The High Cost of Incomplete Physical Exams: Missed Diagnosis of Cushing Syndrome in a Patient with Recurrent Hospital Admissions

Cushing syndrome is a rare but life-threatening endocrine disorder associated with a classic constellation of physical exam findings (e.g. “moon facies”, abdominal striae, etc.). However, thorough biochemical testing is needed to confirm this diagnosis. We present the case of a 35-year-old male with multiple hospitalizations across a variety of healthcare institutions for heart failure, cellulitis, uncontrolled hypertension, and diabetes. While an adrenal mass was eventually identified on imaging, classic signs of Cushing syndrome – including violaceous striae, truncal obesity, and facial plethora – were missed during prior admissions. This case illustrates the diagnostic delay that can result from incomplete physical exams. It highlights the importance of maintaining a high index of clinical suspicion for Cushing syndrome in patients with suggestive features and unexplained cardiometabolic complications. Finally, it underscores how factors like the social determinants of health exponentially amplify the complexity of disease management even after diagnosis