Third Case : An Extra Stimulant

Another day with the same boring series of cases at your job in Emergency is taking its toll on you , you have started to feel the monotony of the affair and go out for a while to fix yourself with a hot steaming cup of cream coffee and a little fresh air to stimulate you up . On your return you find a nice young couple waiting for you with their 22 -month-old baby which seems to be a male .The mother explains that the reason of family's arrival happens to be several episodes of vomiting in baby that began in the middle of the night.The baby had been having intermittent bouts of vomiting beginning two weeks earlier.He had been seen on three separate occasions, diagnosed with acute gastroenteritis. The parents reported that between the bouts of vomiting, their son maintained a very poor appetite and had experienced some weight loss.On this visit,the parents reported the first episode of emesis beginning10 hours prior to their arrival,followed by three more episodes. The patient had refused to take fluids during this period. The family denied recent travel or sick contacts, and the child had not experienced fevers, cough, congestion or diarrhea.
His medical history is significant for a similar episode occurring three months earlier and lasting approximately one week. The patient had no other medical problems and had
been prescribed Phenergan suppositories and Zantac for his symptoms;no Phenergan was given prior to this visit. As usual you proceed with PE

GENERAL APPEARANCE: awake, making good eye contact, but appearing listless and very fatigued.

VITAL SIGNS
Temperature 98.9 F(37.2 C)
Pulse 64 beats/minute
Blood pressure 110/60 mmHg
Respirations 24 breaths/minute
Oxygen saturation 100% on room air
Head Eyes & ENT: Atraumatic, normocephalic, PERRL, EOMI, oropharynx moist.

NECK: fine , no meningeal signs.

CARDIOVASCULAR: Bradycardic,regular rate and rhythm without rubs,murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nontender,nondistended,active bowel sounds present.

EXTREMITIES: No clubbing, cyanosis or edema, capillary refill less than 2 sec.

NEUROLOGIC: Awake, following commands, moving all extremities.

An ECG plus chest and abdominal radiograph is obtained.
The ECG demonstrated sinus bradycardia, otherwise normal for age. The combined chest and abdominal radiograph is shown in Figure . A peripheral intravenous line was placed, and blood was drawn and sent for laboratory testing. A 20 mL/ kg bolus of normal saline IV was administered.Now you were hoping something useful from the Lab but the tests, including a complete blood count, electrolytes, glucose, creatinine and urinalysis,are all so normal.

You admit him for observation. Approximately nine hours after admission, the patient had a witnessed tonic clonic seizure that resolved with intravenous lorazepam. you also note that vomitting bouts worsen around midnight to morning time

Now again , What's your suspected diagnosis?

and how are you going to proceed ??