Hi orris
Hey! How can I help you today?
Hi Dr Afzal Khan ( Pharm. D) here
Welcome, Dr. Afzal Khan! Great to have a clinical pharmacist on board.
How can I assist you today? Whether it's drug information, pharmacokinetics, clinical queries, patient cases, or anything else - I'm here to help.
Just here for ward round practice
Perfect! Ward round practice it is.
Would you like me to present you with a clinical case, or do you have a specific scenario, patient type, or therapeutic area in mind?
For example:
- Cardiology (ACS, heart failure, arrhythmias)
- Infectious disease (sepsis, pneumonia, UTI)
- Renal/electrolytes (AKI, CKD, fluid management)
- Endocrine (DKA, thyroid storm, hypoglycaemia)
- Neurology (stroke, seizures, meningitis)
Or just say "surprise me" and I'll throw a case at you!
Like I am here for a teaching round, through a case and teach me
Excellent! Let's begin the teaching round. I'll play the role of the ward pharmacist/consultant presenting the case. Engage with me as you would on a real ward round - ask questions, challenge, discuss management.
🏥 Ward Round - Bed 7, Medical Ward
Patient: Mr. Tariq, 64-year-old male
Admitted: 2 days ago
Presenting Complaint
Mr. Tariq presented to A&E with a 2-day history of worsening breathlessness, bilateral ankle swelling, and orthopnoea (sleeping on 3 pillows). His wife reports he has been "more confused than usual" over the past 24 hours.
Background History
- Ischemic heart disease (previous MI 4 years ago)
- Type 2 Diabetes Mellitus
- Hypertension
- CKD Stage 3a (baseline creatinine ~130 µmol/L)
Current Medications (on admission)
- Metformin 1g BD
- Amlodipine 5mg OD
- Ramipril 5mg OD
- Atorvastatin 40mg ON
- Aspirin 75mg OD
Observations on Admission
- BP: 158/94 mmHg
- HR: 102 bpm (irregular)
- SpO₂: 91% on air
- RR: 24/min
- Temp: 36.8°C
Over to you, Dr. Afzal...
What is your initial assessment, and what are your immediate pharmacological priorities for this patient?
Can I have a look of patient egfr and BNP
Good thinking - exactly what you'd want to check first! Here are the results:
📋 Investigations - Mr. Tariq, Bed 7
| Test | Result | Reference Range | Flag |
|---|---|---|---|
| eGFR | 38 mL/min/1.73m² | >60 | 🔴 LOW |
| BNP | 1,840 pg/mL | <100 pg/mL | 🔴 HIGH |
| Creatinine | 187 µmol/L | 60-110 | 🔴 HIGH |
| Urea | 11.2 mmol/L | 2.5-7.8 | 🔴 HIGH |
| Na⁺ | 134 mmol/L | 135-145 | 🟡 LOW |
| K⁺ | 5.1 mmol/L | 3.5-5.0 | 🟡 BORDERLINE HIGH |
| Glucose | 14.2 mmol/L | 4.0-7.8 | 🔴 HIGH |
| HbA1c | 9.1% | <6.5% | 🔴 HIGH |
| ECG | Atrial Fibrillation - no acute ST changes | - | 🔴 |
A few prompts to guide your thinking...
BNP of 1,840 - that's significantly elevated. What does this tell you, and how does it influence your management plan?
eGFR has dropped from baseline 130 to 187 µmol/L creatinine - creatinine has worsened from his baseline of ~130. What are the implications for his current medication list?
He's in AF - this is new finding. Does this change anything for you pharmacologically?
Over to you Dr. Afzal - what are your medication review priorities right now? 🎯
¹ BNP indicates Acute decompensated Heart Failure 2- Metformin dose should be adjusted, Ramipril should be avoided 3- AFib leads to introduction of Warfarin
Great clinical thinking! Let me give you feedback point by point, and gently challenge a few things:
✅ Point 1 - BNP & Acute Decompensated Heart Failure
Correct! BNP >400 pg/mL strongly supports ADHF diagnosis. At 1,840 pg/mL, this is severe decompensation.
Teaching point: BNP is released by ventricular myocytes in response to wall stretch/pressure overload. It helps differentiate cardiac vs respiratory cause of dyspnoea.
- BNP <100 = HF unlikely
- BNP 100-400 = grey zone
- BNP >400 = HF very likely
What diuretic would you start, at what dose, and by what route given his current status?
⚠️ Point 2 - Metformin & Ramipril
Metformin:
Partially correct - but I'd push you further. With eGFR of 38, what does guidance actually say?
- eGFR >45 = continue at full dose
- eGFR 30-45 = reduce dose + review regularly
- eGFR <30 = STOP (lactic acidosis risk)
His eGFR is 38, so dose reduction is appropriate - but also consider holding it temporarily given his acute illness and risk of further AKI.
