BEDSIDE ROUNDS

CASE PRESENTATION
MODULE: WEIGHT GAIN & MOON FACIE
PATIENT PROFILE

46 MAMPANG,
ZC

R.A.

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 CHIEF
COMPLAINT
:
PROGRESSIVE
WEIGHT GAIN

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 HISTORY OF PRESENT ILLNESS
•Recurrent joint pain (severe) – knees, ankles & toes (asymmetric); unrelated to activity
•Self medicates dexamethasone; unrecalled dose 10 tabs/week
6 yrs PTA

•Distended abdomen, swollen legs, posterior neck & trunk, and dizziness
•Prompted consult at ZCMC – abdominal UTZ & lab test refused
2 weeks •Home meds prescribed (diuretics & anti-hypertensive); sent home
PTA •Distention and swelling subsided

• Patient non-compliant to meds

•Failed to return for follow-up
•Weakness & fatigability
Interim •Continued self-medication of dexamethasone for joint pain

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HISTORY OF PRESENT ILLNESS

•Face round, eyes puffy & skin flushed

•2-pillow orthopnea & dyspnea without chest pain
5 days • Weaker; undocumented fever
• Weight gain progressed, thus, admitted to ZCMC
PTA

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PAST MEDICAL HISTORY
◈ 2010: diagnosed with hypertension – noncompliant to his
maintenance of Losartan of (unrecalled dose)
◈ No chronic illnesses such as asthma, diabetes mellitus,
renal failure and liver diseases
◈ No history of previous hospitalization, surgical operation
and previous blood transfusion.
◈ No known allergies to food and medication.
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FAMILY HISTORY
◈ Hypertension – maternal side
◈ Arthritis and Cardiac problems – paternal side
◈ No other heredofamilial diseases such as asthma,
diabetes mellitus, adrenal diseases and cancer.

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PERSONAL & SOCIAL HISTORY
◈ Patient is living together with his common law wife and four
children
◈ Non-smoker
◈ Admits on drinking alcohol every night with an unrecalled
amount per occasion. (Started year 2000; ceased year 2010)
◈ Meal intake includes rice, dried fish, fish and vegetables
◈ Spends most of his time at home gardening

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REVIEW OF SYSTEMS
◈ GENERAL: (-) weight loss (+) changes in clothing fit
◈ SKIN: (-) pruritus (-) easy bruising
◈ HEENT:
• Head: (+) Headache (+) lightheadedness (-) head injury
• Eyes: (-) pain
• Ears: (-) earaches
• Nose and sinuses: (-) Frequent colds (-) nasal stuffiness (-)
epistaxis
• Throat: (-) odynophagia (-) dysphagia (-) hoarseness

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REVIEW OF SYSTEMS
◈ NECK: (+) Nape pain (-) stiffness
◈ RESPI: (+) Dyspnea (-) Cough (-) Hemoptysis (-) PND
◈ CARDIO: (+) palpitations (-) pleuritic chest pain or discomfort (-) Chest
pain
◈ GI: (-) nausea and vomiting (-) loss of appetite (-) diarrhea (-)
constipation (-) rectal bleeding (-) abdominal pain
◈ PERIPHERAL/VASCULAR: (-) numbness
◈ URINARY: (-) dysuria (-) hematuria (-) discharges (-) polyuria (-)
nocturia (-) kidney or flank pain
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REVIEW OF SYSTEMS
◈ MSK: (+) Muscle Weakness
◈ NEURO: (+) irritable and emotional lability
◈ ENDO: (+) Polyuria (+) Polydipsia (-) Polyphagia, (-) Excessive
sweating, (-) Heat/cold intolerance
◈ HEMA: (-) blood transfusions, (-) easy bruising
◈ PSYCH: (-) nervousness, (-) memory change

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PHYSICAL EXAMINATION
GENERAL Weak-looking, awake, conscious & coherent

VITAL SIGNS 37.1oC 102 bpm 35 cpm 160/100

mmHg

5’4” 76 kg 28.7 (Overweight)

SKIN fair with irregularly shaped ecchymosis distributed on both
of his upper and lower extremities. Skin is dry, scaly and
friable, warm to touch with good skin turgor
HEENT HEAD: Normocephalic and atraumatic. His face is rounded
and plethoric

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PHYSICAL EXAMINATION
HEENT EYES: Anicteric with pink palpebral conjunctiva and
periorbital edema. PERRLA.
EARS: No purulent discharges, external deformities and
tenderness
NOSE: Septum midline, no sinus tenderness and
discharges.
THROAT/MOUTH: moist pinkish buccal mucosa, no
lesions and deformities, no tonsilopharyngeal congestion.
NECK Buffalo hump noted, no acanthosis nigricans, no
deformities, trachea is midline, no lymphadenopathies. JVP
of 3cm at 30-degree angle bed elevation

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PHYSICAL EXAMINATION
CHEST & Thorax is symmetric with good excursion. No deformities,
LUNGS no retractions, no tenderness, normal tactile fremitus,
resonant on percussion, clear breath sounds on all lung
fields
HEART Adynamic precordium with LV apex and PMI noted at 5 th
ICS midclavicular, no heaves and thrills, regular rate and
rhythm, no extra heart sounds
ABDOMEN Protuberant with purple broad striae, normoactive bowel
sounds, tympanitic on all quadrants, liver span of 6 cm at
midclavicular line, no masses, no tenderness, no fluid
wave, no shifting dullness, no splenomegaly.

