Chapter 6 148 Days after start VPA 116 117 118 119 121 124 125 126 127 129 130 131 132 133 134 Date month MAR MAR MAR MAR MAR MAR MAR MAR APR APR APR APR APR APR APR day 21 22 23 24 26 29 30 31 1 3 4 5 6 7 8 MEDICATION Lithium (Li) mg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Li Serum levels mmol/L Valproic Acid (VPA) mg 4000 4000 3000 3000 3000 3000 3000 3000 0 0 0 0 0 0 0 VPA levels mg/L 24 VPA Free concentration mg/L 15.82 Citalopram mg 0 0 0 0 0 0 0 0 0 0 10 10 10 10 10 Olanzapine mg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,5 Furosemide mg 80 80 40 40 40 40 40 40 0 0 0 0 0 0 0 Prednisone mg 30 30 30 30 30 30 30 30 30 60 60 60 60 60 20 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 >90 61 53 >90 >90 >90 Creatinine (creat) umol/l 51 85 96 58 46 42 Urea mmol/l 7.3 12.2 17.8 11.2 8.2 6.5 Albumin (Alb) g/L 16.6 14 18.6 17.1 18.6 20 Hemoglobin (Hb) mmol/L 5.2 4.4 5.2 4.6 4.3 3.9 Sodium (Na) mmol/L 139 139 149 148 154 Potassium (K) mmol/L 3.2 3.4 3.8 2.8 3.7 C-reactive protein (CRP) mg/L mm/h 28 82 86 52 12 15 Total Protein g/L 0.59 0.39 Total Protein/Creatinine ratio g/mmolKr 0.09 0.08 Aspartate transaminase (AST) U/L Alanine transaminase (ALT) U/L Lactate dehydrogenase (LD) U/L Alkaline phosphatase (ALP) U/L Gamma-glutamyltransferase (yGT) U/L AFFECTIVE MOOD FUNCTIONING NIMHLifeChart 3 3 3 3 4 4 4 4 4 4 4 4 3 3 3 COGNITIVE FUNCTIONING GDS 5 5 5 5 6 6 6 6 6 6 6 5 4 4 4 Delirium 1=still 2=active 1 1 1 1 2 2 2 Life events Redetermination of free VPA 68/37.8 mg/l Sudden shift from hypoactive delirium to hyperactive delirium. Rhinoplasty under light anaesthesia Stop VPA Free VPA 15.8mg/l (pseudo-) epileptic seizure VPA dose reduction Patient could not eat or drink by herself. She did not want to continue living, spending most of her time in fetal position. Visit by author: patient severely deteriorated Transfer to internal ward Administration of Packed cells
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