A 21-year-old woman is brought to the emergency department by her roommate due to anxiety. The patient has generalized anxiety disorder and takes sertraline but has been increasingly restless for the past 2 days, pacing in her room and startling easily. She has been studying for a graduate school entrance examination for the past month, staying up late and drinking 2 cups of coffee a day. The patient has been taking her roommate's tramadol for headaches that have become more frequent. She has no other medical or psychiatric history. Temperature is 37.7 C (99.9 F), blood pressure is 140/80 mm Hg, pulse is 100/min, and respirations are 14/min. The patient appears jittery and has perspiration on her forehead. No abnormalities are noted on cardiopulmonary examination. Muscle tone is mildly increased in the upper and lower extremities. Deep tendon reflexes are symmetric and 3+ throughout. The patient says she feels overwhelmed and unprepared for her exam. Which of the following is the most likely diagnosis?

Question

A 21-year-old woman is brought to the emergency department by her roommate due to anxiety.  The patient has generalized anxiety disorder and takes sertraline but has been increasingly restless for the past 2 days, pacing in her room and startling easily.  She has been studying for a graduate school entrance examination for the past month, staying up late and drinking 2 cups of coffee a day.  The patient has been taking her roommate's tramadol for headaches that have become more frequent.  She has no other medical or psychiatric history.  Temperature is 37.7 C (99.9 F), blood pressure is 140/80 mm Hg, pulse is 100/min, and respirations are 14/min.  The patient appears jittery and has perspiration on her forehead.  No abnormalities are noted on cardiopulmonary examination.  Muscle tone is mildly increased in the upper and lower extremities.  Deep tendon reflexes are symmetric and 3+ throughout.  The patient says she feels overwhelmed and unprepared for her exam.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d75b_630b_bc81_5960e6760332_MD0003_00 This patient's acute onset of increasing anxiety and restlessness and physical examination findings of jitteriness, diaphoresis, tachycardia, hypertension, increased muscle tone, and hyperreflexia are consistent with serotonin syndrome (SS), likely due to the combined effects of 2 serotonergic medications. Sertraline is a selective serotonin reuptake inhibitor for generalized anxiety disorder, and tramadol is an analgesic medication with serotonergic activity. SS is a mild to potentially life-threatening syndrome associated with excessive serotonergic activity that can result from the use of serotonergic medications, alone or in combination, or from intentional overdose. The onset is typically within 24 hours of taking a serotonergic drug or changing the dose. The diagnosis is made clinically based on the classic triad: Mental status changes such as anxiety, restlessness, agitated delirium Autonomic dysregulation such as diaphoresis, tachycardia/hypertension, hyperthermia (severe cases) Neuromuscular hyperactivity such as tremor, muscle rigidity, clonus, hyperreflexia Gastrointestinal symptoms (eg, diarrhea, hyperactive bowel sounds) due to stimulation of serotonin receptors in the gut are also common. (Choices A and E) Intoxication with caffeine and other stimulants (eg, amphetamines, cocaine) can cause anxiety, jitteriness, diaphoresis, tachycardia, and hypertension (sympathomimetic toxidrome) but would not explain this patient's increased muscle tone. Drinking 2 cups of coffee a day is unlikely to cause caffeine intoxication. Her recent exposure to a second serotonergic drug makes SS more likely. (Choice B) Hyperthyroidism can present with increased anxiety, diaphoresis, tachycardia, and brisk reflexes. However, muscle weakness, not rigidity, would be expected. This patient does not exhibit other classic features of hyperthyroidism, such as heat intolerance and weight loss despite increased appetite. (Choice C) Panic attacks are characterized by the abrupt onset of intense anxiety that typically peaks within 10 minutes. This patient's 2-day history of increasing anxiety and the physical findings and known exposure to two serotonergic medications are more consistent with SS. Educational objective: Serotonin syndrome is characterized by the triad of mental status changes, autonomic dysregulation, and neuromuscular hyperactivity. It may be an unintentional result of the combined use of serotonergic agents (eg, selective serotonin reuptake inhibitors and tramadol). References: Tramadol, pharmacology, side effects, and serotonin syndrome: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26218943) Tramadol: understanding the risk of serotonin syndrome and seizures. (http://www.ncbi.nlm.nih.gov/pubmed/29752906)

A 21-Year-Old Woman Is Brought to the Emergency Department by Her