Cognitive impairment during therapeutic total VPA concentration 6 147 Days after start VPA 91 92 93 95 96 97 98 99 100 102 104 109 110 111 113 Date month FEB FEB FEB FEB MAR MAR MAR MAR MAR MAR MAR MAR MAR MAR MAR day 25 26 27 29 1 2 3 4 5 7 9 14 15 16 18 MEDICATION Lithium (Li) mg 400 400 400 400 800 800 800 0 0 0 0 0 0 0 0 Li Serum levels mmol/L 0.4 1.3 1.2 0.8 Valproic Acid (VPA) mg 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 4000 VPA levels mg/L 75 68 VPA Free concentration mg/L 37.5 retrospectively Citalopram mg 0 0 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 120 120 80 80 120 160 160 160 160 160 80 80 80 80 80 Prednisone mg 60 60 60 60 60 60 60 60 60 60 60 60 30 30 30 Cyclophosphamide mg 100 100 100 100 100 100 100 0 0 0 0 0 0 0 0 Lisinopril mg 20 20 20 20 20 20 20 0 0 0 0 0 0 0 0 LABORATORY BLOOD LEVELS Glomerular filtration rate (GFR) ml/min/1.73m2 57 53 54 46 74 76 >90 >90 Creatinine (creat) umol/l 90 96 95 110 73 71 58 57 Urea mmol/l 13.3 16.7 9.6 10.1 7.9 9 Albumin (Alb) g/L 24.9 26.2 21.4 22.6 22.3 21.9 19.4 16.9 Hemoglobin (Hb) mmol/L 5.6 4.1 7.3 7 5.8 5.6 Sodium (Na) mmol/L 148 147 146 146 146 144 142 142 Potassium (K) mmol/L 4.2 4 3.6 3.6 4.5 4.6 4.9 5 C-reactive protein (CRP) mg/L mm/h 12 18 67 16 Total Protein g/L 2.92 1.34 Total Protein/Creatinine ratio g/mmolKr 0.73 0.54 Aspartate transaminase (AST) U/L 53 Alanine transaminase (ALT) U/L 59 Lactate dehydrogenase (LD) U/L 357 Alkaline phosphatase (ALP) U/L 72 Gamma-glutamyltransferase (yGT) U/L 34 AFFECTIVE MOOD FUNCTIONING NIMH-LifeChart 3 2 2 3 2 2 2 2 2 2 2 2 2 3 3 COGNITIVE FUNCTIONING GDS 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 Delirium 1=still 2=active 1 1 1 1 Life events R./ lithium to 800mg Deterioration clinical presentation MoCA 15/30 Hypotension Fall resulting in fracture of her nose Administration of Packed cells MMSE 20/30 Trasfer to internal ward
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