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A 65-year-old obese man presents to his primary care clinic feeling weak. He was in the military and stationed in Vietnam in his youth. His current weakness gradually worsened to the point that he had to call his son to help him stand to get on the ambulance. He smokes a pack of cigarettes every day and drinks a bottle of vodka a week. He has been admitted for alcohol withdrawal multiple times and has been occasionally taking thiamine, folic acid, and naltrexone. He denies taking steroids. His temperature is 98°F (36.7°C), blood pressure is 170/90 mmHg, pulse is 75/min, and respirations are 20/min. He is obese with a significant pannus. Hepatomegaly is not appreciable. Abdominal striae are present. His workup is notable for the following:Serum:Na+: 142 mEq/LCl-: 102 mEq/LK+: 3.9 mEq/LHCO3-: 25 mEq/L BUN: 24 mg/dL Glucose: 292 mg/dLCreatinine: 1.5 mg/dLCa2+: 10.1 mg/dLAST: 7 U/LALT: 14 U/L24-hour urinary cortisol: 400 µg (reference range < 300 µg)Serum cortisol: 45 pg/mL (reference range < 15 pg/mL)A 48-hour high dose dexamethasone suppression trial shows that his serum cortisol levels partially decrease to 25 pg/mL and his adrenocorticotropin-releasing hormone (ACTH) level decreases from 10 to 6 pg/mL (reference range > 5 pg/mL). What is the best next step in management?
CT of the chest
MRI of the adrenal glands
MRI of the pituitary gland
Low-dose dexamethasone therapy for 3 months
High-dose dexamethasone therapy for 3 months
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A 25-year-old woman presents to her physician with a four month history of fatigue and weakness. The weakness has been progressive to the point where she cannot climb stairs and stand from a sitting position. She has only had one menstrual period in the last four months and has never been pregnant. She smokes a pack of cigarettes every day and does not take any medications. Her temperature is 98°F (36.7°C), blood pressure is 160/100 mmHg, pulse is 70/min, and respirations are 15/min. She is obese with a significant pannus. Abdominal striae are present. Her laboratory workup is notable for the following:Serum:Na+: 142 mEq/LCl-: 102 mEq/LK+: 3.9 mEq/LHCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 314 mg/dLCreatinine: 1.1 mg/dLCa2+: 10.1 mg/dLAST: 9 U/LALT: 8 U/L24-hour urinary cortisol: 470 µg (< 300 µg)Serum cortisol 30 µg/mL (5-23 µg/dL)Serum adrenocorticotropin-releasing hormone (ACTH) 2 pg/mL (> 5 pg/mL)A 48-hour high dose dexamethasone suppression trial shows that her serum cortisol levels do not decrease. What is the best next step in management?
MRI of the chest
Low dose dexamethasone suppression test
Inferior petrosal sinus sampling
A 69-year-old man presents with granulomatosis with polyangiitis diagnosed about 8 months ago. He was treated appropriately and states that his symptoms are well controlled. He is presenting today for a general follow up visit. His temperature is 99.0°F (37.2°C), blood pressure is 184/104 mmHg, pulse is 88/min, respirations are 12/min, and oxygen saturation is 98% on room air. His physical examination is notable for the findings in Figures A and B. Which of the following would be found in this patient on serum laboratory studies?
Hyperkalemia and metabolic acidosis
Hyperkalemia and metabolic alkalosis
Hypokalemia and metabolic acidosis
Hypokalemia and metabolic alkalosis
Hypokalemia and normal acid-base status