EPSE

Question 1

Global

Answer 1

Observe for restlessness, I ability to sit/stand still, anxious/tense

Question 2

Face expression

Answer 2

Movements of forehead, eyebrows, periorbital area, cheeks, frowning, blinking, smiling or grimacing. raising (‘Spock eyebrows’) or lowering of eyebrows that could make the person appear anxious or angry. Symptoms confined to the lower face can be called Miege’s Syndrome. The patient does not experience bruxism during sleep. This patient does not show evidence of tardive Parkinsonism - lack facial expressions (mask-like facies) or saliva pooling/drooling.
The candidate should comment that there are no eye symptoms; including blinking of both eyelids (blepharospasm) but that in the past Paul described experiencing an oculogyric crisis when treated with haloperidol.

Question 3

Lips/peri-oral

Answer 3

Puckering, pouting, lip smacking. Oral-mandibular/buccal-lingual symptoms include chewing motions (sometimes called the ‘Wrigley Sign’), biting with nose wrinkling (‘Rabbit Syndrome’) tongue probing in the cheek (‘Bon Bon Sign’), grimacing, pouting and repetitive swallowing. The jaw may open or locked shut (trismus/lockjaw) making eating difficult. The tongue may protrude rapidly (‘Fly Catcher’) or hang flaccidly (tonic).

Question 4

Jaw

Answer 4

Biting, clenching, lateral movements

Question 5

Tongue

Answer 5

Increased movement in and out

Question 6

Salivation

Answer 6

Look under tongue for increased/pooling of saliva

Question 7

Glabellar tap

Answer 7

Tap forehead gently with index finger. Parkinsonian patients continue to blink instead of accommodating after several taps

Question 8

Upper limbs

Answer 8

Abnormal resting movements (choreography/athetoid movements), arm dropping, elbow rigidity, wrist rigidity, cogwheel rigidity, restless legs, gait-reduced arm swing, stiff gait or a stooped shuffling gait (Parkinsonism features). The candidate should assess for evidence of Parkinsonian side effects particularly of the upper limb movements that can have ratchet-like (cog wheel rigidity), smooth led-pipe rigidity or alternatively a clasp-knife quality. Consideration should be make that Parkinsonian side effects may be causing slowed cognition or worsening of negative symptoms. Additionally, the candidate should comment on absence of bradykinesia (mask-like facial expression, reduction of accessory limb movement or problems in initiating movements) and shuffling gait.

Question 9

Dystonia reaction

Answer 9

Oculogyric crisis, torticolis

Question 10

MUST

Answer 10

Skill in history taking
 Skill in examination of abnormal involuntary movements
 Ability to synthesise this information and formulate a diagnosis
 Knowledge of the management of a psychiatric patient presenting with neuroleptic induced side
effects