A 65-Year-Old Woman Comes to the Office Due to Involuntary

question 9

Multiple Choice

A 65-year-old woman comes to the office due to involuntary facial and mouth movements.  The patient first noticed the condition 6 months ago with protruding and twisting movements of the tongue and puckering movements of the lips; the movements have worsened since then.  She has also experienced foot-tapping movements and an uncontrollable twisting of her neck to the right side.  The patient has type 2 diabetes mellitus and chronic gastroparesis.  She also has a long history of bipolar disorder that has been stable over the past year on a combination of lithium and quetiapine.  Other medications include metformin and metoclopramide.  She has no family history of a movement disorder or any neurologic disease.
Temperature is 37.5 C (99.5 F) , blood pressure is 138/76 mm Hg, and pulse rate is 84/min.  Occasional tongue protrusion, facial grimacing, cervical torticollis, slow gait, and reduced arm swing are noted.
Which of the following is the most appropriate next step in management of this patient?

• A)Add benztropine
• B)Add carbidopa-levodopa
• C)Discontinue lithium
• D)Discontinue metoclopramide
• E)Switch quetiapine to risperidone

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