Mr. S is a 31-year-old, single, unemployed gentleman from a low socioeconomic Tamil-speaking background, who first came to psychiatric hospital in 2003 at the age of 17 years within 10 days of onset of symptoms of psychosis and mania. He was treated with tablet risperidone up to 4 mg/day. He responded well and even went back to school. After 9 months of regular treatment, he stopped medicines. Two months after stopping of medicines he had relapse of psychotic symptoms including Schniderian first rank symptoms without any mood symptoms. His diagnosis was revised to paranoid schizophrenia. He failed trials of tablet risperidone 8 mg/day, tablet olanzepine 25 mg/day, a course of 10 sittings of electroconvulsive therapy, and injection fluphenazine decanoate depot 100 mg intramuscular every month. He did not show significant improvement. He was started on tablet clozapine and the dose was gradually built up to 450 mg/day by 2007. He was on regular follow-up for 9 years during which he had fluctuations in psychiatric symptoms but was managing well without any physical health issues.\nIn 2016, he developed pain in the left lumbar region following trivial trauma (while using a crowbar) and later developed a swelling in the region for which incision and drainage were done at a primary health center. When the ulcer did not heal for about 3 months, he was referred to a surgical department of a teaching hospital for further management. The non-healing ulcer in the incision site of left lumbar gradually had increased in size and was associated with passage of air through the ulcer while defecating or straining. There was no history of abdominal distension, vomiting, obstipation, hematemeis, malena, or fever. Physical examination revealed a soft non-tender abdomen.\nRoentgenogram of abdomen and ultrasonography investigations revealed a foreign body in the abdominal cavity just below the diaphragm without any other features of obstruction or perforation. Contrast-enhanced computer tomography and magnetic resonance imaging revealed a linear foreign body forming a fistula communicating with splenic flexure of the colon [].\nThe patient was posted for elective exploratory laparotomy. On laparotomy, an intact ball point pen of size about 11 cm in length was found to be the foreign body with its tip inside the lumen of splenic flexure and its rear end facing the external ulcer []. The pen was carefully delivered through the external wound and the sealed perforation of size 1 × 1 cm was closed primarily []. Postoperative period was uneventful and the patient was discharged on the 11th postoperative day.\nThe patient recollected that he had swallowed the very same pen in 2004 when he had been very psychotic []. He reported that he had vague abdomen pain on and off, which he did not feel serious enough to report. There was no record of abdomen pain in the patient's case notes over the previous 13 years.\nHe is doing physically well and is on regular follow-up. He is not regularly employed but helps his family in household chores. He is currently on clozapine 450 mg/day, on which he has a serum level was 933 ng/mL.
A 50-year-old male presented at the General Surgery Polyclinic due to increased complaints of swelling and intermittent pain in the neck which had been ongoing for 6 years. On the neck ultrasound imaging, heterogeneous nodules were observed in the parenchyma of 27 × 19 mm in the right lobe and 20 × 16 mm in the left lobe and central anechoic cystic nodules 40 × 18 mm at the isthmus level extending towards the lumen. Thyroid function tests were normal and the patient was diagnosed with multinodular goitre. The patient had no comorbid disease and after premedication was admitted to the operating room for elective surgery. Monitorization was applied on the operating table: TA: 130/85 mmHg, pulse: 75 bpm, SpO2: 99%. Sedation was administered by 2 mg midazolam, then anaesthesia induction was made with 2-3 mg/kg propofol, 100 mcg fentanyl, and 0.6 mg/kg rocuronium. After mask ventilation for 3-5 mins, the patient was intubated with no problems. No hemodynamic or respiratory problems were experienced in the intraoperative period. The surgery lasted 1 hr and 45 mins, after which the patient was awakened with no problems and was transferred to the postoperative anaesthesia care unit (PACU). When the patient was fully awake, he was experiencing chest pain and complained that dentures were not in place in his mouth, so a posterior-anterior pulmonary radiograph was taken and a standing direct abdominal radiograph. The dentures were observed in the stomach (). In the history taken from the patient, it was seen that when going to the operating room, partial fixed dentures were in place, and he stated they were in his mouth until reaching the operating room. The emergency gastroenterologist was consulted, and the patient was evaluated but as he had already eaten food, endoscopy procedures were postponed until the following day. In the upper gastrointestinal endoscopy applied the following day, despite having passed the ligament of Treitz, the dentures could not be visualized. On the standing direct abdominal radiograph, the dentures were seen to be in the jejunum (). The abdominal examination was comfortable for the patient, so it was decided to continue medical follow-up. A standing direct abdominal radiograph was taken daily (), and on the radiograph taken on the 5th day, the dentures could not be seen (). The patient was questioned. The dentures had been expelled during bowel evacuation, but the patient did not recall anything other than a slight pain during evacuation.