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Case #19

You are in your office and it's time to see your next patient. She is not on the schedule but called your office to be seen because she feels horrible. She is a 73 year old female with history of CHF, CAD, AFIB, HTN, CRI, DM and COPD. She wants to see you because she has felt extremely nautious all day and vomited once already. She said she just woke up feeling this way. She has no sick contacts, no history of vertigo and felt fine last night and even got to play poker with her friends. She has no abdominal pain or change in stool habits. She has not tried any new foods and has not done anything out of routine. The only thing she admits to is taking an extra lasix last night because she wanted to fit into her nice shoes. On review of systems she states that "My vision is a little more blurry than usual when I woke up".

She has no drug allergies, and is currently on Enalapril, Metoprolol, Lasix, Coumadin,Home O2 PRN, Albuterol Nebs, Glucophage, NPH Insulin, MVI, Digoxin, Aspirin and Colace. Her Vitals are BP 140/75, pulse 73, temp 97.0 and breathing at 18. Physical exam is with in normal limits except for +S3, irregular pulse, distant heart sounds, some crackles at the extreme bases bilaterally, and no other findings with the abdomen totally benign. You tell your nurse to come in and get an EKG and here it is below. Does it help you at all to figure out what is wrong with her?

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This is a great example of where the EKG really gives you the answer, even initially an EKG on a patient with nausea and vomiting may have thought to be of little value. There are two findings on the EKG which give us the reason why our patient feels like crap.

First, the underlying rhythm is Atrial Fibrillation, as there are no p-waves and a very irregular rhythm. The next important finding are the ST segments, especially in II, III, AVF and V6. These are the classic findings of a "sloped" ST from digoxin effect when levels of the drug are higher than normal. The final clue to nail our answer home are the prominent u waves in almost all the precordial leads (v2-v6). What may look like a notched T wave or a double humped T wave is actually a U wave which is classically seen in hypokalemia.

Now we have all the pieces of the puzzle. She is on Digoxin. She is also on Lasix and she stated that the night before she took an extra lasix to fit into her shoes. Well, lasix is a potassium wasting diuretic and to make matters worst, hypokalemia predisposes patients on Digoxin to digoxin toxicity regardless of what the Dig Level is. So in her case she took the extra lasix, managed to pee enough over night to drop her potassium and at the same time percipitate Digoxin toxicity which is why she has these symptoms.

She was sent to an ER and found to have a potassium of 2.9 and a Slightly elevated Digoxin level. She was admitted and on correction of her hypokalemia, all symptoms resolved.