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PHYSICAL EXAMINATION
GENITALIA & Not assessed
RECTUM
EXTREMITIES Brittle and dirty nails on all extremities
Upper extremities: Swollen right hand on IV site, 55x 20
mm poor healing wound on the left index finger
Lower Extremities: Swollen, tender and warm left knee
and ankle, grade 2 edema on both lower extremities more
prominent on the left foot.
PERIPHERIES Good, strong, and bounding bilateral peripheral pulses.
CRT <2 seconds
NEURO Oriented to time and place
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CLINICAL IMPRESSION/S

Iatrogenic Cushing’s Syndrome Secondary To Chronic Exogenous

Steroid Use;
Essential Hypertension;
Chronic Gouty Arthritis In Flare;
Infected Wound 2nd Digit Left Hand

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BASES FOR IMPRESSION
IATROGENIC CUSHING’S
SYNDROME

HISTORY: PHYSICAL EXAM:

◈ 6-year history of steroid use ◈ BP: 160/100 mmHg; PR: 102 bpm; RR: 35 bpm

◈ Progressive Weight gain (94%) ◈ Ecchymoses of irregular sizes (65%)

◈ Dry, scaly and friable
◈ Hypertension (82%)
◈ 55x20 mm Infected Wound 2nd digit left hand 
◈ Progressive swelling of face, neck and trunk
◈ Facial plethora, rounded face (moon facie), periorbital
◈ Weakness ang easy fatigability edema  
◈ Polyuria (23%) ◈ Neck: Buffalo hump  
◈ Polydipsia (23%) ◈ Abdomen: Protuberant abdomen with broad purple striae
(67%)
◈ Mood changes (66%)
◈ Brittle nails
◈ Irritability (66%)
◈ Edema on lower extremities (62%)
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BASES FOR IMPRESSION
ESSENTIAL HYPERTENSION

HISTORY: PHYSICAL EXAM:

◈ Prevalence of 90% ◈ V/S: BP – 160/100 mmHg
◈ Family History – maternal side
◈ Diagnosed with hypertension since 2010
◈ Occasional headaches and lightheadedness
◈ Palpitations
◈ Nape Pain

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BASES FOR IMPRESSION
CHRONIC GOUTY ARTHRITIS IN
FLARE

HISTORY: PHYSICAL EXAM:

◈ Common in middle age ◈ Swollen, Tender and warm left knee and ankle
◈ Common in Male ◈ Grade 2 edema on both lower extremities
more prominent on the left knee and ankle
◈ History of Chronic Alcoholism
◈ History of joint pain since 2013
◈ Family History of Arthritis

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BASES FOR IMPRESSION
INFECTED WOUND

HISTORY: PHYSICAL EXAM:

◈ Nonhealing wound that lasted for 9 days ◈ 55x22 mm wound with pus and redness on
surrounding skin

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DIFFERENTIAL DIAGNOSES

RULE IN: RULE OUT:

• Progressive
Liver weight gain (-) ascites
Cirrhosis • previous history (-) Jaundice
of chronic (-) caput medusae
secondary alcoholism   (-) spider nevi
to Chronic • abdominal (-) hematemesis
distension   (-) clubbing of nails
Alcoholism • easy fatigability
• bipedal edema

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DIFFERENTIAL DIAGNOSES

RULE IN: RULE OUT:

• Progressive
weight gain (-) PND
Easy Fatigability (-) rales, normal
Congestive • 2 pillow JVP, no S3 gallop,
Heart Failure orthopnea no hepatomegaly,
• Hypertension no crackles
• Periorbital Normal JVP
edema (-) ascites
• Tachycardia
• Ankle edema

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DIFFERENTIAL DIAGNOSES

RULE IN: RULE OUT:

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DIFFERENTIAL DIAGNOSES

RULE IN: RULE OUT:

• Progressive
(-) cold intolerance
Weight Gain
• Easy Fatigability (-) hair loss
(-) bradycardia
Hypothyroid • Dry skin
• Dyspnea (-) no constipation
-ism • Muscle (-) no difficult
(-) concentration
• Weakness,
• Puffiness in face,
hands, and feet
• Peripheral edema

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DIFFERENTIAL DIAGNOSES

RULE IN: RULE OUT:

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 1. 24-hour urine free cortisol
excretion
2. Low dose dexamethasone
suppression test
3. Midnight salivary cortisol
4. Serum Electrolytes
5. Serum Uric Acid
6. Fasting lipid profile

PARACLINICALS
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• Admit to ward
• Pharmacologic
a. Cushing’s oral agents:
Metyrapone
Ketoconazole
b. Antihypertensives:
ACE Inhibitors or
ARBS
c. Anti-Gout: Colchicine
d. NSAIDS
• Urate Lowering Therapy
• Lifestyle Modification
MANAGEMENT
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