A mask that masked the diagnosis!

A 31-year-old woman presented with chief complaint of muscle weakness. As this complaint was the most bothersome of all, the patient forgot to mention many other problems that she had. Asking her to remove the face-mask, made us to look for other problems because the typical moon face was masked under the mask!. The other problems were recent weight gain, purple striae on the abdomen, easy bruising and skin acne. She didn't have hypertension. By reviewing her medical data we found out she had diabetes and was taking metformin. She used to have mild exophthalmos one year ago and thought to be due to thyroid disease but thyroid function tests were normal. New lab data was asked by focusing on the diagnosis of cushing syndrome and the results were as follows: FBS: 160; HbA1C: 8%; T4: 6.1 micg/dl (5.1-14.4); TSH: 1.9 micLu/ml; Hb: 11.9 MCV: 67; WBC: 9.5*103 /ul, Plt: 192000; 25 OH vitD: 7 ng/ml, Ca: 8.4 mg/dl; P: 2.5 mg/dl; Na: 139 mmol/L; K: 4.8 mmol/L; ACTH: 5 pg/ml; Cortisol 8 AM after 1 mg dexamethasone: 22.13 micg/dl Urinary free cortisol in two checks: 977 and 700 micg/24h. After biochemical diagnosis of Cushing syndrome, MRI was performed and an adrenal adenoma was confirmed. She underwent left adrenalectomy and in pathology report, cushing syndrome was documented. History taking and accurate physical exam are always important part of visiting a patient, but COVID-19 pandemic and using mask could put us in trouble if we forget to ask the patient to remove the mask.