Cushing's Syndrome C&P Exam Prep

Blood Pressure (Three Readings)

What it measures: Presence and severity of hypertension, which is a key feature assessed under DC 7907 for higher rating levels. Three separate readings are required per DBQ instructions.

What to expect: The examiner will take three blood pressure readings, typically on the same arm, at intervals during the appointment. Readings above 140/90 mmHg generally indicate hypertension.

Pain considerations: Not directly applicable; however, note any headaches associated with elevated blood pressure episodes, as these represent additional functional impact.

Proximal Lower Extremity Muscle Strength Assessment

What it measures: Ability to perform functional tasks requiring proximal lower extremity muscle strength, including rising from a squatting position, climbing stairs, and rising from a deep chair without assistance. This is a critical determinant between 60% and 100% ratings under DC 7907.

What to expect: The examiner will observe or ask you to demonstrate functional movements such as standing from a seated position, attempting to rise from a squatting position, and describe your ability to climb stairs. They may assess hip flexor and quadriceps strength manually.

Pain considerations: Report any pain, fatigue, or weakness that limits your performance of these tasks. Note whether you experience increased fatigue after repeated attempts, as this represents the DeLuca factor of functional loss with repetitive use.

Proximal Upper Extremity Muscle Strength Assessment

What it measures: Ability to raise arms above shoulder level, reflecting proximal upper extremity muscle wasting. Inability to raise arms is specifically enumerated in DC 7907 at the 60% and 100% levels.

What to expect: The examiner will assess your ability to raise your arms to shoulder height and above, and may manually test deltoid and shoulder girdle muscle strength. They will observe for visible muscle wasting in the shoulder girdle area.

Pain considerations: Report any pain or burning sensation associated with arm raising. Note fatigue that develops with repeated arm use, as this demonstrates functional loss on repetitive use per DeLuca factors.

Body Habitus and Skin Examination

What it measures: Presence of classic Cushing's features including central obesity (buffalo hump, abdominal obesity), moon face (rounded facial appearance), and striae (purple or pink stretch marks), as well as vascular fragility signs (easy bruising, thin skin, slow wound healing).

What to expect: The examiner will visually inspect for moon face, central obesity pattern, dorsal fat pad (buffalo hump), purple or wide striae on the abdomen, thighs, or breasts, and signs of skin thinning or easy bruising. They may document measurements or photograph findings.

Pain considerations: Note any pain associated with skin changes, sensitivity, or discomfort from striae or skin thinning. Report how skin fragility affects daily activities.

Glucose Tolerance and Metabolic Assessment

What it measures: Presence of glucose intolerance or diabetes mellitus as a complication of Cushing's Syndrome, which is specifically enumerated in DC 7907 at the 30% level and above.

What to expect: The examiner will review your lab results for blood glucose levels, HbA1c, and any formal glucose tolerance testing. They will ask about symptoms of hyperglycemia and any medications for blood sugar management.

Pain considerations: Report any neuropathic symptoms (burning, tingling in feet/hands) that may be attributable to hyperglycemia as a secondary complication.

Osteoporosis Assessment Review

What it measures: Presence and extent of osteoporosis as a complication of chronic hypercortisolism, which is specifically enumerated as a criterion for the 100% active progressive disease rating under DC 7907.

What to expect: The examiner will review DEXA scan results and any fracture history. They will ask about bone pain, previous fractures from minimal trauma, and any medications for osteoporosis (bisphosphonates, calcium, vitamin D).

Pain considerations: Chronic back pain from osteoporotic vertebral changes should be clearly described to the examiner, including how it affects your ability to sit, stand, walk, and perform daily activities.

100%

Active, progressive Cushing's Syndrome with ALL of the following: areas of osteoporosis, hypertension, AND proximal upper and/or lower extremity muscle wasting that results in inability to rise from squatting position, climb stairs, rise from a deep chair without assistance, OR raise arms. This rating continues for six months following initial diagnosis.

From 38 CFR: 38 CFR 4.119, DC 7907: 'As active, progressive disease, including areas of osteoporosis, hypertension, and proximal upper and lower extremity muscle wasting that results in inability to rise from squatting position, climb stairs, rise from a deep chair without assistance, or raise arms - 100%.' Note: This rating continues for six months following initial diagnosis per the statutory note.

