A 28 year old lady has put on weight (10 kg over a period of 3 years), and has oligomenorrhoea followed by amenorrohoea for 8 months. The blood pressure is 160/100 mm of Hg. Which of the following is the most appropriate investigation?
Answer is B (Plasma coisol) : As all features in the presentation are consistent with a diagnosis of Cushing's Syndrome and there are no points to doubt / disour our diagnosis, plasma coisol would be the most appropriate investigation which would confirm our diagnosis. The clinical presentation of patient in question gives us the follow ing leads: Weight gain (10 kg) Hypeension (160/100) (both systolic and diastolic hypeension for a 28 year old lady) Menstrual irregularities in the form of oligomenorrhea followed by amenorrhea. The above presentation leaves us to consider two possible diagnosis: Cushing's syndrome Hypothyroidism Cushing's Syndrome Signs and symptoms of presentation in decreasing order 1. Typical habitus (centripetal obesity)Q 8. Personality changesQ 2. Increased body weight : Weight gainQ 9. EchymosiseQ 3. Fatiguability and weaknessQ 10. Proximal myopathyQ 4. HypeensionQ (> 150/90 mm Hg) 11. EdemaQ 5. HiruitismQ 12. Polyuria / Polydipsia 6. AmenorrheaQ 13. Hyperophy of clitoris 7. Broad violoceous cutaneous striaQ Hypothyroidism: Although hypothyroidism may also present with all features in the question, the points which go against its probable diagnosis are : 1. Presence of both systolic and diastolic hypeension as against mild diastolic hypeension expected in hypothyroidism. 2. Presence of oligomenorrhea followed by, amenorrheo as against menorrhagia initially which is a much more common form of menstrual irregularity in hypothyroidism. Signs and symptoms of Hypothyroidism: System Symptom / Sign I. Skin Dry scaly skin () Loss of hairy' from scalp and body Generalized oedema Q - initially pitting Brittle nails 2. ENT Hoarseness of voiceQ and slowness of speechQ: impaired hearingQ 3. Gastrointestinal tract ConstipationQ Weight gainQ & loss of appetiteQ BradycardiaQ 4. Cardiovascular system Mild diastolic hypeensionQ BreathlessnessQ Cold intoleranceQ 5. Neurological Physical and mental slownessQ, lethargy and somnalenceQ Delayed tendon reflexesQ Paraestheseas 6. Female reproductive MenorrhagiaQ (Later oligomenorrheo and amenorrheo) system GalactorrheaQ (d/t hyperprolactinemiaQ due to high TRH) 7. Miscellaneous Carpal tunnel syndromeQ Serous cavity effusionQ
Serum electrolytes
Plasma coisol
Plasma testosterone and ultrasound evaluation of pelvis
T3, T4 and TSH