QuestionSBA
QuestionChoice
This patient's U&Es are normal. U&Es may become deranged in cases of digoxin toxicity (and as a consequence of ACE inhibitor therapy). In this case, there are no signs of digoxin toxicity and digoxin levels are below the therapeutic range. There is no indication to repeat the U&Es at this point.
50205
e
Repeat Urea and Electrolytes
QuestionChoice
This patient's digoxin level is below the therapeutic range. Poor adherence to treatment could explain why this is the case. This patient is also tachycardic, suggesting that digoxin that their atrial fibrillation is poorly controlled. Checking adherence to digoxin would be the most appropriate next step before increasing the dose.
50201
a
Check adherence
QuestionChoice
This patient's digoxin level is below the therapeutic range, they are therefore unlikely to be experiencing digoxin toxicity. An ECG may be helpful if toxicity is suspected to check for severe cardiac effects such as; sinoatrial and atrioventricular block,
premature ventricular contractions (resulting in bigeminy or trigeminy) and PR prolongation and ST-segment depression.
50204
d
ECG
QuestionChoice
This patient's digoxin level is below the therapeutic range, decreasing the patient's dose of digoxin would therefore be inappropriate.
50202
b
Decrease the digoxin dose
QuestionChoice
This patient's digoxin level is below the therapeutic range, stopping digoxin in this patient would not be effective in controlling their atrial fibrillation.
50203
c
Stop digoxin
Concept
Chapter
Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.

**Symptoms and Signs**

- Generally asymptomatic until a fragility fracture occurs
- Back pain
- Kyphosis (stooped posture)
- Fragility fractures

**Risk factors**

- Female sex
- Increasing age
- Smoking
- Corticosteroid use
- Low BMI (< 20-25kg/m<sup>2</sup>)
- Low body weight (<58kg)
- Vitamin D deficiency

**Protective factors**

- Higher BMI
- Exercise - mechanical loading stimulates bone formation

**Diagnosis**
Osteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.
A T score of < -2.5 indicates osteoporosis

**Management**

- Fall prevention
- Vitamin D and calcium supplementation
- Hormone replacement therapy (postmenopausal women)
- Oral bisphosphonates
2657
3618
Digoxin Levels
Topic
9
Internal Medicine
10088
Case Presentation: A 73-year-old gentleman takes Digoxin for atrial fibrillation. He attends the GP for a medication review. He is feeling well. His regular medicines are listed below. 




 **PMH**


 * Atrial fibrillation
 * Previous MI
 * Peripheral vascular disease


 **DH**


 * Digoxin 250 micrograms OD
 * Ramipril 10mg OD
 * Amlodipine 5mg OD
 * Aspirin 75mg OD


 **On Examination**


 * HR 108 bpm
 * Blood pressure 126/84 mm/Hg


 **Investigations**


 * Digoxin level: 0.3nanograms/mL (Therapeutic range: 0.7-2nanograms/mL)


Blood tests:



||||
|---------------------------|:-------:|--------------------|
|Sodium|140 mmol/L|135 - 145|
|Potassium|4.2 mmol/L|3.5 - 5.3|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|90 µmol/L|60 - 120|



Question: Given the results of the above investigations, what is the most appropriate next step?
a