Journal of Clinical Case Reports

Seizure-like movements after general anesthesia is not common, but it sometimes happens. However, abnormal movements following general anesthesia may be difficult to differentiate because it is difficult to find out the exact cause of these seizure-like movements. These cases can occur at any stage (during induction of anesthesia and emergence from anesthesia and early and late recovery of anesthesia). This is a rare case of seizure-like movement after tonsillectomy under general anesthesia. 

Objective: The present study aims to investigate a patient with a large number of admissions to adult emergency service, to understand the cost of the patient to the public through the number of admissions and the invoice amount, and to reveal the solutions available for such patients.

Introduction: Emergency services are the units providing free health services with intensive patient admissions in Turkey. Emergency department admissions were gradually increasing in recent years, with claims that emergency services are being abused by patients.

Results: Our patient was found to admit to the emergency department 266 times in two years for reasons such as substance abuse, excessive drug use, and self-harm, and he was hospitalized 4 times in the service and 9 times in the intensive care unit. The invoice total of the examination and treatment bill was 21,763.05 Turkish Lira.

Conclusion: Patients with addictions and psychiatric disorders have the potential to harm themselves and cause multiple emergency service admissions, leading to increased workload in the emergency service. It may be necessary to address these patients differently than other patients and to conduct a more detailed examination.

Introduction: Ventriculoperitoneal (VP) placement is the most common procedure performed by neurosurgeons with a high range of reported complication rates with a mean complication rate of 23.8%. Such complications included shunt failure, infection, shunt migration, pneumocephalus, and subdural hematoma. A small portion of the catheter migrations can lead to abdominal pain by penetrating walls of the viscera or the peritoneal wall. Because 15% of these cases result in death, recognizing and treating this complication quickly is essential.

Case presentation: A 56-year-old Caucasian male with a history of hydrocephalus treated with multiple VP shunt placements presented to the ED in a community setting three times over the course of two months with RLQ pain.

Clinical course: The patient continued to have severe abdominal pain despite multiple visits to the ED and an inpatient stay for treatment of suspected colitis. Referral to general surgery allowed for definitive diagnosis where a diagnostic colonoscopy showed the distal portion of a VP shunt was penetrating the wall of the cecum. Subsequent laparoscopy was performed to remove multiple disconnected VP shunts with closure of the cecotomy with two endoclips, which resulted in rapid improvement of the patient’s pain.

Conclusion: When considering the differential diagnosis for abdominal pain in a patient with a VP shunt, it is necessary to recognize distal shunt migration as an uncommon but serious cause of the pain. Bowel perforation is a complication of VP shunt placement that occurs in 0.1-0.7% of patients, with 15% of these resulting in death.

Rivaroxaban is a Direct Oral Anticoagulant (DOAC), which has six licensed indications, including the use for prevention of stroke and systemic embolism with non-valvular Atrial Fibrillation (AF) and the treatment of Venous Thromboembolism (VTE). The pharmacokinetics and the pharmacogenetics of rivaroxaban are reviewed by the author because of a previously reported case of a 43-year-old Caucasian female, who was diagnosed with popliteal and calf Deep Venous Thrombosis (DVT) while on anticoagulation treatment in the form of rivaroxaban 20 mg PO daily. This treatment was started because of a previously verified bilateral Pulmonary Embolism (PE) 5 months earlier. Rivaroxaban is more frequently used in clinical practice, and many physicians are aware that rivaroxaban requires adaptation mainly on the patient's renal function. However, there is still a need to increase awareness of rivaroxaban's interactions with drugs that share its pathways when the hepatic CYP450 and/or P-gp/BCRP are involved. These pathways are utilized by several medications, which are used in cardiovascular and neurological diseases, and the treatment of infections. These interactions can result in under or overexposure to rivaroxaban, which both effects can be detrimental. The author makes several cautious suggestions to decrease the incidence of under/overexposure of rivaroxaban. Physicians, including primary care physicians, could receive a clinical course focusing on DOACs for anticoagulation treatment or direct clinical training within a short-term Anticoagulation Team (ACT) stewardship program concerning adequate prescriptions of rivaroxaban/DOAC as well as their interactions. Also, patients who are elderly and/or with polypharmacy while taking rivaroxaban require more frequent controls. Furthermore, research exploring the effects of ABCG1, ABCG2, CYP3A4, CYP3A5, and Drug-Drug Interactions (DDI), is warranted. Finally, there is a need to identify a validated method for measuring rivaroxaban in primary care.

Neurosarcoidosis is a rare, chronic inflammatory disease that affects the nervous system. It is diagnosed in 5 to 10% of sarcoidosis patients, but has been found in 25% of autopsies. This suggests that a large percentage of patients are asymptomatic or misdiagnosed. Diagnosis is difficult due to variable expressivity and overlap of symptoms with other neurological disorders, such as multiple sclerosis. Moreover, diagnosis proves challenging because currently, the most specific test for neurosarcoidosis requires a histological biopsy confirmation of the affected neural tissue. This presents with its own complications. Due to the lack of fixed diagnostic methods and symptom overlap, a multidisciplinary approach is recommended in diagnosing a patient with possible neurosarcoidosis. This case describes the difficulty in making the diagnosis and the persistence of the patients physicians.

Objective: Prescribing cascade usually results from the misdiagnosis of a drug-related adverse event or condition. Although the prevalence of prescribing cascade remains unknown, it likely increases the risks associated with polypharmacy (e.g., adverse drug events). Furthermore, consequences of prescribing cascade are more likely to be detrimental for the elderly population due to the presence of multiple chronic diseases and the complexity of the derived medication regimen. This case aims to shed light on a particular prescribing cascade due to angiotensinconverting enzyme (ACE) inhibitor-induced cough.

Case: A 101-year-old male with a past medical hypertension, osteoarthritis, gastroesophageal reflux disease, atrial fibrillation, hyperlipidemia, muscle weakness, and mild intermittent asthma was experiencing worsening of cough. To manage his hypertension, the patient was previously prescribed lisinopril and amlodipine. To control the cough, the patient was then prescribed benzonatate (Tessalon Perles®) and budesonideformoterol (Symbicort®). Lisinopril-induced cough was postulated; after the discontinuation of lisinopril and the initiation of losartan, the cough resolved. However, the use of the benzonatate and budesonide-formoterol was not re-evaluated.

Conclusion: This case is an example of prescribing cascade resulting from a misdiagnosis of an ACE inhibitor-induced cough. Misdiagnosis may result in inappropriate prescribing of medications that increase the risks resulting from polypharmacy, such as adverse drug events. Pharmacists are uniquely positioned to intercept and avoid such prescribing cascade.

Knowledge of root canal anatomy and morphology is one of the significant elements for the successful result of endodontic therapy. Absence of knowledge relating to internal anatomy will lead to mistakes like access, localization of canals, cleaning and shaping and obturation of the root canal. Slowey expressed that root canal morphology has boundless variations and clinicians ought to consistently know that anatomic variations contribute a great challenge to the successful finishing of endodontic treatment.