This was a case of a 32 year old male brought to the ED by his mother for “not acting right.” He had a history of HTN, Crohn’s disease, bipolar disorder type 1 and his meds included infliximab, sertraline, trazodone, paliperidone at baseline. About 2 weeks prior to presentation he went to acute care for new back pain and was prescribed PRN tramadol. On exam he was noted to have increased muscle tone in his extremities but no clonus, he was oriented to person only. His CK was elevated to 18192. He was eventually diagnosed with NMS and treated with IV fluids, lorazepam and bromocriptine. At discharge he was changed from paliperidone to risperidone.