Nms management, psychiatry emergency

1. MORBIDITY AND MORTALITY
REVIEW
A CASE OF NEUROLEPTIC MALIGNANT SYNDROME

2. Name: Mr. MAS
MRN : HSAS00601918
Age :22 years old
Gender : Male
Underlying:
-Mental retardation with psychosis under follow up psychiatry team
Hospital Raub, previously was on syrup clopixol 3 drops ON

3. Chief complaint
Patient was referred from Hospital Bentong on 9/6/202
Presented with history of fever for one day
on a background of new onset of aggressive behaviour for 2/52,
worsening prior admission, first episode of aggressive behaviour
• breaking windows in room, trying to flip fridge at home
• poor self-hygiene

4. • Was initially admitted to Hospital Bentong on 1/6/2022 under medical
treated as TRO meningoencephalitis
• CT brain done on 1/6/22: no intracranial abnormality
• Patient was started on IV Rocephine and IV acyclovir, covering for
meningoencephalitis.
• However due to no evidence of CSF infection, IV Acyclovir was off and
IV Rocephine continued.
• Despite on 6 days of IV Rocephine with no evidence of bacterial
infection from blood culture, noted persistent temperature spike, CRP
increasing trend, worsening AKI and transaminitis. Noted dental
caries, reviewed by dental team, unlikely source of infection.

5. • During admission patient was having persistent temperature spikes,
rigidity and high CK ( 15K ) , sweating and tachycardia. Patient unable
to hold meaningful conversation only able to obey simple command
but most of the time observable hallucinating behaviour
• All psychotropic medication was withheld on 7/6/2022, last dose of
syrup Clopixol was given at 6/6/2022 at 10pm last dose of IM
haloperidol given at 12midnight on 7/6/2022

6. • Given IM haloperidol 5mg on 3/6/2022 till 5/6/2022, and 3 times on
6/6/2022
• Given IV Valium 5mg PRN on 3/6/2022, 5/6/2022 till 6/6/2022
• Syrup clopixol 3 drop ON from 1/6/2022 till 4/6/2022 then increase to
5 drops ON from 5/6/2022 till 6/6/2022), then off on 7/6/20220D

7. • Despite this patient still having persistent temp spike and rigidity. Patient
was given IV Dantrolene total 120mg (80mg loading dose) and oral
Amantadine 100mg stat and BD.
• Patient was treated as neuroleptic malignant syndrome and covering
empirically for Hospital acquired infection and was given IV Cefepime 2g
stat 1g tds before transfer to HoShas
• case referred to :
Medical team oncall
Anaesthetis team oncall
Psychiatry team oncall

8. on examination:
GSC in Hospital Bentong prior to transfer E4V3M6 obeyed commands,
not tachypnoiec , warm peripheries , CRT <2s , good PV
T 38.7, BP 124/74, PR 108, RR 19 , spo2 99% on npo2, DXT 7.2
Lung clear, CVS DRNM, per abdomen soft non tender

9. Investigation done in Hospital Bentong
• blood C&S: NG
• CT brain done 1/6/2022: NAD
• ECHO: no vegetation
• Bedside US abdomen no intra-abdominal collection

10. CXR latest 9/6: no obvious pneumonic changes. no cardiomegaly
LP done 2/6/22 opening pressure- 12cmHg
- csf biochemistry & feme:
• prot 0.17, albumin 0.05, glucose 4.07, biochemistry 4.36 ph 8.0
• wbc 0, rbc 0, appearance clear, csf gram stain no bacteria seen
- csf afb: no afb seen
- csf indian ink: no yeast seen
- latex agglutination (all negative: h influenza ag, n menigitidis ag, strep group b ag, e.coli ag, s pnemoniae)
- csf C&S: pus cell nil, organism not seen, no growth
- cytology, mtb C&S: pending