60%

Proximal upper OR lower extremity muscle wasting that results in inability to rise from squatting position, climb stairs, rise from a deep chair without assistance, OR raise arms - without the full constellation of active progressive disease required for 100%, OR as active progressive disease not meeting all three criteria (osteoporosis, hypertension, and muscle wasting) simultaneously.

From 38 CFR: 38 CFR 4.119, DC 7907: 'Proximal upper or lower extremity muscle wasting that results in inability to rise from squatting position, climb stairs, rise from a deep chair without assistance, or raise arms - 60%.'

30%

With striae, obesity, moon face, glucose intolerance, AND vascular fragility. All five features should be present. This is the minimum rating level under DC 7907 and applies when the full muscle wasting criteria are not met.

From 38 CFR: 38 CFR 4.119, DC 7907: 'With striae, obesity, moon face, glucose intolerance, and vascular fragility - 30%.' Note: After six months from initial diagnosis, if active progressive features resolve, rate on residuals under appropriate diagnostic codes within appropriate body systems.

Proximal Muscle Weakness - Lower Extremities

How to describe it: Be specific about exactly which functional tasks you cannot perform or can only perform with great difficulty or assistance. Use concrete, observable examples rather than general statements about weakness. Quantify how many steps you can climb, whether you need handrails, whether you need someone to pull you up from a chair, and how long tasks take compared to before your condition began.

Example: On my worst days, I cannot rise from a standard chair without pushing up with both arms on the armrests, and even then I sometimes fail on the first attempt. I cannot rise from a squatting position at all - I have not been able to do that for over a year. I cannot climb more than two or three steps without holding the rail with both hands, and by the third step my thighs are burning and trembling. Getting off the toilet is a daily struggle. I have fallen twice attempting to stand from low seating.

Examiner listens for: The examiner is specifically looking for language that matches DC 7907 criteria: inability to rise from squatting position, inability to climb stairs, inability to rise from a deep chair without assistance, and inability to raise arms. These exact functional limitations map directly to the 60% and 100% rating levels.

Avoid: Do not say 'I have some weakness' or 'it's a little hard to get up.' These vague descriptions do not capture the functional threshold required for higher ratings. Do not demonstrate better function than you actually have during the exam - only do what you can safely and accurately do.

Proximal Muscle Weakness - Upper Extremities

How to describe it: Describe specific activities you can no longer do because you cannot raise your arms above shoulder level or sustain overhead positions. Provide examples from daily life that clearly illustrate functional loss, including grooming, dressing, reaching for objects, and any occupational tasks requiring arm elevation.

Example: On my worst days, I cannot raise my arms above my shoulders to wash my hair in the shower - my wife has to help me. I cannot reach overhead cabinets in my kitchen. When I try to raise my arms to put on a shirt, I have to use a button-down and even then I cannot raise my arms high enough to pull a shirt over my head. My shoulders feel like they have bags of sand hanging from them. The weakness is there every day but is much worse after any activity.

Examiner listens for: Inability to raise arms is the specific functional criterion in DC 7907. The examiner needs to hear about specific, concrete limitations with named activities. Descriptions of visible muscle wasting in the shoulder and upper arm area also support this criterion.

Avoid: Do not say 'my arms get tired.' Clearly state if you cannot raise them above shoulder height and give specific daily examples of how this limitation manifests.

Weakness and Fatigability

How to describe it: Describe the nature of your fatigue as distinct from ordinary tiredness. Cushing's-related weakness and fatigability often involve a persistent, pathological exhaustion that does not resolve with rest. Describe onset, duration, triggers, and how it limits your ability to work and perform daily tasks. This aligns with DeLuca factors for functional loss.

Example: On my worst days, I wake up already exhausted even after sleeping eight or nine hours. Within 30 minutes of any physical activity - even walking to the mailbox - my legs feel like concrete and I have to sit down. I cannot complete a full grocery shopping trip without needing to use a cart to lean on and sitting down at least twice. I had to stop working because I could not sustain activity for more than one to two hours without complete exhaustion. The fatigue is not like being tired after exercise - it is a bone-deep weakness that does not go away.

Examiner listens for: The examiner will document weakness and fatigability (DBQ field 439) as a specific manifestation. They are also capturing functional impact on employment and daily activities in the impact section of the DBQ.

