taking the wrong medication of digoxin tablets

introduction: although cardiac glycosides toxicity is common in patients taking these kinds of drugs, poisoning occurs rarely in healthy individuals. this case report describes a one-month duration of mistaken consumption of digoxin tablets in a patient that referred to the hospital with gastrointestinal poisoning manifestations. case presentation: the case was a 75-year-old female with a history of hypertension, hyperthyroidism, and digestive problems with common symptoms of gastrointestinal toxicity, nausea, and vomiting; mild digoxin toxicity was found rather than a simple gastrointestinal poisoning based on further investigations. conclusions: careful examination and ekg evaluation are essential to exclude drug toxicity in all patients referring to the hospital with gastrointestinal symptoms.