Discussion Part One (graded)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:MedicationsDigoxin 0.25 mg QD Cimetidine OTC BIDPseudoephedrine SR 120 BID Warfarin 7 mg QDAllergies: NKDAPhysical ExaminationVS: BP: 180/95, HR 75, irregularly irregular, RR 17Weight: 95 kg HEENT: WNLABD: + Bowel Sounds EXT: Bruising on arms and legsNEURO: Alert & Oriented x 3 GEN: Well developed, well-nourished maleECG: atrial fibrillationLaboratoryNa 143 mEq/L K 4.5 mEq/LCl 99 mmol/L CO2 25 mEq/LBUN 18 mg/dL SCr 0.9 mg/dLINR 4.8 Hct 42%Hbg 15 mg/dL Digoxin 3.8 ng/ml• What problems should be identified in this patient?• What are the precise mechanisms of action of each drug?• What do you think is contributing to the patient’s hypertension?• Are there any drug interactions that you can identify as associated with this current drug regimen, and if so how, mechanistically, are they occurring?• What is the clinical significance of these interactions?(textbook we are using)Edmunds, M. W. & Mayhew, M. S. (2013). Pharmacology for the primary care provider (4th ed.). Retrieved from http://bookshelf.vitalsource.comAny other sources cannot be older than 5 years.

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