Physical Examination and Workup
The patient is alert and in no distress. His face appears plethoric, and his eyes are mildly congested. He is 5 ft, 7 in tall and weighs 187 lb (84.8 kg). His blood pressure is 180/100 mm Hg. His heart rate and respirations are normal. He has 1+ pedal edema.
A pulmonary examination was remarkable for dullness over the left lower lung posteriorly and diminished air entry. He has no visceromegaly. In the past 4 months, he has gained 20 lb. Lung radiography is obtained and reveals loss of volume at the left base, elevation of the diaphragm on the left side, and opacity behind the heart (Figure 1).
His CBC count is unremarkable. His BUN level is 28 mg/dL (reference range, 6-24 mg/dL), and his creatinine level is 0.9 mg/dL (reference range, 0.7-1.3 mg/dL). Serum electrolyte levels were all within reference ranges, except for a low potassium level (3.2 mmol/L). His serum glucose level is 234 mg/dL, and his glycated hemoglobin level is 9.2%.
He has type 2 diabetes mellitus and is diagnosed with recovering pneumonia in the setting of left lower lobe atelectasis. Weight gain, hypertension, facial flushing, and hypokalemia are also present. He is scheduled for bronchoscopy to evaluate his lung mass and referred to an endocrinologist for further evaluation. Given the lung mass and facial flushing, further testing was performed.
His fasting plasma cortisol is 27 µg/dL (reference range, 5-25 µg/dL), and his adrenocorticotropic hormone (ACTH) level is 127 pg/mL (reference range, 10-60 pg/mL). The patient fails a high-dose (8 mg) overnight dexamethasone suppression test (morning plasma cortisol, 26 µg/dL; ACTH level is 132 pg/mL).
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