Deepak, who has acute psychosis and has been on haloperidol 20 mg/day for the last 2 days, has an episode characterized by tongue protrusion, oculogyric crisis, stiffness and abnormal posture of limbs and trunk without loss of consciousness for 20 minutes before being presented to casualty. This improves within a few minutes after administration of diphenhydramine HCl. The most likely diagnosis will be?

1. A

   Tardive dyskinesia

2. B

   Acute dystonia

3. C

   Akathisia

4. D

   Neuroleptic malignant syndrome

Appeared in: JSSH Staff Nurse - 2019

Explanation

• Acute dystonia is an extrapyramidal side effect (EPS) characterized by sudden, sustained, and often painful muscle spasms.
• It is commonly triggered by high-potency typical antipsychotics like haloperidol, especially within the first few hours to days of treatment.
• The patient's symptoms of oculogyric crisis (eyes rolling upwards), tongue protrusion, and abnormal posturing are classic signs of dystonia.
• The rapid resolution of symptoms after administering an anticholinergic agent like diphenhydramine is diagnostic for acute dystonia, as it corrects the underlying dopamine-acetylcholine imbalance.

Why Other Options Were Wrong

• Option A: Tardive dyskinesia is a late-onset syndrome, occurring after months or years of antipsychotic use. It features repetitive, rhythmic movements (like lip-smacking), not sustained muscle spasms, and does not improve with anticholinergics.
• Option C: Akathisia is characterized by a subjective feeling of inner restlessness and a compelling urge to move (e.g., pacing, inability to sit still). It does not involve fixed muscle spasms or oculogyric crisis.
• Option D: Neuroleptic malignant syndrome (NMS) is a life-threatening emergency characterized by high fever, severe 'lead-pipe' muscle rigidity, altered mental status, and autonomic instability (e.g., high blood pressure, tachycardia). It would not resolve within minutes of a single dose of diphenhydramine.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Identification of extrapyramidal side effects (EPS) of antipsychotic medications in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Recognizing acute dystonia is a critical nursing skill, as it is extremely frightening for the patient and can be life-threatening if it involves the larynx (laryngospasm), compromising the airway.
• Immediate administration of an anticholinergic agent (like benztropine or diphenhydramine) as per standing orders or a physician's prescription is the priority nursing action.
• What if? If the patient's symptoms did not resolve with diphenhydramine and they also had a high fever and confusion, the nurse should immediately suspect Neuroleptic Malignant Syndrome (NMS) and initiate emergency protocols, as this is a medical emergency.

How to Approach the Question

• First, analyze the patient's medication: Haloperidol is a high-potency typical antipsychotic known for causing extrapyramidal symptoms (EPS).
• Next, evaluate the timeline. The symptoms appeared within 2 days, which points towards an acute, early-onset reaction.
• Then, correlate the specific symptoms (oculogyric crisis, tongue protrusion, muscle spasms) with the known profiles of different EPS.
• Finally, consider the response to treatment. Rapid improvement with diphenhydramine (an anticholinergic) is a key diagnostic clue that points specifically to acute dystonia.

Concept Tested & Keywords

• Concept Tested: Identification of extrapyramidal side effects (EPS) of antipsychotic medications.
• Stem keywords: acute psychosis, haloperidol, tongue protrusion, oculogyric crisis, stiffness, abnormal posture, diphenhydramine HCl
• Lead-in keywords: most likely diagnosis
• Clinical cues: Patient on haloperidol (high-potency antipsychotic) for 2 days, indicating an acute reaction.
• Clinical cues: Symptoms include oculogyric crisis and tongue protrusion, which are classic dystonic signs.

Question ID

QdxOSRbGr4HoSd9uUhw1AD

Copy ID

Reference Book

E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 1887-1889

E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) pp. 10037-10039, 10791-10793