Review Question - QID 109375

Action	Numeric Key	Letter Key	Function Key
Choose 1	1
Choose 2	2
Choose 3	3
Choose 4	4
Choose 5	5
Submit Response			Enter
Previous Question			Left Arrow
Next Question		N	Right Arrow
Open/Close Bookmode		C
Open Image			Spacebar

Antipsychotics Introduction Toxicity QID: 109375 (M2.PY.17.4817)

QID 109375 (Type "109375" in App Search)

A 27-year-old man arrives to your walk-in clinic complaining of neck pain. He reports that the discomfort began two hours ago, and now he feels like he can’t move his neck. He also thinks he is having hot flashes, but he denies dyspnea or trouble swallowing. The patient’s temperature is 99°F (37.2°C), blood pressure is 124/76 mmHg, pulse is 112/min, and respirations are 14/min with an oxygen saturation of 99% O2 on room air. You perform a physical exam of the patient's neck, and you note that his neck is rigid and flexed to the left. You are unable to passively flex or rotate the patient's neck to the right. There is no airway compromise. The patient's was recently diagnosed with schizophrenia, and he denies current auditory or visual hallucinations. He appears anxious, but his speech is organized and appropriate. Which of the following is the best initial step in management?

Type & Select Correct Answer

Type in at least one full word to see suggestions list

Change medication to clozapine

10%

3/30

Dantrolene

2/30

Diphenhydramine

83%

25/30

Lorazepam

0/30

Propranolol

0/30

Select Answer to see Preferred Response

Review TC In New Tab

This patient is presenting with a neck spasm that began in the setting of recently diagnosed schizophrenia, suggesting the diagnosis of acute dystonia. The best initial step in management is diphenhydramine.

Acute dystonia presents with involuntary muscle contractions that occur usually within four hours of an antipsychotic, especially typical antipsychotics that are strong D2 blockers (e.g. haloperidol and fluphenazine). The most characteristic spasms are those of the face, neck, tongue, and extraocular muscles. The underlying pathway involves low dopamine, which results in a high acetylcholine output. Acute treatment involves anticholinergic medications, such as diphenhydramine or benztropine.

Incorrect Answers:
Answer 1: Clozapine is an antipsychotic that is known to have a lower risk of tardive dyskinesia and other extrapyramidal symptoms. Tardive dyskinesia normally arises after chronic use (i.e. six months to years) of an antipsychotic and is characterized by involuntary movements, such as lip smacking, facial grimacing, and choreoathetoid movements. Although switching to an antipsychotic with a lower risk of extrapyramidal symptoms is appropriate for patients who experience these complications, this patient's dystonia should be treated first in the acute setting.

Answer 2: Dantrolene is a skeletal muscle relaxant that can be used to treat malignant hyperthermia and neuroleptic malignant syndrome (NMS). Symptoms of NMS include mental status change, muscular rigidity, hyperthermia, and autonomic instability.

Answer 4: Lorazepam is a benzodiazepine that can be used as second-line treatment of akathisia. Akathisia is an extrapyramidal symptom of antipsychotics and presents as motor restlessness, an urge to move, and an inability to sit still.

Answer 5: Propranolol is the appropriate first-line treatment for akathisia which presents with a sustained feeling of restlessness.

Bullet Summary:
Acute dystonia presents with muscular contractions in the setting of antipsychotic use and should be treated initially with diphenhydramine or benztropine.

Rating

Please Rate Question Quality

4.7

(7)