This page is dedicated to organizing various examples of standardized exam questions whose answer is neuroleptic malignant syndrome (NMS). While this may seem a odd practice, it is useful to see multiple examples of how NMS will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a tradition question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a disease is quite valuable.
KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)
When it comes to standardized exams, each topic has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for NMS.
Question # 1
A 26 year old man is admitted to the inpatient service after being found on the roof of a building. He appears severely depressed and states that “it is all over”. The patient is financially broke, and his wife has recently left him and taken his three dogs with her. He is crying, has trouble sleeping, admits to a decreased appetite, and continues to express suicidal thoughts and feelings of hopelessness. He was taking phenelzine for depression, but had to stop this mediation last month due to side effects. In the hospital the patient is given both sertraline and clonazepam for his symptoms. Later on in the day the staff notices that he is tearful and agitated, and he begins to blame himself for destroying his life. He is started on olanzapine, and continues to be agitated for the next 2 days. On the third day, he is found to be notably calmer, but a nurse becomes concerned when she notices that he is unable to get out of bed. He appears confused and does not respond when she asks him any questions. He si diaphoretic and has a temperature of 104.2°F. His blood pressure is 170/98 and his pulse is 114/min. As staff members attempt to get him out of bed they notice that his arms and legs are very stiff and are difficult to bend. What condition does this patient very likely have?
Explanation # 1
Question # 2
A 27 year old man is brought to the emergency room from a psychiatric hospital because he has been experiencing a decreased level of consciousness for the past few days. He has progressively gotten worse, and is less and less responsible as time goes by. He is not speaking or following commands. He has a history of schizophrenia and has been hospitalized multiple times for this condition. Currently he is being treated with haloperidol and benztropine. Hi temperature is 103.3°F, pulse is 123/min, reparations are 27/min and blood pressure is 175/105 mm Hg. He withdraws weakly to noxious stimuli. While his eyes are open, he does not fix or follow visual stimuli. He is mute and will not follow simple commands. Physical exam reveals marked rigidity of the neck, as well as the arms/legs. Lab results reveal a white count of 18,000/mm³ and serum creatine kinase of 12,000 U/L. CSF analysis is unremarkable. What condition does this patient likely have?
Explanation # 2
Question # 3
A 27 year old man is brought to the emergency room due to aggressive behavior and severe agitation. He speaks in a very loud volume, and is speech is very rapid. He explains the he has superpowers of mind control, and he has to resort to violence to prevent “the government from gaining control”. The patient’s medical history is notable for a history of bipolar disorder that has been treated with fluoxetine and lithium previously. He currently is not taking any medications. After being given several doses of medication in the emergency room, the patient becomes more responsive and mis much more calm. The following day he awakens in a state of confusion with a temperature of 104.8°F. On physical exam the nurse notices that he has muscle rigidity in all of his extremities. What is the most likely explanation for the symptoms in this patient?
Explanation # 3
Question # 4
A 20 year old male is brought to the ER because he has been lying in bed unresponsive to words or shaking. His father explains hat his son felt very hot to the touch. Two days ago the patient began taking risperidone after an acute episode of agitation and visual hallucinations. Since taking this new medication the patient has become increasingly withdrawn. His past medical history is otherwise unremarkable. His temperate is 103.5°F, push is 105/min, respirations are 16/min, and blood pressure is 155/90mm Hg. His eyes are open and the pupils are 5 mm and reactive. There is rigidity in all of the extremities. The patient responds very sluggishly to any painful stimuli. Lab studies reveal a leukocyte count of 11,500/mm³ and a serum creatine kinase activity of 1400 U/L. Myoglobin is present in the urine. What is the likely diagnosis?
Explanation # 4
Recently started antipsychotic + fever + rigidity + elevated CK = NMS
TESTABLE FACTS ABOUT THIS TOPIC (BEYOND ITS IDENTIFICATION)
Many questions on standardized exams go beyond simply recognizing the underlying topic. Often there are specific testable facts regarding some aspect of the topic’s pathophysiology/management/clinical implications that are commonly asked. Some of these are listed below:
Page Updated: 09.12.2016