Medicine question 115 from Archer
#586632
misshyd - 05/17/11 23:17
A 34 year old male nurse is brought to the Emergency Room by the EMS with altered mental status. As per his sister, the patient has been on Lithium for his manic symptoms for the past one year. However, his psychiatrist added Fluoxetine and Amitriptyline about 1 week ago for history of depression symptoms.
On physical examination, he has low grade fever at 100.5F, Blood pressure of 110/82 and Heart rate of 120/min. He is confused and the pupils are dilated. There is rigidity in extremities and deep tendon reflexes are exaggerated. Complete blood count, creatinine and Creatine kinase level are within normal limits. Most likely diagnosis:
A) Neuroleptic Malignant Syndrome
B) Lithium Toxicity
C) Serotonin Syndrome
D) Amphetamine abuse
E) Cocaine Intoxication
Answer is Serotonin syndrome (dilated pupils is a classic sign of SS)
This is my key also dilated pupil
Thanks
Want to make sure
sorry hays, i was very busy , logged in after three days
Clonus and hyperreflexia do not ocuur in NMS but occur in serotonin syndrome. Clonus and hyperreflexia may be a good way to differentiate Mild to moderate serotoin syndrome from NMS. If serotonin syndrome is severe, clonus becomes masked by extreme rigidity (hypertonicity) and you can not elicit reflexes or clonus. This is the question they ask on the exam . At that time, the prinicipal differentiating feature is "mydriasis" in Serotonin syndrome where as normal pupils in NMS.
The following points are directly from Dr.Red psychiatry lecture :
1. know to differentiate NMS from Serotonin Syndrome as patients may be on both types of drugs at same time ( eg: pts with bipolar disorder may be may be on an antimanic drug/antipsychotic + SSRI)
2. recognize that classic features such as muscular hypertonicity and hyperthermia occur only in life threatening cases. Hyperkinetic neuromuscular findings of tremor or clonus and hyperreflexia should lead the clinician to consider the diagnosis of the serotonin syndrome.
3. Recognize that Clonus and Hyperreflexia are highly suggestive of serotonin syndrome in mild to moderate cases.
4. Remember that if there is severe muscle rigidity ( hypertonicity ), it can mask the diagnostic features of serotonin syndrome such as clonus and hyperreflexia
5. Remember MYDRIASIS is the KEY. Where as in Neuroleptic Malignant Sydrome, you will usually see Normal sized pupils
Thanks. Misshyd. I know you are busy, please try to come more often
Hi,
We miss you and Sami, it's been long time , did not see both of you.
hays and forever, thank you. I miss writing here too , but it got busy last few days
I will be back in evening
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Looking for research positions to improve CV?
If interested in research positions, contact me at MariaRez2010. We have positions in different states and specialties. Some are in the top 5 universities in the US. Provide some brief info about yourself, your visa status, your USMLE scores, what (sub)specialty, which state, when you want to start and for how long. In the subject, please mention what you’re looking for. For example: “Endocrine research in Chicago.”
We do have paid positions too, but you need to have had a prior experience in LAB research (chart-review and data collection do NOT really count as research experience that qualifies you to get paid). Otherwise, it's unlikely you can get a paid position. Also remember the visa limitation (you can't get paid on all visas). Some positions are non-paid initially, but may become paid with time as you gain experience and prove yourself to be productive.
We can provide a list of customers that you can contact for feedback about the service. These customers approved to be references, otherwise, we don't disclose any private information of any of our old customers without their knowledge and consent.
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