Cognitive impairment during therapeutic total VPA concentration 6 145 Days after start VPA 1 15 18 21 25 32 39 42 47 49 54 Date month OCT OCT OCT OCT NOV DEC DEC DEC DEC DEC JAN JAN JAN JAN JAN day 1 14 17 26 27 11 14 17 21 28 4 7 12 14 19 MEDICATION Lithium (Li) mg 1200 1200 0 0 0 0 0 0 0 0 0 0 0 0 0 Li Serum levels mmol/L 0.8 3.1 Valproic Acid (VPA) mg 0 0 0 0 300 600 600 1200 1200 1200 1200 2500 2500 2500 2500 VPA Serum levels mg/L 21 29 13 27 30 VPA Free concentration mg/L Citalopram mg 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 Olanzapine mg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Furosemide mg 0 0 0 0 0 0 0 40 40 40 40 40 40 40 40 Prednisone mg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Cyclophosphamide mg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Lisinopril mg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 LABORATORY BLOOD LEVELS Glomerular filtration rate (GFR) ml/min/1.73m2 63 74 53 40 Creatinine (creat) umol/l 83 73 92 124 124 Urea mmol/l 5.4 4.4 Albumin (Alb) g/L 24 26.2 23 24.7 24.7 Hemoglobin (Hb) mmol/L 8.7 6.5 6.8 6.3 Sodium (Na) mmol/L 141 147 144 142 Potassium (K) mmol/L 4.3 4.1 3.9 C-reactive protein (CRP) mg/L mm/h 12 26 Total Protein g/L 11.8 5.81 Total Protein/Creatinine ratio g/mmolKr 1.19 1.49 Aspartate transaminase (AST) U/L 19 Alanine transaminase (ALT) U/L 13 Lactate dehydrogenase (LD) U/L 192 Alkaline phosphatase (ALP) U/L 129 Gamma-glutamyltransferase (yGT) U/L 17 AFFECTIVE MOOD FUNCTIONING NIMH-LifeChart 0 0 0 0 3 3 3 3 3 3 3 3 3 3 3 COGNITIVE FUNCTIONING GDS 1 5 4 1 1 1 1 1 1 1 1 1 1 1 1 Delirium 1=still 2=active Life events Admition to an internal ward Mental health emergency service VPA 13mg/l, but after 23h by mistake patient Nephrology Stop lithium Start R./ VPA Albmicro 2643mg/L urine MoCA 24/30 Stop citalopram Creat 3.1mmol/L urine Proteinuria Suspected nephrotic syndrom e.c.i. Ratio alb/creat 849 mg/ mmol
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