This trial is testing the safety and effectiveness of a new investigational drug for the treatment of Cushing’s Syndrome. Under the supervision of qualified physicians, cortisol levels and symptoms of Cushing’s Syndrome will be closely followed along with any signs of side effects.
The link below will take you to the trial website where you can review additional information and the patient screener.
Cushing’s and Addison’s Disease. An endocrine NCLEX review on how to differentiate between Cushing’s Syndrome/Disease vs Addison’s and Addisonian Crisis. In this video, I will discuss the pathophysiology, signs & symptoms, and nursing interventions for these endocrine disorders of the adrenal cortex and pituitary glands.
Addison’s Disease and Cushing’s Syndrome/Disease review notes for nursing school and NCLEX exam. In nursing school and for the NCLEX exam, you will need to know how to provide care to a patient with either Addison’s Disease or Cushing’s.
However, many students get these two endocrine disorders confused, but these review notes will help you differentiate between them.
These NCLEX review notes will cover:
Signs and Symptoms of Addison’s Disease vs Cushing’s
Causes of Addison’s Disease and Cushing’s
Nursing Management of Addison’s Disease and Cushing’s
Role of Adrenal Cortex: releases steroid hormones and sex hormones
Role of Aldosterone: regulates blood pressure through renin-angiotensin-aldosterone system, helps retain sodium and secretes potassium (balances sodium and potassium levels).
Role of Cortisol: “STRESS Hormone” helps the body deal with stress such as illness or injury, increases blood glucose though glucose metabolism, break downs fats, proteins, and carbs, regulates electrolytes.
Cushing’s (Syndrome & Disease)
Cushing’s: hyper-secretion of CORTISOL (watch video for clever ways to remember this)
Cushing’s Syndrome vs Cushing’s Disease
Cushing’s Syndrome: caused by an outside cause or medical treatment such as glucocorticoid therapy
Cushing’s Disease: caused from an inside source due to the pituitary gland producing too much ACTH (Adrenocorticotropic hormone) which causes the adrenal cortex to release too much cortisol.
Signs & Symptoms of Cushing’s
Remember the mnemonic: “STRESSED” (remember there is too much of the STRESS hormone CORTISOL)
Skin fragile
Truncal obesity with small arms
Rounded face (appears like moon), Reproductive issues amennorhea and ED in male(due to adrenal cortex’s role in secreting sex hormones)
Ecchymosis, Elevated blood pressure
Striae on the extremities and abdomen (Purplish)
Sugar extremely high (hyperglycemia)
Excessive body hair especially in women…and Hirsutism (women starting to have male characteristics), Electrolytes imbalance: hypokalemia
Dorsocervical fat pad (Buffalo hump), Depression
Causes of Cushing’s
Glucocorticoid drug therapy ex: Prednisone
Body causing it: due to tumors and cancer on the *pituitary glands or adrenal cortex, or genetic predisposition
Nursing Management for Cushing’s Syndrome
Prep patient for Hypophysectomy to remove the pituitary tumor
Prep patient for Adrenalectomy:
If this is done educate pt about cortisol replacement therapy after surgery
Risk for infection and skin breakdown
Monitor electrolytes blood sugar, potassium, sodium, and calcium levels
Addison’s Disease
Addison’s: Hyposecretion of Aldosterone & Cortisol (watch the video for a clever way on how to remember this and not get it confused with Cushing’s)
Signs & Symptoms of Addison’s Disease
Remember the phrase: “Low STEROID Hormones” (remember you have low production of aldosterone & cortisol which are STEROID hormones)
Sodium & Sugar low (due to low levels of cortisol which is responsible for retention sodium and increases blood glucose), Salt cravings
Tired and muscle weakness
Electrolyte imbalance of high Potassium and high Calcium
Reproductive changes…irregular menstrual cycle and ED in men
lOw blood pressure (at risk for vascular collapse)….aldosterone plays a role in regulating BP
Increased pigmentation of the skin (hyperpigmentation of the skin)
Diarrhea and nausea, Depression
Causes of Addison’s Disease
Autoimmune due to the adrenal cortex becoming damaged due to the body attacking itself:
Tuberculosis/infections
Cancer
Hemorrhaging of the adrenal cortex due to a trauma
Nursing Management of Addison’s Disease
Watching glucose and K+ level
Administer medications to replace the low hormone levels of cortisol and aldosterone
For replacing cortisol:
ex: Prednisone, Hydrocortisone
Education: Patient needs to report if they are having stress such as illness, surgery, or extra stress in life ( will need to increase dosage), take medication exactly as prescribed….don’t stop abruptly without consulting with MD.
