A 63 year old man was brought to the hospital by his daughter as he was confused since morning. Peeing a lot and seems tired. Daughter is anxious, when you asked, he is diagnosed with bipolar mood disorder for which he has been taking lithium for months. He doesn’t have other co morbidity, like DM, HITN, Thyroid problem. Retired and Lives with daughter, daughter takes care for him. No smoking or drinking habit. No history of dementia, fever, infection, stroke, trauma or fall
Task:
Talk to the daughter, assess him and do management
Concern: What happened to my father?
Take history
Access the confusion state
Since when?
what do you mean by confused ?
Exclude dementia by asking: has he been forgetful recently?
Does he struggle to find words ?
Getting lost in familiar places ?
DDs for confusion :
UTI: ask about urinary symptoms: going yo the loo more often ? Any pain passing urine ? Any fever ?
Diabetes: Drinking more than usual lately ?
Stroke: Any weakness anywhere in his body ?
Head injury : Any recent falls ?
MMA: when lithium is mentioned ask about
Why prescribed ?
Since when ?
Taking as prescribed ?
Going Follow up appointments?
Dose change recently ?
Other side effects of lithium toxicity: Nausea & vomiting? Heart racing ?
Tremors ?
Any other medications? (to exclude interaction)
psychosocial of father and daughter:
does he live alone ?
Any one caring for him other than yourself?
Is he independent with daily activities?
Who else do you care for ?
Do you find it difficult to care for him?
Any help we can offer ?
Do ICE
Examination: Take observation, head to toe, Neurological examination, MMSE
Management:
Explain that you suspect that his confusion is due to lithium toxicity , that’s when the lithium level in the blood increases over the recommended dose ( mention cause if said by daughter, if not then say we need to do further investigations to see why this happened
History taking
Access the confusion state , what do you mean by confused ? Exclude dementia by asking : has he been forgetful recently? Does he struggle to find words ? Getting lost in familiar places ?
DDs for confusion :
UTI : ask about urinary symptoms : going yo the loo more often ? Any pain passing urine ? Any fever ?
Diabetes : Drinking
more than usual lately ?
Stroke : Any weakness anywhere in his body ?
Head injury :
Any recent falls ?
Then move the MMA , when lithium is mentioned ask about
Why prescribed ? Since when ? Taking as prescribed ? Going Follow up appointments? Dose change recently ? Other side effects of lithium toxicity : Nausea& vomiting? Heart racing ? Tremors ?
Any other medications ? ( to exclude interaction )
Then move to psychosocial of father and daughter , does he live alone ? Any one caring for him other than yourself ? Is he independent with daily activities? Who else do you care for ? Do you find it difficult to care for him? Any help we can offer ?
3)Diagnosis :
Explain that you suspect that his confusion is due to lithium toxicity , that’s when the lithium level in the blood increases over the recommended dose ……( mention cause if said by daughter , if not then say we need to do further investigations to see why this happened )
Manegment:
Hospital admission
IV fluids
Recheck lithium level every 6-12 hours
Might need heamodialysis if level is too high
Refer to psychiatrist for bipolar reassement and dose adjustment.
Advice about continuous monitor / follow up appointments
Advice not to take OTC NSAIDs and to maintain hydration by fluid intake
Advice not to stop lithium suddenly and always seek medical advice first .
Ask if carer is needed .
Safety net about deterioration , neurological manifestations ( other signs of toxicity)
You are the FY2 in A/E
Jacob Prize, aged 78 years has presented with tremors and problems with coordination.
His daughter Mary Prize has come to speak to you regarding her father’s condition.
Talk to her and address her concerns.
NB: Consent has been taken from her father
PATIENT INFORMATION
Your father has been having tremors, problems with coordination and drowsiness which started 2 days ago. He also has trouble buttoning his shirt since this started.
In the past 24 hours, he has not been able to pass urine.
He was diagnosed of bipolar affective disorder a few months ago and he was placed on lithium by the psychiatrist.
He presently lives alone as your mother passed on three weeks ago due to cancer.
He has a healthy lifestyle.
You have no idea why your dad is having all these symptoms.
CONCERNS
What is wrong with him?
What are you going to do for him?
APPROACH
How may I help?
FODIPARA of tremors
Associated symptoms
DDs
Parkinson’s disease (TRAP)
Hyperthyroidism- does your dad complain of heat when others feel normal?
Dementia - any hx of forgetfulness?
Stroke- any weakness in any part of his body? Any slurred speech?
Delirium- rule out chest infection and UTI
Just rule out 3 to 4 differentials and move
PMAFTOSA
Once you get hx of BAD, then do some more clerking
when was it diagnosed?
when was it prescribed?
who prescribed it?
has he been taking it as prescribed?
when last was his lithium levels checked? What was the result?
Rule out side effects: any vomiting? Any fits ? Etc
Diagnosis
Lithium toxicity
From our discussion, I suspect the cause of your dad’s symptoms may be due to the side effects of the lithium he’s taking for BAD
Management
Since patient is in A/E, admit.
If patient is in GP, then refer to the hospital for admission.
Investigate
-Serum and urine levels of lithium
U,E,Cr , TFT, LFT, FBC
ECG
Consider brain CT scan
STOP lithium immediately
Psychiatrist to review the patient’s medications
IVFs
Monitor urine output and vitals
consider haemodialysis
Discharge home if symptoms resolve and serum levels are normal
-Arrange follow up