A 76-year-old man developed recurrent encephalopathy, visual disturbance, myoclonus, generalised seizures and atonic drop attacks on a background of a gastrectomy for adenocarcinoma and stable chronic lymphocytic leukaemia. He presented to three different hospitals and was admitted twice, with normal investigations. His symptoms transiently improved during each admission (and with starting levetiracetam) but recurred each time on hospital discharge. Subsequent careful inspection of his medication box identified that his community pharmacy had in error been dispensing baclofen 80 mg per day instead of his prescribed Buscopan 80 mg per day. This case highlights the importance of physically inspecting a patient’s medications and emphasises the spectrum of baclofen-related toxicity; it also highlights potential deficiencies in the pharmacy dispensary process and the need for multiple checks by patients and professionals.

中文翻译：

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看不见：药物错误的教训

一名 76 岁男性在因腺癌和稳定的慢性淋巴细胞白血病接受胃切除术的背景下出现复发性脑病、视力障碍、肌阵挛、全身性癫痫发作和张力性下降。他去了三个不同的医院，两次入院，检查正常。他的症状在每次入院期间（以及开始服用左乙拉西坦）都会暂时改善，但每次出院时都会复发。随后仔细检查了他的药盒，发现他的社区药房错误地每天配发巴氯芬 80 毫克，而不是他开出的每天 80 毫克的 Buscopan。该案例强调了对患者药物进行身体检查的重要性，并强调了巴氯芬相关毒性的范围；