Approach to pancreatic masses Quiz: Ace Your Exams

A 45-year-old man presents to the primary care office for his yearly visit. He has been fasting since yesterday evening for bloodwork that was done that morning. While in the waiting room, the patient becomes diaphoretic, lightheaded, and then confused. A fingerstick glucose is checked and is 46 mg/dL. He is given a carton of juice and thirty minutes later, fingerstick glucose is 110 mg/dL. The patient has experienced several similar episodes over the last few weeks, all of which have improved with food intake. A review of systems is positive for heartburn, diarrhea, constipation, and anxiety. Vital signs are unremarkable. On physical exam, the abdomen is nontender and nondistended, with a reducible umbilical hernia present. Computer tomography imaging with pancreatic protocol is shown below and demonstrates a well-defined 2 cm mass in the tail of the pancreas that enhances during the arterial phase. Which of the following historical or physical exam-related elements is associated with the likely underlying diagnosis?
  ^{Image courtesy of STATdx}