11. 1/6/22 3/6/22 5/6/22 6/6/22 7/6/22 8/8/22 (8pm) 9/6/22
Twc 10.7 8.8 8.6 10.5 12
Hb 16 16.2 16.6 16 16.1
Hct 47.5 49.7 51 49.6 50.3
Plt 373 384 300 252 196
Na 121 137 139 152 157 141 151 154
K 3.2 4.3 3.6 3.2 3.8 3.312 4.3 4.1
urea 4.7 4.8 8.9 10.2 10 10.4 10.2 10.7
Creat 99 85 139 163 182 155 159 132
Cl 46 105 115 116 117 129 117 115
CK - 1426 1117 2766 13173 15460 12144
LDH 466
albumin 466 45 43 44 43 41 42
ALP 61 80 72 61 54 49 49
ALT 69 228 192 145 137 111 105
Tbil 16 17 17 18 23 22 22
Tprot 85 90 87 88 84 81 84
AST 51 144 134 118 235 216 195
CRP 5.7 38.58 11
ca 2.29
Mg 1.17 1.19
phos 1.32 1.55

12. Emergency department (Yellow zone)
9/6/2022 12.11pm
GCS E4V3M5
T: 37, BP 110/84, PR 128, RR20, spo2
99 %, dxt 7
lungs: equal air entry, clear, CVS:
s1S2 , Pa: soft non tender
IMP:
TRO Neuroleptic malignant
syndrome
Plan:
• Keep under RA
• refer medical, psy and anaest
• Continue IVD D5% maintenance

13. MEDICAL REVIEW
09/06/2022 13:57:55
*hx taken from referral letter
comfortable under RA, no fitting episode at ED
upon further history from mother: prior to this, patient
was ADL independent, able to eat by himself/bathing but
with supervision however noted being aggressive since
19/5 - easily triggered; history of breaking
windows/flipping object at home- mother unsure reason
denied history of contact with soil/jungle/water activities ,
denied fitting episode
o/e
GCS E4V2M5 (staring, able to obey simple command) , pink , not
tachypniec , good PV , CRT <2sec
no rigidity bilateral upper and lower limb
CNS examination:
power bilateral UL- 3, able to move against gravity , normotonia,
normoreflex
power bilateral LL- 3, able to move against gravity , normotonia,
normoreflex
lungs clear , CVS DRNM , PA soft not distended , no bilateral pedal
oedema

14. impression:
1/ TRO neuroleptic malignant syndrome
2/ rhabdomyolysis 2' 1
3/ cover for HAI
4/ AKI secondary to 1
5/ hypernatremia 2' over hydration/SIADH
PLAN:
admit K11
for NPO2 - supportive
start IVD D5 4pints/24H
monitor DXT QID
- sc actrapid 6u prn if DXT >12
IO charting
GCS charting
meds
IV Cefepime 1g TDS
IV pantoprazole 40mg OD
Ix
for daily CK
send fbc rp electrolye lft ce inr abg crp ufeme
repeat septic w/up
am cortisol, urine osmol, blood osmol, urine Na

15. ANAEST REVIEW
09/06/2022 14:13:33
Patient comfortable under room air , clinically not tachypnic.
o/e
GCS E4V2M5 (11/15) , pink , pulse volume good , warm to touch ,
crt <2s
no neck stiffness, no rigidity bilateral upper and lower limb
normotonia , hyperreflexia
under room air spo2 96, rr 18 , bp 110/84 , pr 116
hemodynamically unsupported
lungs clear, cvs drnm , p/a soft , no pedal edema
on ivd D5% maintenance from Bentong
given impression:
1/ Unlikely neuroleptic malignant syndrome
2/ Acute infection TRO viral cause with concomitant HAI
3/ Rhabdomyolysis
4/ Electrolytes imbalances
Plan :
Not for ICU admission for now.
admit ward , anaest review patient in ward
keep nasal prong 3l/min as supportive measure
refer chest physio in ward , TED stocking , propup pt 30 degree
suggest not for further iv dantrolene
to hydrate patient adequately, suggest for forced alkaline diuresis with isotonic bicarbonate solution -
to use D5%.
watch out for worsening AKI
to push in ryles tube further anchor at 60cm.
to get premorbid history from family member
ix
repeat baseline blood ix in ward
for daily CK for now
send CRP , ABG, Urine feme
digitize CXR
meds : iv pantoprazole 40mg od

