A 33-year-old G1P1 Caucasian female presents with intermittent episodes of weakness, abdominal discomfort and nausea lasting days at a time over the past 3 months. Except for treated hypothyroidism she has no other medical problems.

On exam she is alert, thin, well-tanned, in no acute distress and non-toxic. Vitals are normal except for a BP of 84/56. Her exam is otherwise unremarkable. She looks well hydrated. Her abdomen is benign.  Pelvic exam is refused because “the pain isn’t down there.”

Look at the picture below and use the few clues from the case narrative. What does she have?

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