A 44-year-old man was referred for investigation of cortisol excess. He had poorly controlled hypertension, and a long history of type 2 diabetes mellitus with retinopathy and peripheral neuropathy. His medication comprised aspirin, ramipril, atenolol,
carbamazepine, metformin and simvastatin.
Initial investigations:
serum cortisol (09.00 h)350 nmol/L (200C700)
serum cortisol (22.00 h)48 nmol/L (50C250)
overnight dexamethasone suppression test (after 1 mg dexamethasone):
serum cortisol93 nmol/L (<50)
24-h urinary free cortisol (day 1)225 nmol (55C250)
24-h urinary free cortisol (day 2)200 nmol (55C250)
24-h urinary free cortisol (day 3)185 nmol (55C250)
What is the most appropriate next step in management?
A . CT scan of adrenal glands
B . dexamethasone-suppressed corticotrophin-releasing hormone test
C . high-dose 48-h dexamethasone suppression test
D . MR scan of pituitary
E . reassure and discharge
Answer: E
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