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Friday, October 2, 2026
EndocrineEasy
A 28-year-old female has Cushing's syndrome confirmed biochemically (elevated midnight salivary cortisol × 2, 24h urine free cortisol 3× upper limit of normal (ULN)). She is on no exogenous steroids. Which of the following is the most appropriate next test to determine the cause?
ADexamethasone suppression test
BPlasma ACTH level
CAdrenal CT scan
DPituitary MRI scan
Reveal the answer & full explanation
Correct answer: B — Plasma ACTH level
ADexamethasone suppression test
BPlasma ACTH level✓
CAdrenal CT scan
DPituitary MRI scan
Why Plasma ACTH level is correct
Once Cushing's syndrome is biochemically confirmed, the next step is plasma adrenocorticotropic hormone (ACTH) to determine whether the cause is ACTH-dependent or ACTH-independent.
Elevated ACTH (>20 pg/mL) = ACTH-dependent → pituitary (Cushing's disease, 70%) or ectopic source (15%) → pituitary MRI → corticotropin-releasing hormone (CRH) stimulation test plus inferior petrosal sinus sampling if needed.
Why the others are wrong
Dexamethasone suppression test — this is a screening/confirmation test for the diagnosis of Cushing's syndrome, which has already been established biochemically here; it does not localize whether the source is adrenal, pituitary, or ectopic.
Adrenal CT scan — imaging is premature before ACTH is measured; ordering it first risks chasing incidental adrenal "incidentalomas" and misses ACTH-dependent (pituitary/ectopic) causes, so it is reserved for confirmed ACTH-independent disease.
Pituitary MRI scan — pituitary imaging is only indicated once ACTH is shown to be elevated (ACTH-dependent); obtaining it first is wasteful and misleading, as ~10% of normal people have nonfunctioning pituitary incidentalomas.
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Every day, FirstPassPA publishes one free, board-style question modeled on the PANCE (Physician Assistant National Certifying Exam) and PANRE. Each one is a clinical vignette with a single best answer and a full explanation — including why the other options are wrong — so a two-minute daily habit steadily builds the pattern recognition the boards reward.
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Read the vignette, commit to an answer before you reveal it, and then read the explanation even when you get the question right — the reasoning for the distractors is usually where the real learning is. Rotate through the daily questions to keep every organ system fresh, and when your exam date gets closer, layer in longer, blueprint-weighted question blocks in the app.
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