You are asked to evaluate a 46-year-old man who has presented to the emergency department with profound fatigue, muscle weakness, and “pins and needles” of both feet and legs. He states that he has become increasingly tired over the past two months, and has been missing work (he is an accountant) because of the fatigue.
On close questioning, he admits to a 35-pound weight loss over the past six months. He also states that he seems to have lost his appetite and is never hungry. The patient denies alcohol or drug abuse, and he takes no medications.
He does indicate that he has had substantial anxiety lately due to a variety of marital difficulties for which he and his wife have sought professional counseling. He has had no surgery, and is not currently under the care of a physician.
On examination, the patient is in no distress, and his vital signs are normal. The only positive findings on exam include a systolic ejection murmur, mild facial edema, patchy vertex hair loss, and the nails of both hands as depicted in the photograph. What is your doorway diagnosis? (Hint: Be complete in your diagnosis!)