For replacing aldosterone:
ex: Fludrocortisone aka Florinef
Education: consume enough salt..may need extra salt
Wearing a medical alert bracelet
Eat diet high in proteins and carbs, and make sure to consume enough sodium
Avoid illnesses, stress, strenuous exercise
Watch for Addisonian Crisis
This develops when Addison’s Disease isn’t treated.
In addisonian crisis, the patient has extremely LOW CORTISOL levels (life threatening).
Remember the 5 S’s
Sudden pain in stomach, back, and legs
Syncope (going unconscious)
Shock
Super low blood pressure
Severe vomiting, diarrhea and headache
NEED IV Cortisol STAT:
Solu-Cortef and IV fluids (D5NS to keep blood sugar and sodium levels good and fluid status)
Watch for risk for infection, neuro status (confusion, agitation), electrolyte levels (sodium and potassium, glucose)
“I just can’t seem to lose weight,” the 59-year-old woman said quietly. She had tried everything, she told the young doctor, who was training to be an endocrinologist at Mount Sinai Hospital in New York City. Weight Watchers. Exercise. She ate more vegetables, less fat, then fewer carbs. But still she was gaining weight, 30 pounds during the past seven months, including 12 in the past two weeks. She had never been skinny, she continued, but shapely. In her mid-40s, she started gaining weight, slowly at first, then rapidly. She was considering bariatric surgery, but she wanted to make sure she wasn’t missing something obvious. She had low thyroid hormones and had to take medication. Could her thyroid be off again?
The doctor asked her about symptoms associated with a low thyroid-hormone level. Fatigue? Yes, she was always tired. Changes in her hair or skin? No. Constipation? No. Do you get cold easier? Never. Indeed, these days she usually felt hot and sweaty.
It was probably not the thyroid, the doctor said. She asked if the woman had any other medical problems. She had high blood pressure and high cholesterol — both well controlled with medications. She also had obstructive sleep apnea, a disorder in which the soft tissue at the back of the throat collapse during sleep, cutting off air flow and waking the person many times throughout the night. She had a machine that helped keep her airway open, and she used it every night. She also had back pain, knee pain and carpal-tunnel syndrome. The pain was so bad that she had to retire from her job years before she was ready.
Big, Bigger, Biggest
The doctor examined her, then went to get Dr. Donald Smith, an endocrinologist and director of lipids and metabolism at Mount Sinai’s cardiovascular institute. After hearing a summary of the case, Smith asked the patient if she had anything to add. She did: She didn’t understand why she was getting so much bigger. Her legs were huge. She used to have nice ankles, but now you could hardly see them. Her doctor had given her a diuretic, but it hadn’t done a thing. Everything was large — her feet, her hands, even her face seemed somehow bigger. She hardly recognized the woman in the mirror. Her doctors just encouraged her to keep trying to lose weight.
Worth a Thousand Words
“Let me show you a picture,” she said suddenly and reached over to her purse. The patient’s sister had made a comment recently that led the patient to wonder whether the changes she saw in the mirror were more than simple aging. The patient pulled out a photograph of an attractive middle-aged woman and handed it to Smith. That was me eight years ago, she told him. Looking at the two faces, it was hard to believe they belonged to the same woman. Smith suspected this was something more than the extra pounds.
Two possibilities came to mind. Each was a disease of hormonal excess; each caused rapid weight gain. The first was Cushing’s disease, caused by overproduction of one of the fight-or-flight hormones, cortisol. The doctor looked at the patient, seeking clues. On her upper back, just below her neck, the woman had a subtle area of enlargement. This discrete accumulation of fat, called a buffalo hump, can occur with normal weight gain but is frequently seen in patients with Cushing’s. Do you bruise more easily these days? he asked. Cushing’s makes the skin fragile. No, she said. Did she have stretch marks on her stomach from the weight gain? The rapid expansion of the abdomen can cause the fragile skin to develop dark purple stretch lines. No. So maybe it wasn’t Cushing’s.
A 37-year-old woman developed clinical manifestations of Cushing’s syndrome over a span of 2 years. Physical examination revealed features that best describe Cushing’s syndrome, such as wide purple striae (>1 cm) over the abdomen, facial plethora and easy bruisability.1 Other features observed were hypertension, moon facies, acne, a dorsocervical fat pad, central obesity and dyslipidaemia.