Ramipril - this needs a challenge! ⚡
You said avoid - but think carefully. ACE inhibitors are actually cornerstone therapy in Heart Failure with reduced EF (HFrEF). The question is timing.
- In acute decompensation with AKI + hyperkalaemia risk → hold temporarily
- Once stabilised, fluid-overload resolved, renal function improving → restart and potentially up-titrate
Don't discard Ramipril permanently - it reduces mortality in HF + post-MI patients. The goal is to reintroduce it, not abandon it.
⚠️ Point 3 - AF and Anticoagulation
Good instinct - AF does require anticoagulation. But Warfarin in 2026? Let me challenge you here:
Current guidelines (ESC/NICE) prefer DOACs over Warfarin for non-valvular AF:
| Drug | Consideration in this patient |
|---|---|
| Apixaban | ✅ Preferred - safest in CKD, least renal clearance (~27%) |
| Rivaroxaban | 🟡 Use with caution in CKD |
| Dabigatran | 🔴 Avoid - 80% renal clearance, eGFR 38 is risky |
| Warfarin | 🟡 Still used in valvular AF or eGFR <15, but NOT first choice here |
Also - before starting anticoagulation, what score would you calculate, and what is his score?
🎯 Summary of Immediate Medication Actions:
| Drug | Action | Reason |
|---|---|---|
| Metformin | Hold/reduce | AKI + acute illness |
| Ramipril | Hold temporarily | AKI, hyperkalaemia risk |
| Amlodipine | Review - can worsen peripheral oedema | |
| Add IV Furosemide | For acute decongestion | ADHF |
| Add Apixaban | AF anticoagulation | After CHA₂DS₂-VASc scoring |
Over to you Dr. Afzal:
- What is his CHA₂DS₂-VASc score based on the information we have?
- What IV diuretic dose would you start him on?
Calculate CHA2DS2-VASc score for AFib stroke risk
Let's calculate it from Mr. Tariq's known history:
CHA₂DS₂-VASc Score - Mr. Tariq
| Letter | Risk Factor | Points | Mr. Tariq | Score |
|---|---|---|---|---|
| C | Congestive Heart Failure | 1 | ✅ Yes (ADHF confirmed) | 1 |
| H | Hypertension | 1 | ✅ Yes (known + BP 158/94) | 1 |
| A₂ | Age ≥ 75 years | 2 | ❌ He is 64 | 0 |
| D | Diabetes Mellitus | 1 | ✅ Yes (T2DM) | 1 |
| S₂ | Prior Stroke/TIA | 2 | ❓ Not mentioned | 0 |
| V | Vascular Disease (MI, PVD) | 1 | ✅ Yes (previous MI) | 1 |
| A | Age 65-74 years | 1 | ✅ He is 64... almost! | 0 |
| Sc | Sex Category (Female) | 1 | ❌ Male | 0 |
🔢 Total Score: 4 / 9
What Does Score 4 Mean?
| Score | Annual Stroke Risk | Recommendation |
|---|---|---|
| 0 (male) | ~0% | No anticoagulation needed |
| 1 (male) | ~1.3% | Consider anticoagulation |
| 2+ | ≥2.2% | Anticoagulation recommended |
| 4 | ~4% | Anticoagulation strongly indicated |
✅ Decision: Anticoagulate Mr. Tariq
With a score of 4, anticoagulation is clearly indicated.
Drug Choice - Apixaban is preferred here:
| Apixaban | Rivaroxaban | Dabigatran | Warfarin | |
|---|---|---|---|---|
| Renal clearance | ~27% | ~33% | ~80% | Minimal |
| eGFR 38 safe? | ✅ Yes | 🟡 Caution | 🔴 Avoid | 🟡 Option |
| Dosing in this patient | 5mg BD (check dose reduction criteria) | - | - | - |
⚠️ Apixaban Dose Reduction Rule (ISTH criteria):
Reduce to 2.5mg BD if 2 of 3 criteria met:
- Age ≥ 80
- Weight ≤ 60 kg
- Creatinine ≥ 133 µmol/L
Mr. Tariq: creatinine is 187 µmol/L ✅ - that's 1 out of 3 criteria met. So he gets the standard dose: Apixaban 5mg BD.
🎯 Teaching Point
Always calculate CHA₂DS₂-VASc before choosing the anticoagulant, and always check renal function before dosing the DOAC. These two steps together prevent both under-treatment (stroke) and over-treatment (bleeding).
Also consider: Should you check a HAS-BLED score to assess bleeding risk before starting?
Next question for you Dr. Afzal:
His AF - is this rate control or rhythm control territory, and what would you use given his current haemodynamic status and HF? 🎯
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