47-Year-old woman with spells of slurred speech, blurred vision, and loss of consciousness.

A 47-year-old woman presented with a 1-year history of spells characterized by slurring of speech, visual blurring, and on 2 occasions, loss of consciousness occurring 2 to 4 hours after meals and lasting 5 to 30 minutes. The spells were unrelated to fasting or physical activity. She also had milder spells of tremulousness, diaphoresis, and weakness occurring initially every other week but progressing to almost daily. Because the symptoms were alleviated with snacks or small drinks, the patient had begun consuming nuts continually throughout the day to prevent an episode. She had no history of prominent headaches, cutaneous flushing, chest pain, dyspnea, seizures, or psychiatric disorders. The patient had a history of type 2 diabetes mellitus and had undergone Roux-en-Y gastric bypass surgery 2 years previously for medically complicated obesity. Her diabetes resolved shortly after the surgery, and she had lost more than 50 kg. Aside from multivitamins, she was taking no other medications. She had been treated previously with metformin and subsequently with insulin, which were discontinued soon after bariatric surgery. No other members of the household took diabetic medications. Her medical history was otherwise unremarkable; specifically, she had no cardiac disease. On physical examination, the patient’s blood pressure was 105/63 mm Hg, pulse rate was 68/min and regular, and body mass index (calculated as weight in kilograms divided by the square of height in meters) was 26 kg/m (presurgery, 46 kg/m). Well-healed surgical scars were noted on abdominal examination, along with a palpable nontender liver edge at the right costal margin. She had no murmurs or extra heart sounds, and findings on the remainder of her physical examination were normal. 1. Given the patient’s history, which one of the following would be the most likely cause of her spells? a. Carcinoid syndrome b. Pheochromocytoma c. Atypical migrainous spells d. Paroxysmal atrial fibrillation e. Hypoglycemia