
-         Total protein  :  70g/L
-         Albumin  :  30g/L (Decrease)
-         Globulin  :  40g/L (Increase)
-         A/G ratio  :  0.8 (Decrease)
-         Total bilirubin  :  4 Umol/L
-         ALP  :  135 U/L  (Increase)
-         Alanine transaminase : 50 U/L (Increase)
3)      Renal Profile
-         Serum creatinine : 87 micromol/L
-         Uric acid : 387 micromol/L
-         Urea  :  6.3mmol/L
-         Sodium : 137mmol/L
-         Potassium : 3.4mmol/L
-         Chloride : 100mmol/L
4)   ECG  :  No abnormal changes
 
Discussion
Application of  steroid due to rheumatoid arthritis can cause Cushing’s syndrome. ( Its possible to have cushings syndrome even after consuming steroids for 2 years. There are case reports showing that it may develop even with a single dose!! The reason other RA patients or others consuming steroids don't develop it is because steroid dosage is  judiciously regulated while treating such patients. Such patients are also put on DMARDs (disease modifying antirheumatoid drugs) that bring down the steroid requirement even further.
Effects of long-term/excessive steroid usage :-
-         Muscle wasting due to excess protein catabolism, decrease muscle protein synthesis and induction of insulin resistance in muscle via a post-insulin receptor defect.
-         Centripetal obesity where abdominal fat deposition due to unequal distribution of fat occur because of intra-abdominal fat have a higher density of glucocorticoid receptors than other fat tissue.
-         The redistribution of adipose tissue which affects mainly the face, neck,trunk and abdomen that producing the characteristics of moon facies, buffalo hump, supraclavicular fat pads, truncal obesity, short neck appearance and abdominal striae.
-         Thinning of skin, easy bruisability and poor wound healing are due to glucocorticoid excess inhibits fibroblasts leading loss of collagen and connective tissue.
-         Facial telangiectasia and plethora over the cheeks are due to loss of subcutaneous tissue.
-         Hyperpigmentation of the skin can be due to markedly elevated circulating ACTH, which has some MSH-like activity. This is common in ectopic ACTH syndrome.
-         Hypertension occurs in 75-85% of patient with spontaneous Cushing’s syndrome. It may be related to salt and water retention from the mineralocorticoid effects of excess glucocorticoid. Alternatively, it may be due to increased secretion of angiotensinogen.
Traditional medicine usually contains steroid that may be the cause but this patient do not take any traditional medicine.
The immature cataract may be due to senile cataract.
The palpable liver with the altered LFT results might indicates that there is underlying chronic liver disease which need further investigations.
The routine laboratory tests in Cushing’s syndrome usually demonstrate a high normal haemoglobin, hematocrit and red cell number. It is not here in this patient where may be there is any other underlying causes of anaemia, chronic rheumatoid arthritis condition etc.
 
Follow up
1)      10/5/06
-         No complaints
-         Patient’s right arm at the wound site had been bandaged.
-         BP : 130/90mmHg
-         Unable to fully assess the patient today.
2)      11/5/06
-         Patient had been discharged upon request yesterday
-         Pending investigations :  Hepatitis B and C, HIV and serum cortisol


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