Somali Medical Forums
Medical Student Forums => Problem-Based Learning Center => Topic started by: Qooryare on December 09, 2011, 11:19:54 PM
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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.
Medications:
Metoprolol, digoxin, ASA (aspirin), lisinopril, furosemide (Lasix), Coumadin (warfarin), esomeprazole (Nexium).
Physical examination:
In pain, combative and confused.
VSS.
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?
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Dx is digitalis toxicity due to Warfarin inhibtion of CYP450 resulting decreased metabolism of Digoxin.
What to do is to decrease dose of digitalis.
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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.
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most likely diagnosis: digoxin toxicity.
what would you do:
- stop digoxin.
- monitor digoxin level .
- control symptoms.
- sitter in the room ( bed rest).
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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)
Plan;
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.