PHSC 2433 Fall 2020
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KR presents to an Urgent Care Clinic on 8/10/2018 with increasing lethargy and confusion. An intravenous
line is placed for administration of fluids and blood samples are obtained to assess electrolyte status,
complete blood counts, blood glucose, and total phenytoin levels. Patient reports having taken his morning
and afternoon meds today and regularly takes his medications: Dilantin 100mg capsule TID; atorvastatin 20
mg QD; sertraline 100mg QHS. Neuro exam reveals ataxia and nystagmus.
Lab Results:
Albumin: 4.3 g/dL
Phenytoin: Total Pending
Previous Clinic Notes:
1/27/18 Discharged from hospital with generalized seizures controlled on oral Dilantin.
Weight: 72 kg; Height: 5 ft, 10 in
Labs: Scr 1.0 mg/dL; Albumin 4.5 g/dL
Liver Function Tests (LFTs) normal
Labs: Total phenytoin trough level 16.3 mg/L (Dose 300 mg/day)
Allergies: None
Medications: 100 mg TID Extended Release Phenytoin Sodium Capsules
20 mg QD atorvastatin
6/27/18 Primary Care Visit: Regular follow‐up visit. Complaining of some difficulty sleeping with
some increasing signs and symptoms of depression that have been ongoing the past 6
months. Initiated low dose of sertraline with follow‐up in 3 weeks.
Weight: 74 kg; Height: 5 ft, 10 in
Labs: Total phenytoin trough level 15.8 mg/L (Dose 300 mg/day)
Allergies: None
Medications: 100 mg TID Extended Release Phenytoin Sodium Capsules
20 mg QD atorvastatin
50 mg QHS sertraline
7/23/18 Primary Care Visit: Still some sleeping difficulty and ongoing symptoms of depression with
some response to sertraline. Sertraline dose increased and scheduled for follow‐up in 4
weeks for reassessment.
Weight: 74 kg; Height: 5 ft, 10 in
Medications: 100 mg TID Extended Release Phenytoin Sodium Capsules
20 mg QD atorvastatin
100 mg QHS sertraline
PHSC 2433 Fall 2020
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