A 37-year-old adult was admitted 2 days ago for acute psychosis and was shouting and pacing on admission. The client received several intramuscular haloperidol doses over 48 hours, then a higher scheduled dose. Yesterday the client had a neck spasm that resolved after IM diphenhydramine. The client takes no antidepressant and has had no surgery or anesthesia. Current assessment at 0400: the client is mute and opens the eyes only to a loud voice; the arms and legs resist passive movement evenly through the range; no clonus at either ankle; pupils 4 mm and briskly reactive; skin is diaphoretic. Temperature 40.2 C (104.4 F), HR 132/min, RR 30/min, SpO2 95% on room air. Blood pressure was 176/102 mm Hg at 0200 and 88/50 mm Hg now. The client continues to mumble about hearing voices. Laboratory results are pending.
一名 37 歲成人因急性精神病於 2 天前入院，入院時大聲喊叫並來回踱步。個案在 48 小時內接受了數劑肌肉注射氟哌啶醇，隨後又接受了更高劑量的預定劑量。昨天個案出現頸部痙攣，在肌肉注射苯海拉明後緩解。個案未服用抗憂鬱劑，且未曾接受手術或麻醉。凌晨 0400 的目前評估：個案緘默，且僅對大聲說話有睜眼反應；四肢在整個運動範圍內對被動運動呈現均勻阻力；雙踝無陣攣；瞳孔 4 毫米，對光反應靈敏；皮膚出汗。體溫 40.2°C (104.4°F)，心率 132 次/分，呼吸 30 次/分，室內空氣下血氧飽和度 95%。血壓凌晨 0200 為 176/102 mm Hg，目前為 88/50 mm Hg。個案持續喃喃自語說聽到聲音。實驗室結果待定。