Cognitive impairment during therapeutic total VPA concentration 6 149 Days after start VPA 139 140 144 145 146 152 154 158 165 176 197 215 248 Date month APR APR APR APR APR APR APR MAY MAY MAY JUNE JUNE JULY day 13 14 18 19 20 26 28 2 9 20 10 28 31 MEDICATION Lithium (Li) mg 0 0 0 0 0 0 0 0 0 0 0 300 600 Li Serum levels mmol/L 0.4 0.6 Valproic Acid (VPA) mg 0 0 0 0 0 0 0 0 0 0 0 0 0 VPA levels mg/L VPA Free concentration mg/L Citalopram mg 10 10 10 10 10 10 10 10 10 10 20 20 20 Olanzapine mg 5 5 5 5 5 5 5 5 5 5 5 5 5 Furosemide mg 160 80 0 0 0 0 0 0 0 0 0 0 0 Prednisone mg 20 20 20 20 20 20 20 20 20 20 0 0 0 Cyclophosphamide mg 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 LABORATORY BLOOD LEVELS Glomerular filtration rate (GFR) ml/min/1.73m2 >90 121 >90 81 Creatinine (creat) umol/l 45 45 45 67 Urea mmol/l 3.2 4.8 4.8 Albumin (Alb) g/L 17 37.2 Hemoglobin (Hb) mmol/L 6.1 6.7 6.6 7 9.4 Sodium (Na) mmol/L 146 142 138 Potassium (K) mmol/L 4.4 3.8 5.8 C-reactive protein (CRP) mg/L mm/h Total Protein g/L 0.9 1.03 0.26 Total Protein/Creatinine ratio g/mmolKr 0.29 0.36 0.15 Aspartate transaminase (AST) U/L 31 Alanine transaminase (ALT) U/L 25 Lactate dehydrogenase (LD) U/L Alkaline phosphatase (ALP) U/L 127 Gamma-glutamyltransferase (yGT) U/L 58 AFFECTIVE MOOD FUNCTIONING NIMH-LifeChart 3 3 3 2 2 2 2 0.5 0.5 0.5 0.5 COGNITIVE FUNCTIONING GDS 3 3 3 3 3 1 1 1 1 1 1 Delirium 1=still 2=active Life events Transfer to old age psychiatry ward Discharge old age psychiatry ward Suddenly reacting to visitors No cognitive complaints at intake interview Reintroduction lithium MMSE 27/30 MoCA 27/30
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