Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Lithium toxicity (suspected or confirmed)
History of Present Illness:
Briefly describe the reason for suspicion of lithium toxicity. This may include:
Recent change in lithium dose or medication adherence.
Symptoms suggestive of lithium toxicity (e.g., nausea, vomiting, diarrhea, tremor, ataxia, confusion, drowsiness, seizures).
Laboratory results indicating elevated lithium levels.
Inquire about the time of onset and progression of symptoms.
Past Medical History:
Include any relevant past medical history, such as:
Underlying medical conditions that may increase risk of lithium toxicity (e.g., renal dysfunction, dehydration, electrolyte imbalances).
Concomitant medications that can interact with lithium (e.g., diuretics, NSAIDs, ACE inhibitors).
Previous episodes of lithium toxicity (if applicable).
Medications:
List all current medications, including lithium dosage and route of administration.
Social History:
Briefly inquire about alcohol or illicit drug use, which can worsen lithium toxicity.
Family History:
Not typically relevant for lithium toxicity, but can be included if pertinent.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure.
Neurological exam: Assess mental status (orientation, alertness, coordination), presence of tremor, ataxia, nystagmus (involuntary eye movements).
Gastrointestinal exam: Assess for signs of dehydration (dry mucous membranes, poor skin turgor) and abdominal tenderness.
Other relevant exams: Depending on the severity of toxicity, may include cardiovascular exam (assess for heart rhythm abnormalities) and respiratory exam (assess for signs of respiratory depression).
Laboratory Tests:
Mention relevant laboratory findings, including:
Serum lithium level: The most crucial test to diagnose lithium toxicity.
Electrolytes (sodium, potassium, calcium, magnesium): Abnormalities can worsen or be a consequence of lithium toxicity.
Blood urea nitrogen (BUN) and creatinine: Assess kidney function, which can impact lithium clearance.
Urinalysis: May reveal signs of dehydration or kidney dysfunction.
Arterial blood gas (ABG):: May be necessary if respiratory depression is suspected.
Assessment:
Diagnosis: State the diagnosis of lithium toxicity (confirmed if serum lithium level is elevated and clinical presentation is consistent).
Severity: Briefly describe the perceived severity based on the serum lithium level, presenting symptoms, and potential for complications.
Plan:
Treatment:
Outline the treatment plan based on the severity of lithium toxicity, which may involve:
Gastrointestinal decontamination: May be considered if lithium ingestion was recent (e.g., activated charcoal).
Intravenous fluids: To address dehydration and promote lithium excretion.
Diuretics (with caution): To increase lithium excretion in the urine (used selectively based on electrolytes and kidney function).
Dialysis: May be necessary in severe cases with high lithium levels or life-threatening complications.
Medications to address specific symptoms (e.g., antiemetics for nausea/vomiting).
Electrolyte correction:
Address any abnormalities in electrolytes (potassium, magnesium) to prevent complications.
Cardiac and respiratory monitoring:
Close monitoring for potential complications like arrhythmias or respiratory depression.
Lithium level monitoring:
Frequent monitoring of serum lithium levels to assess response to treatment.
Follow-up:
Depending on the severity, the patient may require hospitalization for ongoing monitoring and treatment.
Schedule follow-up clinic visits to monitor lithium levels and adjust medication regimen as needed.
Consider referral to a mental health professional to address medication adherence and potential underlying mental health conditions.