Scenario
You graduated 3 months ago and are working with a home care agency. Included in your caseload is J.S., a 60-year-old man suffering from chronic obstructive pulmonary disease (COPD) related to (R/T) cigarette smoking. He has been on home oxygen, 2 L oxygen by nasal cannula (O2/NC), for several years. Approximately 10 months ago, he was started on chronic oral steroid therapy. Medications include ipratropium-albuterol (Combivent) inhaler, formoterol (Foradil) inhaler, dexamethasone (Decadron), digoxin, and furosemide (Lasix).
On the way to J.S.’s home, you make a mental note to check him for signs and symptoms (S/S) of Cushing’s syndrome.
Clinical Presentation
• Centripedal (truncal) obesity or generalized obesity
• Thin arms and legs
• Bruising
• Weakness and fatigue
• Moon-facies with facial plethora
• Purplish-red striae on abdomen, breasts, and buttocks
• Hypertension
• Impaired glucose metabolism
Clinical presentation
• Unexplained hypokalemia
• Acne
• Hirsutism
• Menstrual irregularities
1. Differentiate between Cushing’s syndrome and Cushing’s disease. Cushing’s syndrome is the term used to describe a group of symptoms that occur when a persons’ cortisol levels are too high (known as hypercortisolism) for too long. The majority of people have Cushing’s syndrome because they are regularly taking certain medicine(s) that continually add too much cortisol to the body. Doctors call this an “exogenous” (outside the body) cause of Cushing’s syndrome. Other people have Cushing’s syndrome because something is causing the adrenal gland(s) to overproduce cortisol.5 Doctors call this an “endogenous” (inside the body) cause of Cushing’s syndrome. Cushing’s disease is the most common form of endogenous Cushing’s syndrome. It is caused by a tumor in the pituitary gland that secretes excessive amounts of a hormone called Adrenocorticotropic hormone, or ACTH.
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2. Your assessment includes the following findings. Determine whether the findings are attributable to J.S.’s COPD or possible Cushing’s syndrome. Place an “L” beside the symptoms consistent with lung disease and a “C” next to those consistent with Cushing’s syndrome.
L- A. Barrel chest
C- B. Full-looking face (“moon face”)
C- C. Blood pressure (BP) 180/94 mm Hg
L- D. Pursed-lip breathing, especially when patient is stressed
C- E. Striae over trunk and thighs
C- F. Bruising on both arms
C- G. Acne
L- H. Diminished breath sounds throughout lungs
C- I. Truncal obesity with supraclavicular and posterior upper back fat and thin extremities
3. You inform the physician of the patient’s S/S. The physician believes J.S. has developed Cushing’s syndrome and decides to discontinue dexamethasone therapy. Identify possible consequences of suddenly stopping the dexamethasone therapy. Withdrawal symptoms: severe fatigue, weakness, body aches, and joint pain. It takes weeks to months for the adrenal glands to start making cortisol on their own again, so patient needs to taper off to allow time for body to start making cortisol again on its own in the right amounts.
4. Cushing’s syndrome can affect memory. Patients can easily forget what medications have been taken, especially when there are several different drugs. List at least three ways you can help J.S. remember to take his pills as prescribed. 1- put all pills in a weekly or monthly pill box.
2- Set an alarm on his cell phone to remind him to take his pills. 3- Place the pillbox by toothbrush so that pt can see them every morning when brushing teeth.
5. J.S. states that his appetite has increased but he is losing weight. He reports trying to eat, but he gets short of breath (SOB) and cannot eat any more. How would you address this problem? Tell the patient to eat several smaller more frequent meals. Drink after eating.
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Eat high protein diet.
Eat when well rested.
6. You advise J.S. to take his prednisone in the morning with food. You ask him a series of questions R/T possible gastric discomfort, vision, and joint pain. Discuss the rationale for your line of questioning. Prednisone can cause upset stomach. It can have serious side effect with vision problems. If it’s not helping with joint pain then the dose may need altering.
8. Differentiate between the glucocorticoid and mineralocorticoid effects of prednisone. Mineralocorticoids= The name mineralocorticoid derives from early observations that these hormones were involved in the retention of sodium, a mineral. The primary endogenous mineralocorticoid is aldosterone, although a number of other endogenous hormones (including progesterone and deoxycorticosterone) have mineralocorticoid function. Aldosterone acts on the kidneys to provide active reabsorption of sodium and an associated passive reabsorption of water, as well as the active secretion of potassium in the principal cells of the cortical collecting tubule and active secretion of protons via proton ATPases in the lumenal membrane of the intercalated cells of the collecting tubule.
This in turn results in an increase of blood pressure and blood volume. Glucocortiocoids= Glucocorticoids (GC) are a class of steroid hormones that bind to the glucocorticoid receptor, which is present in almost every vertebrate animal cell. GCs are part of the feedback mechanism in the immune system that turns immune activity (inflammation) down. They are therefore used in medicine to treat diseases that are caused by an overactive immune system, such as allergies, asthma, autoimmune diseases and sepsis. GCs have many diverse (pleiotropic) effects, including potentially harmful side effects. They also interfere with some of the abnormal mechanisms in cancer cells, so they are used in high doses to treat cancer. Difference between Glucocorticoid receptors and Mineralocorticoid receptors? Glucocorticoid have a high affinity for cortisol and Mineralocorticoid have a high affinity for Aldosterone AND cortisol.
9. How would your assessment change if J.S. were taking a glucocorticoid that also has significant mineralocorticoid activity? I would look at potassium levels because he is taking furosemide and this mineralocorticoid. I would also look into hypertension symptoms or hypotension symptoms.
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10. Review J.S.’s list of medications. Based on what you know about the side effects of loop diuretics and steroids, discuss the potential problem of administering these in combination with digoxin. Loop diuretics loose potassium and can alter sodium/water balance. Steroids cause increased cortisol, which is anti-inflammatory, and it also increases levels of glucose in blood while raising BP. It makes the patient at risk for infection. Diuretics lower BP while steroids can increase BP along with digoxin. Taking loop diuretics and digoxin can lead to digoxin toxicity, cardiac arrytymia’s and electrolyte imbalances. All three of those: diuretics, steroids, and digoxin lower potassium levels in body. Hypokalemia. They also enhance the levels of digoxin in the body so toxicity can occur easier.
