BMJ case reports
-
Hospitals and specialists in the UK are increasingly prescribing and dispensing off-license drugs such as ketamine which are not routinely included in the prescribing record of the general practitioner (GP). We present the case of a 67-year-old woman who developed an episode of uncontrolled raised blood pressure (BP) (224/124 mm Hg) following hospital introduction of oral ketamine for chronic pain. This raised BP was not followed up, and she was then found to be persistently hypertensive in the community some months later. ⋯ We postulate that long-term ketamine use may have been associated with this unexpected and persistent rise in BP. Clinicians should monitor BP closely during ketamine therapy and be wary of new hypertension associated with its long-term use. Further research is needed on the long-term effects of ketamine on BP.
-
A 59-year-old man with a background of poststroke epilepsy, lung cancer, chronic obstructive pulmonary disease and hypertension, presented to the medical assessment unit with acute confusion and altered consciousness. Medications included sodium valproate, aspirin and antihypertensives. On examination he was confused, with his Glasgow Coma Scale fluctuating between 10 and 14. ⋯ Serum ammonia was elevated (75 µg/dL), consistent with a diagnosis of valproate-related hyperammonaemic encephalopathy. Sodium valproate was changed to a different antiepileptic drug and his confusion gradually resolved. Valproate-related hyperammonaemic encephalopathy is a treatable condition which should be considered as a diagnosis in anyone taking sodium valproate with new onset confusion, even in the presence of therapeutic sodium valproate levels and normal liver function tests.
-
Subcostal transversus abdominis plane (TAP) blocks provide good postoperative analgesia for laparoscopic cholecystectomies. We hypothesised that adding hyaluronidase may improve the efficacy of this technique by increasing spread of the local anaesthetic (LA). In this case, we performed a bilateral ultrasound-guided subcostal TAP block using lignocaine (40 mL 1%) with hyaluronidase (75 IU/mL) for postoperative analgesia following elective laparoscopic cholecystectomy. ⋯ Regular paracetamol was administered postoperatively. We monitored serial serum lignocaine levels and recorded the patient's visual analogue scale (VAS) pain scores postoperatively. We found that the patient experienced excellent analgesia throughout the postoperative period and that the serum lignocaine levels did not exceed the therapeutic range.
-
Two cases of adult intussusception (large bowel and small bowel) are presented highlighting the challenges posed by their often innocuous presentation in addition to significant morbidity resulting from delayed diagnosis.
-
This report presents a case of brachial neuritis following a subacromial corticosteroid injection. The patient developed an anterior interosseous neuropathy shortly after the injection, with no other trigger being identified. This neuropathy has unfortunately not shown any sign of recovery at 2 years. The authors propose that corticosteroid injection be added to the list of possible triggering events of brachial neuritis and highlight the frequent use of oral corticosteroids in its treatment. (1) The injection of local anaesthetic and corticosteroid should be considered as a potential trigger for brachial neuritis. (2) Brachial neuritis should be considered in the differential diagnosis for patients presenting with severe arm pain and weakness. (3) The nerves originating from the upper trunk of the brachial plexus are most commonly affected. (4) The anterior interosseous nerve is involved in one-third of cases.