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Elliot is a 74 year-old male who presents to your clinic with complaints of frequent nosebleeds (4 in the past week) and several severe bruises scattered variously throughout his anatomy. The patient is also complaining of a runny nose, cough, and head/chest congestion. He has a history of chronic atrial fibrillation and is currently prescribed and taking warfarin. Approximately 3 weeks previously, he started taking over-the-counter cimetidine for heartburn he was experiencing. Below is a list of the patient's medications, his physical examination, and his laboratory findings:
Medications
Digoxin 0.25 mg QD
Cimetidine OTC BID
Pseudoephedrine SR 120 BID
Warfarin 7 mg QD
Allergies: NKDA
Physical Examination
VS: BP: 180/95, HR 75, irregularly irregular, RR 17
Weight: 95 kg
HEENT: WNL
ABD: + Bowel Sounds
EXT: Bruising on arms and legs
NEURO: Alert & Oriented x 3
GEN: Well developed, well-nourished male
ECG: atrial fibrillation
Laboratory
Na 143 mEq/L
K 4.5 mEq/L
Cl 99 mmol/L
CO2 25 mEq/L
BUN 18 mg/dL
SCr 0.9 mg/dL
INR 4.8
Hct 42%
Hbg 15 mg/dL
Digoxin 3.8 ng/ml
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