54-year-old man with weight gain and muscle weakness

Physical Examination

  • General appearance: Slightly unkempt. Has truncal adipose tissue distribution with relatively thin legs, a moon-like face, and posterior cervical fat pad.

  • Vital signs:
  • Temperature: 36.8° C
  • Pulse: 72 beats/min
  • Respirations: 18/min
  • BP: 188/92 mm Hg

  • Skin: Skin is generally thin; there is acne on the upper thorax and wide purple striae on the lower abdomen and around the axillae. There are a few bruises on the legs and forearms. No obvious pallor or jaundice. Hair is thin and sparse with temporal balding.

  • HEENT: On examination of eye movements, left eye is deviated down and laterally with mild ptosis and left pupil is 1 mm bigger than the right and weakly reacting to light. Patient reports double vision on looking to the right.

  • Pulmonary: Bilateral and symmetric air entry, a few bibasal end-inspiratory crackles on auscultation of the lungs.

  • Cardiovascular: Normal heart sounds, no murmurs, rubs, or gallops. Jugular venous pulse visible but not elevated. Bilateral moderate pitting leg edema. The dorsalis pedis pulses are difficult to palpate due to leg edema.

  • Gastrointestinal: There is an old surgical scar in the epigastric area. Abdomen is soft, nontender on palpation and bowel sounds are normal. Rectal normal, stool heme negative.

  • Genitourinary: Unremarkable

  • Musculoskeletal: Slim legs and arms except for visible bilateral lower leg edema that is not red or tender. No muscle tenderness or fasciculations.

  • Neurologic: Alert and oriented. Muscle tone is generally normal, Strength 5/5 and symmetric except for weakness of quadriceps 4+/5 bilaterally; weakness is constant and does not increase following use of the quadriceps during testing. Reflexes are brisk and symmetric in upper and lower limbs; plantar reflexes are down-going.

  • Mental status: Patient reports a decreased mood but no suicidal thoughts.