Clinical Challenge: Sudden Onset of Vomiting and Sweating

History of Present Illness

A 52-year-old man presents to the emergency department (ED) after experiencing vomiting, sweating, and generalized weakness for the past 12 hours. He notes that he suddenly started having generalized weakness and multiple episodes of vomiting with no blood while driving. He also started sweating but experienced no fever, chills, chest pain, or shortness of breath. Since the onset of his symptoms, he lost his balance and fell once but did not hit his head. He reports no diarrhea, abdominal pain, headache, or other complaints.

Vital Signs and Physical Examination

The patient’s vital signs are normal and his physical examination is normal except for vomiting. The abdomen is benign and cranial nerves and motor strength are normal. There is no nystagmus. The patient, however, did not feel steady enough to try to walk. Initial diagnostic testing included complete blood count, gastrointestinal (GI) laboratory tests, and basic metabolic panel are all normal. An electrocardiogram and troponin test are normal and a computed tomography (CT) scan of the brain is normal.