16. PSYCHIATRY REVIEW
09/06/2022 14:56:06
Lying on bed with 4 points restrain
respond to call by moving his eyes
unable to answer questions verbally
unable to get further history from patient
O/E:
E4V2M6
no cogwheel rigidity, unable to assess lead pipe rigidity as patient is restrained
+neck stiffness
no hyper salivation,
T 37, BP 110 /84 , PR 128 , Pain Score: 0 , RR 20 , SpO (%): 99
MSE:
medium Malay man
unkempt in hospital attire, long and dirty nails
in 4 points restrain
cover 1/2 body with blanket
able to respond and give eye contact upon calling
speech nil, open mouth, dental carries seen
no hyper salivation
unable to assess further
Given Impression:
Neuroleptic Malignant Syndrome
-high grade fever, stiffness/muscle rigidity, rhabdomyolysis,
autonomic instability (very high temperature ,irregular HR with
tachycardia),altered mental status
plan:
for ECG in ED
continue medical/anaest plan
not for psychotropic for now
PSY review as liaison with SP cm
to get further for family members regarding patient background,
baseline behaviour, social support and OKU card.

17. FURTHER HISTORY taken by psychiatry team
called patient’s aunt as patient’s mother was unreachable
Education hx:
Patient was in Kelas Pelajar Khas during primary and secondary school for slow learner
However unsure details regarding his performance in school
Social hx:
Patient stay with mother, have OKU card (due to slow learner? ID)
mother was diagnosed with chronic kidney disease since 2015 on regular HD 3x/week , used to work as factory worker, currently unemployed, received
SOCSO RM1000
patient premorbid:
less socialize, likes playing phone games
ADL independently but requiring multiple prompting
no hallucinating behaviour or abnormal behaviours observed by aunt
have history of mental disease from both paternal and maternal sides (patient cousin and nephew)

18. Day 1 of admission (10/6/2022)
Under Medical team for:
1. Cover for meningoencephalitis
ddx autoimmune meningoencephalitis
Ddx neuroleptic malignant syndrome
-iv antibiotic was escalated to Meropenem
2. High CK sec to daily im injection
3. Cover for HAI
4. Hypernatremia 2’1 / overhydration / SIADH
5. AKI secondary to 1
6. Transaminitis sec 1
under Psychiatry:
Neuroleptic malignant syndrome

19. Medical review:
Afebrile , saturating under npo1 , no fit
GCS E4V2M5 ( staring , obey simple command)
Bp 109/66 PR 108 T 37 spo1 95% under Npo2
Neck stiffness present , Babinski downgoing
Plan
Escalate Iv meropenem 2g TDS
IVD 5 pint NS /24 hr
Bladder irrigation
To get MRI brain
Anaest review:
Comfortable , not tacypniec
Saturating under npo2
Hemodynamicallly unsupported
Plan :
Discharge anaest

20. Psychiatry review:
lying on bed with 4 points restrain
unable to answer questions verbally , respond to questions by nodding , obey simple
commands
O/E:
E4V2M6
no cogwheel rigidity, unable to assess lead pipe rigidity as patient is restrained
+neck rigidity
+jaw stiffness (unable to close his mouth)
no hyper salivation
urine haematuria
T 37, BP 119 /70 , PR 121 , Pain Score: 0 , RR 20 , SpO (%): 99
MSE:
medium built Malay man
unkempt in hospital attire, in 4 points restrain
able to respond to questions by nodding and give eye contact upon calling
mouth opened, dental carries seen
no hyper salivation
unable to assess further psychopathology
IMPRESSION:
Features highly suggestive for Neuroleptic Malignant Syndrome
-high grade fever,
-stiffness/muscle rigidity, (oculogyric crisis, jaw stiffness)
-rhabdomyolysis, autonomic instability (very high temperature,irregular HR with
tachycardia)
-altered mental status
-increased CK
-urine haematuria
Plans:
1/ensure adequate hydration
2/ reduce to 2 points restrain to avoid muscle injury
3/start medications:
T Bromocryptine 2.5mg TDS
T lorazepam 2mg TDS
4/ watch out for respiratory depression
5/ withhold other antipsychotics
6/ PSY review cm

