Squiggler

Two days of vomiting, poor appetite and confusion

The case

79-year-old man. Two days of vomiting, poor appetite and confusion

Permanent atrial fibrillation on digoxin 125 micrograms daily, bisoprolol and apixaban. Chronic kidney disease with a baseline creatinine of 110 umol/L. Started clarithromycin five days ago for a chest infection. Lives in a care home.

On arrival

HR
46
SpO₂ (%)
95
Respiratory rate
16
Temperature (°C)
36.7
Systolic BP (mmHg)
108
Diastolic BP (mmHg)
64

Stage 1 of 2

Idris Chaudhry was sent in by the care home because he had stopped eating and had been sick again overnight. He is drowsy but orientated to place, says the light looks wrong to him, and has vomited twice since arriving. The carer who came with him has brought the medicines box. This tracing was recorded in majors.

Tracing 1 of 2 for the quiz “Two days of vomiting, poor appetite and confusion”.
Twelve-lead in majors, 25 mm/s, 10 mm/mV. Open this tracing in the studio
What is the rhythm?
What do the ST segments show?
What do you do?

Stage 2 of 2

The digoxin level taken on arrival was 3.9 micrograms/L, against a therapeutic range of 0.8 to 2.0. Potassium was 5.6 mmol/L and creatinine 178 umol/L. Digoxin, bisoprolol and clarithromycin were stopped, he was rehydrated, and the potassium settled to 4.4 mmol/L without specific treatment. This tracing was recorded on day three.

Tracing 2 of 2 for the quiz “Two days of vomiting, poor appetite and confusion”.
Twelve-lead on day three, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR
78
SpO₂ (%)
97
Respiratory rate
15
Temperature (°C)
36.6
Systolic BP (mmHg)
124
Diastolic BP (mmHg)
72

Bloods

Magnesium (mmol/L)
0.82
Potassium (mmol/L)
4.4
Creatinine (umol/L)
178
Digoxin (micrograms/L)
3.9
What has changed on the second tracing?

Diagnosis

Digoxin toxicity causing regularised atrial fibrillation

This tracing was generated, not recorded. It carries no patient data and no textbook copyright, and it opens in the studio with every dial live — move the rate, the axis, the ST segment and the conduction and watch the reading change.

Open the studio

Discussion

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