Mehl. extrapyramidal side effects + neuroleptic 04-08 (1)

Question 1

Extrapyramidal side-effects = The name for the movement disorders associated with anti-psychotic use.

Answer 1

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Question 2

“Rule of 4s”?
After a patient is started on an antipsychotic, a general trend is seen in terms of the onset of particular symptoms.
The time frame is not strict/rigid; use it as a general trend – i.e., acute dystonia wouldn’t just start at 4 months; tardive dyskinesia wouldn’t occur as early as 2 weeks.

Answer 2

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Question 3

Acute dystonia at 4 hours. CP?

Answer 3

torticollis, oculogyric crisis, muscle rigidity without fever.

Question 4

torticollis, oculogyric crisis, muscle rigidity without fever. when?

Answer 4

Acute dystonia at 4 hours.

Question 5

Torticollis = ?

Answer 5

stiff / crooked neck.

Question 6

stiff / crooked neck.?

Answer 6

Torticollis

Question 7

Oculogyric crisis=?

Answer 7

= weird eye movements (don’t confuse with tongue movements of tardive dyskinesia).

Question 8

= weird eye movements (don’t confuse with tongue movements of tardive dyskinesia).?

Answer 8

• Oculogyric crisis

Question 9

Muscle rigidity without…?

Answer 9

Muscle rigidity without fever = acute dystonia.

Question 10

…………..= acute dystonia.

Answer 10

Muscle rigidity without fever = acute dystonia.

Question 11

Muscle rigidity with fever = …?

Answer 11

neuroleptic malignant syndrome.

Question 12

………….. = neuroleptic malignant syndrome.

Answer 12

Muscle rigidity with fever

Question 13

Treat acute dystonia with (muscarinic receptor antagonists, which decrease muscle tone) ….?

Answer 13

Treat acute dystonia with benztropine or trihexyphenidyl

(muscarinic receptor antagonists, which decrease muscle tone)

Question 14

Treat acute dystonia with <..> OR 1st generation H1 blocker???2

Answer 14

1st generation H1 blocker (diphenhydramine or chlorpheniramine).

Question 15

1st generation H1 blocker (diphenhydramine or chlorpheniramine). The latter have nasty anti-cholinergic (anti-muscarinic) side-effects that are actually what we want when we’re treating acute dystonia. Maybe 2/3 of acute dystonia Tx Qs will have benztropine as the answer; ~1/3 will have one of the 1st gen H1 blockers as correct.

Answer 15

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Question 16

Akathisia at 4 days ->?

Answer 16

restlessness.

Question 17

Akathisia at 4 days -> restlessness. Tx?

Answer 17

Treat with propranolol (beta-blockade).

Question 18

Treat with propranolol (beta-blockade).??

Answer 18

Akathisia at 4 days -> restlessness.

Question 19

Parkinsonism at 4 weeks ->?

Answer 19

akinesia / bradykinesia.

Question 20

Parkinsonism at 4 weeks -> akinesia / bradykinesia. Tx?

Answer 20

Treat with amantadine.

Question 21

Tardive dyskinesia at 4 months ->?

Answer 21

abnormal facial movements (notably tongue).

Question 22

abnormal facial movements (notably tongue).?

Answer 22

Tardive dyskinesia at 4 month

Question 23

Risk is greater with typicals compared to atypicals, what CP to occur??

Answer 23

Tardive dyskinesia at 4 month

Risk is greater with typicals compared to atypicals, but TD can be seen in the latter on NBME.

Question 24

Tardive Tx?

Answer 24

stop the typical and give an atypical.

Question 25

Couple of weird Psych NBME Qs on TD: - Patient on atypical + gets TD; Tx?

Answer 25

stop the atypical and give another atypical. (Just stop the drug and switch to yet another atypical.)

Question 26

Couple of weird Psych NBME Qs on TD: Patient on typical for 15 years and has no problems whatsoever (i.e., does not have TD); patient asks the psychiatrist what can be done to decrease his risk of developing TD?

Answer 26

The correct answer is "stop the typical and give an atypical"; wrong answer is "maintain current drug regimen." Apparently even if the patient has been on a typical long term without an issue, switching to an atypical still confers a reduction of risk of TD.

Question 27

What can do metoclopramide?

Answer 27

Metoclopramide (D2 antagonist used as anti-emetic / pro-kinetic) can also cause EPS side-effects and prolong QT interval, same as the anti-psychotics. There is 2CK Psych Q where they give Parkinsonism in patient on metoclopramide, and the next best step is “discontinue metoclopramide.”

Question 28

Neuroleptic malignant syndrome (NMS). definition?

Answer 28

Muscle rigidity and fever following commencement of anti-psychotic.

Question 29

Muscle rigidity and fever following commencement of anti-psychotic.?

Answer 29

Neuroleptic malignant syndrome (NMS)

Question 30

NMS. The fever will usually be 103+ F, as per my observation on NBME exams. This is because mere anti- cholinergic side-effects can sometimes give low-grade fever (i.e., hot, red, dry patient).

Answer 30

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Question 31

Mechanism for NMS?

Answer 31

the ryanodine channel, which allows calcium to move from the sarcoplasmic reticulum into the cytosol, gets stuck open, so ­incr. calcium moves into the cytoplasm. The cell then needs to use a lot of ATP to pump the calcium back into the sarcoplasmic reticulum. This generates heat -> fever.

Question 32

This mechanism for NSM secondary to anti-psychotic administration is the same as ......

Answer 32

Same as malignant hyperthermia (MH) due to succinylcholine (nicotinic neuromuscular blocking agent used during surgery).

Question 33

Neuroleptic malignant syndrome (NMS), Tx?

Answer 33

Tx is dantrolene, which closes the ryanodine channe

Question 34

NBME will sometimes give vignette of NMS or MH, and then the answer for Tx is “decreases sarcoplasmic calcium release.”

Answer 34

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Question 35

In theory, bromocriptine (D2 agonist) can be used in the setting of NMS only as an alternative to dantrolene, but I haven’t seen NBME assess this. This is more a pedantic Q students will ask sometimes.

Answer 35

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