Part Three:
He returns a month later complaining of increased fatigue, visual disturbances, weakness, and nausea; however, his ECG is normal.
Based on this information, what is occurring in this patient? Include precise mechanism(s) of how it is occurring?
Additionally, please include any drug interactions associated with any new medications initiated keeping in mind the current regimen.
History:
74 y/o obese male who presents with frequent nosebleeds (4 in the past week), several severe hematomas scattered variously throughout his anatomy, rhinorrhea, cough, and head/chest congestion. Pt added OTC cimetidine 3 wks. ago without consulting this office for dyspepsia. HTN at visit (180/95). PMH significant for chronic atrial fibrillation (treated with Warfarin). Laboratory testing reveals serum Na WNL (136-145 mEq/L), K WNL (3.5 -5.5 mEq/L), Cl WNL (98-106 mmol/L), CO2 WNL (22-26 mEq/L), BUN WNL (adult - 5-20 mg/dL, elderly 8-21 mg/dL), SCr WNL (0.4 - 1.5 mg/dL), INR ? 4.8 (normal levels while in anticoagulant therapy: 2 - 3.5), Hct WNL (males - 40%-54%),Hgb WNL (males - 14-18 g/dL), Digoxin ? 3.8 (negative therapeutic level 0.5-2 ng/mL, panic level (adult) >2.4 ng/mL). Medications: digoxin 0.25 mg QD, cimetidine OTC BID, pseudoephedrine SR 120 BID and warfarin 7 mg QD.
Plan: Hold Warfarin 7 mg QD x 1 day, hold digoxin 0.25 mg QD x 1 day, d/c cimetidine OTC replaced with ranitidine 150 mg QHS, d/c pseudoephedrine SR 120 BID replaced with guaifenesin 200 to 400 mg orally every 4 hours as needed.
The patient returns for his monthly follow-up appointment, and it is noticed that his blood pressure (195/80) has not come under control. You decide to start him on chlorthalidone recommend 25 mg PO QD initially, may increase to 50 mg daily if response is insufficient, (max dose - 100 mg daily). Follow up x 1 month.
Could the above symptoms (increased fatigue, visual disturbances, weakness, and nausea; however, his ECG is normal) be present if the patient is not taking digoxin