21. Patient was been admitted for 10 days in ward 10/6/2022-19/6/2022
Throughout the admission , after starting on treatment :
-T Bromocriptine highest dose of 5mg TDS on day 2 of admission in view of persistent of jaw
stiffness and present of tongue tremor but subsequently able to reduce to 2.5mg BD upon discharge
-T Lorazepam 2mg TDS and subsequently reduce to 1mg BD upon discharge
Notice improving of in term of stiffness and rigidity ,
able to understand conversation, obeying simple command
able to answer simple question by head nodding and minimal word
oral hydration improving
No hallucinating behavior observable
Also notice CK was reducing in trend from 10957 1176
There was no documented temperature > 72 hours prior to discharge
Patient do

22. Prior to discharge on 19/06/2022
Psychiatry review:
respond to his name
but not answering to any question given
unable to assess further
on examination,
jaw rigidity improving
no muscle rigidity
T 37, BP 105/68, HR 86, RR 20, SPO2 98% under RA
MSE
in 2 points restrain
not forthcoming
no eyes contact and rapport
PLAN
1. allow discharge if primary team discharge
2. if still not discharge by today for PSY to
review cm
3. TCA psy clinic in Hosp Bentong –
30/6/2022 @ 9.30AM
- to review condition
- to further reduce or off bromocriptine
4. discharge medication:
T Bromocryptine 2.5mg BD
T lorazepam 1mg ON/PRN (4 tabs)
Syr Clopixol 3 drops ON

23. Investigation

24. 9/6 11/6 12/6 13/6 14/6 15/6 17/6
hb 15.8 13.3 12.0 11.6 12.1 12
twc 11.5 10.2 8.5 5.7 5.8 6.6
Plt 180 134 115 153 230 244
hcte 46.8 38.8 33.9 34.0 33.6 33.7
ESR/ CRP /42.9 36/
CK 10957 8155 5701 3488 1541 1176
LDH 443 447 413 489
urea 9.1 8.1 6.8 4.8 5.4 5.3 6.1
Na 153 144 143 130 138 134 131
K 4.31 3.53 3.57 - 3.89 4.03 4.80
creat 128 114 100 88 68 67
chloride 116 109 108 104 101 98
UA 741 496 427 226 155
TP 80 66 12.4 54 68
Alb 46 36 30 29 34
Glo 34 30 27 25 34
AST 152 153 150 114 115
ALT 92 70 68 109 96
ALP 54 41 36 49 61
TBIL 18.7 14.2 12.4 9.6 10.7

25. CA 2.22 2.12 2.16 2.15
MG 1.20 1.06 0.78 1.08
PHOS 1.30 0.68 1.04 1.04
PT 14.2
APTT 31.8
INR 1.09
UFEME BLOOD
++
PROTEIN
+-
LEU +-
NPO2
PH 7.42 7.41
Paco2 37.4 38.8
Pao2 141 120
So2 98.4 54.1
Hco3 24.6 24.0
BE -0.1 0.1
lactate 1.4 1.4
TFT 10/6/22: TSH 3.010/ FT4 14.3
RF (10/6/22) : Negative
ANA (10/6/22) pending
C3C4 (10/6/22) pending
Blood osmol: 317
Urine osmol : 366
Serum cortisol 497.1
Urine Na 143
AM cortisol 497
Urine C+S: NG

26. Medication:
IV Meropenem 2g TDS ( 9/6/2022-)
IV Pantoprazole 40mg OD
T Bromocriptine 2.5mg BD
T Lorazepam 1mg BD

30. During follow up in Hospital Bentong
Come for follow up in Psychiatry clinic Hospital Bentong on 30/6/2022
Progress
After discharged patient had 2x fitting episode at home and was admitted to Hospital Kuala Lipis from 23-
24/6/22
-CT Brain done normal
-Started on T epilem 200mg BD ,
Upon review in Bentong
Manageable at home , no irritability, able to sleep , no hallucinating behavior, , no documented temp , rigidity
or stiffness
Medication: T bromocriptine 2.5mg TDS and syrup clopixol 3mg ON was discontinued .
Next follow up will be on 28/7/22