1. - Cosyntropin is the best ACTH sec. stimulator
2. Rx. I. Surgery, if surgery is not possible then II. Ketoconazole
3. Screen Inv. LOW dose Dexamethasone suppression test
   1. Morning Cortisol HIGH
      1. Inv. 24h. Urinary Cortisol level
         1. High
            1. Dx. True HYPER-Cortisol
            2. Inv. High Dose Dexamethasone suppression test
            3. High Cortisol = NO suppression to cortisol levels
            4. Dx. ACTH secreating Adenoma
            5. Inv. ACTH level
            6. low
            7. Dx. Cortisol-secreting adrenal adenomas
            8. Inv. Abdominal CT
            9. less then 4cm mass maybe a normal incidental-oma
            10. more then 4 cm mass is higher risk for CA
            11. High
            12. Dx. ACTH secreting - small cell lung cancer
            13. Inv. Lung CT
            14. LOW Cortisol= Suppression of cortisol level
            15. Dx. Pituitary Adenoma = Cushing's Disease
            16. Inv. ACTH level = High OR normal
            17. Inv. brain MRI
            18. if nothing seen on MRI -> petrosal sinus sampling
            19. if negative sampling
            20. if positive sampling
            21. mass seen
         2. NORMAL
            1. Dx.
            2. Alcohol
            3. Depression
   2. morning Cortisol is low
      1. Dx. is NOT cushing's
4. small cell lung cancer