The diagnosis of hypercortisolism was confirmed using a 1 mg overnight dexamethasone suppression test (19.7 ng/dL, N: <1.8) and 24 h urine free cortisol (185.9 μg/24 h, N: 3.5–45). A suppressed adrenocorticotropic hormone (ACTH) level (4 pg/mL, N: 5–20) and a lack of hyperpigmentation suggested ACTH-independent Cushing’s syndrome. Further work up using CT with contrast of the adrenals showed a 2.4×2.3×2.4 cm right adrenal mass. The patient then underwent laparoscopic adrenalectomy of the right adrenal gland. Steroids was started postoperatively and tapered over time. Histopathology results were consistent with an adrenocortical adenoma (2.5 cm widest dimension). Six months after surgery, there was resolution of the physical features, weight loss and improvement in blood pressure.
Figure 1 is a serial photograph of the physical features seen in Cushing’s syndrome, such as moon facies, a dorsocervical fat pad and wide purple striae, taken preoperatively, and at 3 and 6 months after surgery. With treatment, physical and biochemical changes of Cushing’s syndrome both resolve through time.2 The time course of the resolution of these changes, however, is varied.2,3 We observed that the physical features were ameliorated at 3 months and resolved at 6 months.
Learning points
Physicians as well as patients should be aware that improvement of the features of Cushing’s syndrome after treatment does not occur immediately.
Dramatic resolution of the physical features of Cushing’s syndrome, however, can be observed as early as 6 months after surgery.
Physical features of Cushing’s syndrome (top to bottom: moon facies, a dorsocervical fat pad and wide purple striae (>1 cm) over the abdomen) documented before surgery, and at 3 and 6 months after surgery.
Contributors JPMQ worked up the case and wrote the case report. MASS reviewed the case report and critically appraised it. JPMQ incorporated his suggestions.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
. Cushing’s syndrome-killing disease: discriminatory value of signs and symptoms aiding early diagnosis.Lancet 1982;2:646–9. doi:10.1016/S0140-6736(82)92749-0
Over the years, we went on several Windjammer Barefoot Cruises. We liked them because they were small, casual and were fairly easy on the wallet.
They sailed around the Caribbean to a variety of islands, although they sometimes changed itineraries depending on weather, crew, whatever. One trip we were supposed to go to Saba but couldn’t make port. A lot of people got off at the next port and flew home.
The captains were prone to “Bedtime Stories” which were often more fiction than true but they added to the appeal of the trip. We didn’t care if we missed islands or not – we were just there to sail over the waves and enjoy the ride.
The last trip we took with them was about two years before I started having Cushing’s problems. (You wondered how I was going to tie this together, right?)
The cuise was uneventful, other than the usual mishaps like hitting docks, missing islands and so on. Until it was a particularly rough sea one day. I was walking somewhere on deck and suddenly a wave came up over the deck making it very slippery. I fell and cracked the back of my head on the curved edge of a table in the dining area. I had the next-to-the-worse headache I have ever had, the worst being after my pituitary surgery. At least after the surgery I got some morphine.
We asked several doctors later if that hit could have contributed to my Cushing’s but doctors didn’t want to get involved in that at all.
The Windjammer folks didn’t fare much better, either. In October 1998, Hurricane Mitch was responsible for the loss of the s/v Fantome (the last one we were on).
All 31 crew members aboard perished; passengers and other crew members had earlier been offloaded in Belize.
The story was recorded in the book The Ship and the Storm: Hurricane Mitch and the Loss of the Fantome by Jim Carrier. The ship, which was sailing in the center of the hurricane, experienced up to 50-foot (15 m) waves and over 100 mph (160 km/h) winds, causing the Fantome to founder off the coast of Honduras.
This event was similar to the Perfect Storm in that the weather people were more interested in watching the hurricane change directions than they were in people who were dealing with its effects.
I read this book and I was really moved by the plight of those crew members.
I’ll never know if that hit on my head contributed to my Cushing’s but I have seen several people mention on the message boards that they had a traumatic head injury of some type in their earlier lives.
by Jim Carrier. The ship, which was sailing in the center of the hurricane, experienced up to 50-foot (15 m) waves and over 100 mph (160 km/h) winds, causing the Fantome to founder off the coast of Honduras.
CushieBlog 