# A 45-year-old patient stable on sertraline 100 mg daily was prescribed tramadol for acute back pain three days ago. Today the patient presents with restlessness, diaphoresis, tremor, hyperreflexia and inducible clonus, dilated pupils, and a temperature of 38.6 °C. Which is the nurse's best interpretation of these findings?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372709&lang=en  
> language: en  
> subject: Blood/Blood Products  
> category: PPT

## Question

A 45-year-old patient stable on sertraline 100 mg daily was prescribed tramadol for acute back pain three days ago. Today the patient presents with restlessness, diaphoresis, tremor, hyperreflexia and inducible clonus, dilated pupils, and a temperature of 38.6 °C. Which is the nurse's best interpretation of these findings?

## Option

1. Neuroleptic malignant syndrome from sertraline use — administer dantrolene and apply cooling measures.
2. Anticholinergic toxicity caused by tramadol — administer physostigmine and monitor for seizure activity.
3. Sertraline discontinuation syndrome from missed doses — restart the medication and monitor for improvement.
4. Serotonin syndrome from the sertraline-tramadol combination — hold both drugs and notify the provider immediately. **✔ Correct answer**

**Correct answer: 4**

## Explanation

The clinical picture — agitation, diaphoresis, tremor, hyperreflexia and clonus (especially lower-extremity), dilated pupils, and hyperthermia — in a patient who recently combined an SSRI with tramadol is classic for serotonin syndrome. Tramadol is a weak opioid plus a serotonin and norepinephrine reuptake inhibitor and can precipitate serotonin syndrome when added to an SSRI. The priority action is to hold both serotonergic agents and notify the provider for further management (supportive care, benzodiazepines for agitation, cyproheptadine for moderate-to-severe cases, cooling for hyperthermia). Anticholinergic toxicity (1) presents with dry skin, not diaphoresis. NMS (4) typically has lead-pipe rigidity and hyporeflexia, not hyperreflexia/clonus, and develops in patients on antipsychotics, not SSRI+tramadol.

## In-depth explanation

Differentiating serotonin syndrome from its mimics is a high-yield NCLEX skill. Serotonin syndrome — neuromuscular hyperactivity (clonus, hyperreflexia, tremor), autonomic hyperactivity (diaphoresis, tachycardia, mydriasis, hyperthermia), and altered mental status (agitation, restlessness). Onset is usually within 24 hours of adding a serotonergic drug. Common combinations: SSRI/SNRI + tramadol, MAOI + SSRI/SNRI, SSRI + linezolid, SSRI + St. John's wort. Neuroleptic malignant syndrome differs by lead-pipe rigidity (not clonus), hyporeflexia, slower onset, and exposure to a dopamine antagonist (antipsychotic). Anticholinergic toxidrome differs by dry skin and absent bowel sounds — "hot, dry, blind, mad." Sympathomimetic toxicity (cocaine, amphetamine) shares hyperthermia and mydriasis but lacks clonus.

## Clinical scenario

A **45-year-old patient** stable on **sertraline 100 mg daily** was prescribed **tramadol** for acute back pain **three days ago**. Today the patient presents with **restlessness, diaphoresis, tremor, hyperreflexia and inducible clonus, dilated pupils, and temperature 38.6 °C**.

## Key concepts

- **Serotonin Syndrome** — A potentially life-threatening drug-induced syndrome from excessive serotonergic activity. Triad: neuromuscular hyperactivity (clonus, hyperreflexia, tremor), autonomic instability (diaphoresis, tachycardia, mydriasis, hyperthermia), and altered mental status (agitation). Onset usually within 24 hours of adding a serotonergic agent.
- **Tramadol Pharmacology** — A weak μ-opioid agonist with additional serotonin and norepinephrine reuptake inhibition. Risk for serotonin syndrome and seizures, especially in patients already on SSRIs, SNRIs, MAOIs, or with epilepsy. Generally avoided in patients on SSRIs.
- **Cyproheptadine** — A serotonin antagonist used as an antidote in moderate-to-severe serotonin syndrome that does not improve with supportive care and benzodiazepines. Initial dose 12 mg, then 2 mg every 2 hours until resolution. Supportive care, cooling, and stopping the offending agent remain first-line.

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