TUTORIAL 1

PAGE 1

Mrs. Kuchi Hotahai, a 44-year-old woman, presented to the outpatient clinic in Siloam Hospital
with chief complaint of 12.5 kg weight gain over 6 months. She notices that her abdomen getting
bigger and had some purple marks on it. She had also increased hair growth and acne on her
face. She complained of getting up two or three times a night to urinate. Her menstrual period
became irregular since 3 months ago. She had history of a trauma since 20 years ago and usually
took Prednisone 3x5mg without doctor’s prescription. She did not smoke, take recreational drugs
or alcohol.

1. What are the patient’s problems?

a. Weight gain 12,5kg over 6 months
b. Abdomen getting bigger n had some purple marks on it
c. Increased hair growth n acne on her face
d. Nocturia 2 sampai 3 kali
e. Irregular menstrual period
f. History of trauma 20 years ago

2. What are the possible causes and explanations of the problems?

a. Cushing syndrome exogenous etiology -> Bcs of long period of time using steroid
b. Bisa krn pituitary
c. Cortisolnya tinggi
d. Masalah di ginjal

3. What are the possible explanations for the possible etiology?

a. Pituitary adenoma / trauma
b. Prednisone -> mirip cortisol
c. Cushing syndrome / disease
PAGE 2

Dr. Krino was the physician who examined her. Upon physical examination it was found that she
had round, red and full face with thick facial hair. There was collection of fat between her
shoulders with purple marks around the shoulder girdle. Purple marks were also found on
abdomen, thighs, and breasts.

Body weight = 77 kg, height = 166 cm, abdominal circumference = 92 cm.

Vital signs: BP = 140/95 mmHg, RR = 16x/min, pulse = 80x/min, T = 36.9  C.

0

1. Does this information change your hypothesis?

a. BMI -> 27 ( Overweight )
b. Ada buffalo hump
c. Moon face
d. Purple striae

2. How do you explain each of the findings?

a. Hypertension
b. Corticosteroid -> BP naik

3. What further information do you want?

a. CBC
b. EKG
c. Anamnesis lanjut -> Soal trauma
d. 24 hours urine cortisol -> lanjut ke dexamethasone test
e. Serum cortisol
f. Cek RBS

LO

1. Physiology of cortisol ( Negative Feedback )

2. Anatomy, histology, physiology of adrenal

3. Persamaan dan perbedaan cushing syndrome n cushing disease

4. DD cushing syndrome + alasannya

PAGE 3

Dr. Krino requested some laboratory examinations and the results returned:

 HBg : 12 g/dL
 WBC : 9,000/mm3
 Platelets : 155,000/mm3
 Random blood glucose : 242 mg/dL
 Serum cortisol at 8 a.m : 50 mcg/dL (N: 6-23 mcg/dL)
 24 hour Urine free cortisol : 110 mcg/ day (N < 50 mcg/ day)

Dr. Krino made a request for Dexamethasone suppression test.

1. Does this information change your hypothesis?

a. RBS naik
b. Serum + urine cortisol naik

2. How do you explain each of the findings?

a. Krn prednisone

3. What is dexamethasone suppression test? How is it performed?

a.
4. What is your next step?
a. Dexamethasone suppression test
b. Decreased the dose of the prednisone gradually ( 1,25 mg perhari, jangka waktu
2-6 minggu )
c. Inhibitor cortisol -> Glucocorticoids
TUTORIAL 2
PAGE 1

The dexamethasone suppression test result showed that:

Overnight 8 a.m serum cortisol = 1.3 mcg/dL (N < 1.8 mcg/dL)

Urinary free cortisol on day 3 = 9 mcg/day (N < 10 mcg/day)

1. Does this information change your hypothesis?

a. Exogenous cushing syndrome

2. How do you explain the finding?

a. Masalahnya bkn dari dalem berarti dri luar, krn klu dari dalem dikasih dexa pun
tetep naik cortisolnya, cth: Adenoma pituitary

3. What is your next step?

PAGE 2

Dr. Krino made the diagnosis of Cushing’s syndrome and discusses with Mrs. Kuchi the
importance of careful control of her prednisone intake. Dr. Krino started tapering off the
prednisone dose gradually every 3 days, started from 2x5 mg/day, followed by 1x5 mg/day.

1. How cortisol hormone should be regulated?

2. What factors could give the influences to the cortisol level?
a. Stress
b. Pituitary adenoma
PAGE 3

Dr. Krino prescribed Mitotane 3 x 2g/ day and asked Mrs. Kuchi to do regular follow up every
month.

1. What is the role of medication in controlling cortisol level?

2. What factors should be monitored in follow up of Cushing’s syndrome?
TUTORIAL 3
PAGE 1

One week later, Mrs. Kuchi was carried to the emergency department at Siloam Hospital with
severe pain on her right hip after she bumped to a table at home. The physical examination
showed that her right hip was swelling, red, and painful. There was tenderness to palpation over
injured hip.

1. What are Mrs. Kuchi’s problems now?

a. Injured right hip
b. Tenderness to palpation

2. What are the possible causes?

a. Dislocation
b. Fraktur

3. What are the explanations of these problems?

a. Fracture due to osteoporosis(?)

4. What are your next steps?

a. X-ray
PAGE 2

The X-ray examination of Mrs. Kuchi right hip was shown below:

1. Does this information change your hypothesis?

a. Fracture

2. What are complications that usually occur in Cushing’s syndrome?

a. Ada di CO

3. What is the pathogenesis of complications in Cushing’s syndrome?

a.

4. What is your conclusion about Mrs. Kuchi’s case?

a. Exogenous cushing syndrome with complication of pathologic fracture in right
femur

5. What is her prognosis?

a.
EPILOG
Mrs. Kuchi was referred to an orthopedist to get treatment for her hip injury. She got a hip
replacement with satisfied result. She continued to follow the management plan and no other
complications were reported.