Next Action Items

Dr. Hani Louis (Mar 5, 2026): Taper carbamazepine (Tegretol) over 4 months. Current dose: 200mg TID (600mg/day). WAIT for Prof. Hassan Hosny second opinion before starting taper. Monitor: seizure frequency, ANC (should improve as CBZ reduces), quetiapine levels (will rise as CYP3A4 de-induces).

Confirm with Dr. Ahmed Farahat (oncologist) whether a CBCT Arch scan is safe given Shadia's cancer history. The dentist needs this scan to evaluate infections under broken teeth and plan implants, but CBCT involves extra radiation.

DONE: B12, folate, homocysteine, zinc, CK, ammonia, 25(OH)D vitamin D. STILL NEEDED: serum PLP (vitamin B6 level), free & total carnitine, serum copper, IGF-1. Coordinate remaining into a single lab draw.

Prof. Hosny (07 Mar 2026): Do NOT increase Depakine. Instead TAPER: 250mg evening for 3 weeks then STOP. Starting 17 Mar 2026.

BP dropped to 95/55 during standing physio on 21 Feb 2026 — not the first time. Likely caused by Baclofen + residual Quetiapine + postprandial hypotension + autonomic dysfunction. Discussion points: • Consider reducing morning Baclofen dose (5mg AM instead of 10mg) • Quetiapine levels will rise 5-10x as CBZ tapers — will worsen BP drops • Schedule physio BEFORE breakfast or 2+ hours after eating • Should we add standing BP checks as part of physio protocol? • Consider compression stockings during physio • Review fluid intake (currently 3L/day — should be 1.5-2L for SIADH)

Once oncologist approves, schedule CBCT Arch scan at the dental clinic. This will reveal any hidden infections under the broken/missing back teeth and guide the implant plan.

Research whether dental implants are safe and recommended for patients with TBI history, seizure medications (Tegretol/Depakine), neutropenia (low ANC), and post-mastectomy cancer history. Check drug interactions with anesthesia.

Schedule a bone density / bone X-ray. Important for evaluating bone health before dental implants and general monitoring given long-term immobility and medication effects.

Increase total protein by ~5g/week over 3-4 weeks (current ~30g → target 80-95g). Distribute evenly: 25-30g per meal, never >40g per sitting. Check ammonia at each step (fasting + postprandial). Start L-carnitine concurrently to support urea cycle. After VPA fully tapered, ammonia constraint disappears.

Introduce ONE new supplement every 1-2 weeks to identify adverse effects (patient cannot reliably self-report due to severe dysarthria and memory impairment). Priority order: 1) L-Carnitine (most urgent), 2) Vitamin D3 + K2 + Calcium, 3) Folate + B12, 4) Lactoferrin dose increase, 5) Magnesium, 6) Omega-3, 7) NAC, 8) CoQ10.

Creatine supplementation raises serum creatinine ~0.1-0.3 mg/dL (from baseline 0.57 to ~0.7-0.9) reflecting increased production NOT renal impairment. All future renal function monitoring must use cystatin C-based eGFR. Document creatine supplementation prominently in the medication list.

CRITICAL FINDING: Copper deficiency is an established cause of reversible neutropenia. ANC 0.8 (Feb 28) may have copper deficiency component alongside carbamazepine effects. If copper is low, correcting it may partially resolve neutropenia. Check serum copper and zinc BEFORE any zinc supplementation. Zinc already checked Jun 2025 (43 µg/dL — low). COORDINATE with remaining baseline labs.

Strongly recommended given: wheelchair dependence (prolonged immobility), AED-induced vitamin D depletion, sarcopenic obesity, cancer survivorship. Essential before starting calcium/D3/K2 supplementation to establish baseline. Already in pending tests.

NEVER checked since starting Keppra. Current dose 500mg BID. May be sub- or supra-therapeutic. Ask Prof. Hosny if dose adjustment needed. Already in pending tests list.

14 Apr 2026: • Baclofen: Reduce to 2.5mg AM + 10mg PM Monitor spasticity levels. If significant increase, discuss with Prof. Hosny.

28 Apr 2026: • STOP Baclofen completely All tapers complete. Remaining medications: Tegretol (CBZ), Keppra, Escitalopram, Crestor. Follow-up with Prof. Hosny to review.