Emergency Department Minute Quiz: Weak and Tan

Case: A Caucasian woman in her 30s presents to the emergency department for 10 days of gradually worsening generalized weakness, nausea without vomiting and occasional mid-abdominal pain. She also mentions that she has recently been on a keto-diet and also has had a surprising tan despite it being mid-winter. She denies any diarrhea, fever, missed periods or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for a BP of 85/61, which she does not think is normal for her. The pulse is 90 and temperature is 97.7. Physical exam is otherwise normal except for the skin findings and gum findings shown below.

Initial Diagnostic Testing:

CBC: normal except for 8% eosinophils

Chem 7: normal except for a sodium of 131, potassium of 5.3 and glucose of 62