Clinical Commander

All dossiers
endo.cushing_syndrome.v1

Cushing syndrome (endogenous + exogenous excluded)

endocrinologychronicsubacuteadultoutpatientinpatienttransition
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Cushing syndrome dossier — exogenous steroid exclusion FIRST; two-stage workup; surgery first-line. Inferior petrosal sinus sampling is gold standard for pituitary vs ectopic when MRI equivocal. Medical bridges (ketoconazole, metyrapone, osilodrostat, mitotane, mifepristone, pasireotide) per cause and tolerability. High VTE risk — escalate prophylaxis perioperatively; postop adrenal insufficiency requires stress-dose hydrocortisone. Open: manifest, problem-package, RxCUI verification, IPSS / mortality calculators absent, tests.

Entry points (5)

  • symptom
    Central obesity, moon facies, buffalo hump, purple striae, proximal myopathy, easy bruising (ADA 2026)
    cushingoid_features
  • symptom
    Rapid weight gain, hirsutism, amenorrhea, mood change (ADA 2026)
    rapid_weight_gain_hirsutism_amenorrhea
  • lab_abnormality
    New hypokalemic HTN with new diabetes (ADA 2026)
    hypokalemia_hypertension_diabetes_combination
  • imaging
    Incidental pituitary or adrenal mass (ADA 2026)
    incidental_pituitary_or_adrenal_mass
  • history
    MEN1 family history (ADA 2026)
    family_history_men1

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Different cause distribution by age (ADA 2026)
  • exogenous_steroid_reviewrequired
    history • used at CONTEXT
    Cardinal first exclusion (inhaled / topical / injected / OTC) (ADA 2026)
  • 24h_urine_free_cortisol_x2required
    lab • used at INITIAL_WORKUP
    First-line confirmation; ≥2× ULN suggestive (ADA 2026)
  • late_night_salivary_cortisol_x2required
    lab • used at INITIAL_WORKUP
    First-line confirmation; high specificity (ADA 2026)
  • overnight_1mg_dex_suppressionrequired
    lab • used at INITIAL_WORKUP
    First-line confirmation; cortisol <1.8 µg/dL excludes (ADA 2026)
  • acthrequired
    lab • used at INITIAL_WORKUP
    ACTH-dependent (>20 pg/mL pituitary or ectopic) vs independent (<5 adrenal) (ADA 2026)
  • cmp_glucose_a1c_lipidsrequired
    lab • used at INITIAL_WORKUP
    Comorbidities; hypoK common; new DM (ADA 2026)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Drug dosing (ADA 2026)
  • high_dose_dex_suppression_or_crh_stim
    lab • used at BRANCHING_WORKUP
    Pituitary vs ectopic in ACTH-dependent (ADA 2026)
  • pituitary_mri
    imaging • used at BRANCHING_WORKUP
    Pituitary adenoma (ADA 2026)
  • adrenal_ct
    imaging • used at BRANCHING_WORKUP
    Adrenal mass (ADA 2026)
  • ct_thorax_abdomen_or_dotatate_pet
    imaging • used at BRANCHING_WORKUP
    Ectopic source localisation (lung SCC, carcinoid) (ADA 2026)
  • inferior_petrosal_sinus_sampling
    imaging • used at BRANCHING_WORKUP
    Gold standard pituitary vs ectopic when MRI equivocal (ADA 2026)
  • depression_alcohol_obesityrequired
    history • used at CONTEXT
    Pseudo-Cushing differential (ADA 2026)
  • current_medsrequired
    medication • used at CONTEXT
    Drug interactions + steroid review (ADA 2026)

12-phase flow (12)

  1. 1FRAME
    Rule out exogenous steroid; confirm hypercortisolism on ≥2 different first-line tests; determine ACTH-dependent vs not (ADA 2026)
    inputs: exogenous_steroid_review, 24h_urine_free_cortisol_x2, late_night_salivary_cortisol_x2, overnight_1mg_dex_suppression, acth
    advance: Hypercortisolism confirmed and ACTH status known
  2. 2ENTRY
    Cushingoid features / new hypoK HTN with new DM / incidental mass / family history (ADA 2026)
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Exogenous steroid (cardinal), depression, alcohol, obesity, OSA, family (ADA 2026)
    inputs: exogenous_steroid_review, depression_alcohol_obesity, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Severe Cushing — Ca, K, infection, psychosis, thrombosis (high VTE risk) (ADA 2026)
    advance: Stabilised
  5. 5INITIAL_WORKUP
    24-h UFC × 2, late-night salivary cortisol × 2, 1 mg dex suppression, ACTH, BMP, glucose, A1c, lipids (ADA 2026)
    inputs: 24h_urine_free_cortisol_x2, late_night_salivary_cortisol_x2, overnight_1mg_dex_suppression, acth, cmp_glucose_a1c_lipids, creatinine_egfr
    actions: panel.hormone, panel.glucose_a1c, panel.renal, specialty.cushings
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    High-dose dex / CRH stim / IPSS for pituitary vs ectopic; pituitary MRI; adrenal CT; ectopic search (CT thorax + DOTATATE) (ADA 2026)
    inputs: high_dose_dex_suppression_or_crh_stim, pituitary_mri, adrenal_ct, ct_thorax_abdomen_or_dotatate_pet, inferior_petrosal_sinus_sampling
    advance: Source localised
  7. 7DIFFERENTIAL
    Cushing disease (pituitary) vs ectopic ACTH vs adrenal adenoma vs ACC vs macronodular hyperplasia vs pseudo-Cushing
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    UFC magnitude; comorbidities; perioperative risk; mortality score (ADA 2026)
    inputs: 24h_urine_free_cortisol_x2
    advance: Tier documented
  9. 9TREATMENT
    Surgery first-line: transsphenoidal for Cushing disease, adrenalectomy for adrenal cause, resect ectopic. Medical: ketoconazole / metyrapone / osilodrostat / mitotane / mifepristone / pasireotide / cabergoline as bridge or recurrence. Stress-dose hydrocortisone post-op. (ADA 2026)
    inputs: creatinine_egfr, cmp_glucose_a1c_lipids
    advance: Plan documented
  10. 10DISPOSITION
    Outpatient endo; admit if severe hypoK / infection / psychosis / preop / postop (ADA 2026)
    advance: Disposition documented
  11. 11MONITORING
    Cortisol, ACTH, K+, glucose, BP, BMI, mental health; recurrence surveillance lifelong (ADA 2026)
    advance: Schedule documented
  12. 12FOLLOWUP
    Endo q3–6 mo; surveillance lifelong (Cushing disease recurrence ~20%) (ADA 2026)
    advance: Follow-up booked