Medical Student Forums > Problem-Based Learning Center

Case (80)


A 96-year-old female was admitted from a nursing home with complaints of abdominal pain, nausea and vomiting (N/V), dizziness, confusion and double vision for 5 days. She was discharged from the hospital just 4 days ago. Digoxin was started during that previous hospitalization for control of tachycardia in atrial fibrillation. One day prior to discharge, digoxin level was 1.8 mg/mL and digoxin dose was decreased to 125 mcg PO Q 48 hr.

Past medical history (PMH):
Hypertension, atrial fibrillation, coronary artery disease, stroke, congestive heart failure.

Metoprolol, digoxin, ASA (aspirin), lisinopril, furosemide (Lasix), Coumadin (warfarin), esomeprazole (Nexium).

Physical examination:
In pain, combative and confused.
Chest: Occasional bibasilar crackles.
Cardiovascular System: Clear S1 and S2, irregularly irregular rhythm, HR 101 bpm.
Abdomen: Soft, epigastric tenderness, no rebound, + BS.
Extremities: No edema.

What is the most likely diagnosis?
What would you do?

Dx is digitalis toxicity due to Warfarin inhibtion of CYP450 resulting decreased metabolism of Digoxin.
What to do is to decrease dose of digitalis.

I would add to the first answer that this pt is 92y/o and most likely has decreased kidney function, which results retaining more digitalis in the system. consider dehydration.
The second answer: as there was a decrease of the dose laready, I think that decreasing dose much more would work but if toxcicity continues then need digitallis toxicity Tx: stop digitalis, correct the K+ level, give Mg2+, and if need be use anti-dig Fab fagments. Still, I think that decreasing much more would solve the problem.

most likely diagnosis: digoxin toxicity.

what would you do:
   - stop digoxin.
   - monitor digoxin level .
   - control symptoms.
   - sitter in the room ( bed rest).

Dr. Acromion:

Diagnosis ; Digoxin Toxicity

Typically, digoxin levels are considered therapeutic for heart rate control between 1.0 and 2.0 ng/mL. The patient in question had a history of plasma digoxin level of 1.8mg/ml, that's almost 1000 times more than the normal level (there are 1000 nanograms in 1 milligram)

1. Stop degoxin
2. An ECG is done to check for irregular heart beats.
3. Blood tests will be done to check:

      -BUN and creatinine (which help reveal kidney function)
      -Digoxin level should be monitored.
      -Potassium level (if decreased which is very likely , potassium supplement must be prescribed)
      -Magnesium level.


[0] Message Index

Go to full version