Avoid: Do not minimize fatigue by saying 'I just get tired easily.' Describe specifically how it limits duration of activity, interferes with your ability to maintain employment, and prevents completion of basic daily tasks.

Skin Changes - Striae and Vascular Fragility

How to describe it: Describe the appearance, location, and extent of striae and any bruising or skin fragility. Note when these changes appeared relative to your Cushing's diagnosis. Describe incidents of bruising from minimal contact, cuts that take unusually long to heal, or skin that tears easily.

Example: I have wide purple stretch marks on my abdomen, both thighs, and my upper arms that appeared after my cortisol levels were elevated. My skin bruises from almost any contact - I have bruises on my arms right now from simply leaning on a table. Last week I got a bruise the size of my fist from bumping the edge of a countertop. My skin tears from adhesive bandages being removed. Cuts from minor injuries take weeks to heal and sometimes reopen.

Examiner listens for: Striae and vascular fragility are two of the five criteria required for the 30% rating. The examiner needs to document these as objectively present findings. Describe incidents that demonstrate the vascular fragility component specifically.

Avoid: Do not fail to point out existing striae or bruises during the physical examination. These are objective findings the examiner must see and document.

Central Obesity and Moon Face

How to describe it: Describe the characteristic fat redistribution pattern of Cushing's Syndrome: truncal weight gain with relatively thin extremities, buffalo hump (dorsal fat pad at base of neck), and rounded moon face. Describe when these changes began and how they have progressed.

Example: My face has become very rounded and puffy - my family says I look completely different from photos taken before I got sick. I developed a large fat deposit at the back of my neck and shoulders. My abdomen has grown significantly while my arms and legs remain thin. My clothes do not fit properly because of the unusual body shape changes. These changes appeared gradually after my cortisol began rising and have worsened as my condition has progressed.

Examiner listens for: Obesity and moon face are two of five criteria for the 30% rating level. The examiner will visually document these during the physical exam, but your description of the progression and chronological relationship to Cushing's diagnosis helps establish these as manifestations of the condition.

Avoid: Do not attribute these body changes solely to general weight gain or aging. Clearly connect them to the onset and course of your Cushing's Syndrome.

Glucose Intolerance

How to describe it: Describe your blood sugar management, symptoms of hyperglycemia, and any medications required for glucose control. Establish the temporal relationship between your Cushing's diagnosis and the onset of glucose problems.

Example: My blood sugar was normal before my Cushing's diagnosis. After my cortisol levels rose, my fasting glucose climbed to over 140 mg/dL and my HbA1c reached 7.1%. I now take metformin daily. I experience significant fatigue, blurred vision, and increased thirst on days when my blood sugar is poorly controlled. My endocrinologist says the glucose intolerance is directly caused by the elevated cortisol from Cushing's Syndrome.

Examiner listens for: Glucose intolerance is one of five criteria for the 30% rating. The examiner needs laboratory documentation and a description of symptoms and treatment required.

Avoid: Do not describe glucose intolerance as a separate, unrelated condition. Clearly connect it to your Cushing's Syndrome and provide your lab values and medication list.

Functional Impact on Occupational and Daily Activities

How to describe it: The DBQ specifically asks about impact on occupational and daily functioning. Describe concretely how your condition has affected your ability to work, including specific job tasks you can no longer perform, any accommodations required, and whether you have had to reduce or stop working entirely. Also describe impact on daily self-care, household tasks, and social activities.

Example: I had to stop working as a warehouse supervisor because I can no longer stand for extended periods, cannot climb ladders or stairs safely, and cannot lift or carry materials. I have also had to give up driving long distances because the fatigue and muscle weakness make it unsafe. At home, I cannot do yard work, laundry that requires carrying baskets, or cooking that requires standing at a stove for more than 10-15 minutes. My spouse handles most household tasks. I rarely leave the house on bad days because I am afraid of falling.

Examiner listens for: The DBQ has a specific section (field 360) asking for a description of the impact of each endocrine condition on occupational and daily functioning. This narrative directly influences how the examiner describes functional loss, which can support a TDIU claim or higher rating.

Avoid: Do not say 'it affects my daily life' without specifics. List actual named tasks, jobs, or activities you can no longer do or can only do with significant limitation or assistance.