A 27-Year-Old Man Is Brought to the Emergency Department After

question 20

Multiple Choice

A 27-year-old man is brought to the emergency department after becoming agitated in a grocery store and screaming that voices are tormenting him and telling him to kill himself.  The patient has a history of bipolar disorder currently treated with lithium and fluoxetine.  In the emergency department, he becomes combative when approached by staff and receives several doses of intramuscular haloperidol and lorazepam.  Urine toxicology is negative.  The patient is admitted to the inpatient psychiatry unit, where he is placed in seclusion and restraints due to continued agitation.  The following day he is calm but appears confused.  He is disoriented to time and place and unable to respond to questions.
Temperature is 39.9 C (103.8 F) , blood pressure is 180/90 mm Hg, pulse is 112/min, and respirations are 16/min.  On examination, the patient is diaphoretic.  He has tremors and severe, generalized muscle stiffness but no hyperreflexia or myoclonus.  His examination is otherwise normal.  Laboratory tests have been ordered but are still pending.
Which of the following is the most likely diagnosis in this patient?

• A)Drug-induced parkinsonism
• B)Lithium toxicity
• C)Malignant hyperthermia
• D)Neuroleptic malignant syndrome
• E)Serotonin syndrome

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