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Part 1: A 44-year-old man with a history of bipolar affective disorder had his first medical contact for a manic episode 20 years ago, when he was hospitalized and treated with haloperidol in doses of 20-40 mg/day. After a second episode of mania, treatment with lithium carbonate was recommended. Pretreatment hematological, renal, hepatic, and thyroid function indices, as well as ECG, were normal. Showing no contraindications to lithium carbonate, beginning with 900 mg/day and increasing to 1500 mg/day, with the major portion of the daily dose administered in the evening.

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Monthly serum lithium levels were in the range of 0.6 to 0.8 mmol/L. The patient remained symptom-free on a maintenance dose of 1500 mg/day. Part 2: Two years later he was hospitalized for another manic episode during which he received haloperidol, and the lithium dosage was increased to 2100 mg/day. His mood stabilized over a 3-week period, haloperidol was slowly discontinued, and he was discharged on 2100 mg/day lithium carbonate. This was then slowly reduced to 1800 mg/day, plasma lithium levels stabilized at 0.8-1.0 mmol/L, and over the next 15 years on this maintenance therapy the patient experienced only two depressive episodes of moderate severity. Hematological, biochemical, thyroid and cardiac monitoring performed at 6-month intervals remained normal. In recent years, however, the patient reported increased urinary output and increased consumption of liquids (polydipsia). Part 3: About a year ago the patient’s serum lithium levels gradually rose to 1.0-1.1 mmol/L, and serum creatinine increased to 110 umol/L. The lithium carbonate dosage was decreased to 1500 mg/day, and then to 1200 mg/day, to maintain plasma lithium concentrations in the range of 0.8 to 1.0 mmol/L. At a routine visit 6 months later the patient’s blood pressure was 160/110 mmHg, serum creatinine was 160 umol/L, blood urea nitrogen (BUN) was 7.5 mmol/L, and microhematuria was noted on urinalysis. ECG indicated first degree heart block. Elevated IgA antibodies, elevated serum creatinine, and 24-hour urine output of 4.5 liters with reduced urine osmolarity allowed the diagnosis of IgA nephropathy and lithium-induced nephrogenic diabetes insipidus. Part 4: The lithium dosage was gradually reduced and stopped at the end of a 4-week interval. The hypertension was controlled with enalapril 20 mg/day. Because of the absence of recurrences of affective disorder for many years, the patient was allowed a drug-free period of observation. A week after lithium had been stopped, he experienced an abrupt shortening of his usual sleeping time increased activity, irritability, and expansive mood. He was brought to the hospital in a hypomanic state, which escalated rapidly into a full manic episode within 48 hours. Treatment was instituted with perphenazine 24-32 mg/day, and clonazepam 2.5 mg/day in three to four divided doses, followed by carbamazepine 400 mg/day in divided doses. After 1 week, serum carbamazepine levels were 20 umol/L, which rose to 24 umol/L over the next week and then declined to 17 umol/L. His mania resolved quickly.. Get  Nursing Assignments  Help Today

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