Hi orris, this is Dr AFZAL KHAN (Pharm.D)
Welcome, Dr. Afzal Khan! It's great to have a Pharm.D on board. How can I assist you today? Whether it's pharmacology, clinical queries, drug interactions, patient care, or anything else - I'm here to help.
Just teaching ward round stimulation
That sounds like a great educational exercise! I can run a teaching ward round simulation with you.
Here are a few ways we can do this:
1. I present a case, you manage it
- I give you a patient presentation (history, vitals, labs)
- You work through the diagnosis and management
- I guide, question, and teach along the way (Socratic style)
2. You present a case, I play the learner
- You run the round as the consultant/clinical pharmacist
- I ask questions as a junior doctor/student
- Good for practicing your teaching style
3. Mixed - rapid-fire cases
- Quick clinical vignettes focused on pharmacotherapy
- Ideal for drug dosing, interactions, monitoring, counseling
Your preferences?
Asking for Preferences
How would you like to run the simulation? · Any preferred clinical area or specialty?
Perfect! I'll play the role of a junior doctor/pharmacist student on ward round. You're the consultant clinical pharmacist leading the teaching session.
Setting: Morning ward round, general medical ward.
I'll start us off in character:
[Student, clipboard in hand, slightly nervous]
"Good morning, Dr. Khan. Ready when you are. Should we start with the first patient? I've got the list here - Bed 4 looks like a new admission from last night that the night team flagged for a medication review."
What would you like to do, Dr. Khan? You can present the case, give me a patient to review, or quiz me on anything you'd like to teach today.
Let's start
[Walks to Bed 4, opens the chart nervously]
"Dr. Khan, this is Mr. Tariq, a 58-year-old male admitted last night through A&E.
-
Presenting complaint: Sudden onset breathlessness and bilateral leg swelling for 3 days
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PMH: Hypertension (10 years), Type 2 Diabetes (7 years), CKD Stage 3
-
Regular medications at home:
- Metformin 1000mg BD
- Amlodipine 5mg OD
- Lisinopril 5mg OD
- Aspirin 75mg OD
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On examination: Bibasal crackles, pitting oedema to the knees, JVP raised, HR 105 bpm, BP 158/96 mmHg, SpO₂ 91% on room air, RR 22/min
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Bloods: Na 138, K 5.1, Creatinine 198 µmol/L (baseline ~160), eGFR 32, BNP 1240 pg/mL, Blood glucose 14.2 mmol/L
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ECG: Sinus tachycardia, no acute ST changes"
[Looks up at you expectantly]
"Dr. Khan... the night doctor started him on IV furosemide 40mg and continued all his home medications. Is there anything on his drug chart we should be concerned about?"
Okay, I can't allow metformin that too a dose of 1000 my in such patients with egfr 32 , Amlodipine can cause peripheral edema, lisnopril can inc sr potassium
[Writing rapidly, nodding]
"Okay, okay - that makes sense now that you explain it. Let me make sure I understand each point..."
On Metformin:
"So Dr. Khan, why exactly is Metformin dangerous in CKD? I know we stop it but... is it the glucose control that fails, or something else?"
[Pen hovering, waiting for your explanation]
On Amlodipine:
"That's interesting - so the leg swelling we're seeing... it could partly be the Amlodipine and not just the heart failure? How do we tell the difference clinically? And should we stop it completely or switch to something else given he's also hypertensive?"
On Lisinopril:
"His potassium is already 5.1 and he's on Lisinopril... and now he's getting IV furosemide which can drop potassium. So are they kind of... balancing each other out? Or is that dangerous thinking?"
[Looks slightly unsure]
"And one more thing Dr. Khan - his creatinine has gone from 160 to 198. Could the Lisinopril be making his kidneys worse too? Should we hold it?"
[Flips page on clipboard]
"Also - you haven't mentioned the Aspirin yet. Is that okay to continue?"
Metformin dose depends on egfr in this case patients is having a egfr of 32 , in such case metformin will not be appropriate, instead stat insulin detemir 10 unit iv Do you think creatinine is elevated due to lisnopril, I even I am confused about aspirin I think it's for DVT prophylaxis
[Scribbling notes, then pauses and looks up with a curious but respectful expression]
On Metformin - understood!
"Got it - so the cutoff is eGFR-based. Just to confirm my understanding:
- eGFR ≥45 → Metformin okay
- eGFR 30-45 → reduced dose, use with caution
- eGFR <30 → contraindicated - risk of lactic acidosis
So at eGFR 32, we're right at that danger zone. Makes sense to stop it."
On Insulin Detemir - a small query...
[Hesitantly raises hand]
"Dr. Khan, I want to respectfully flag something - Insulin Detemir is a long-acting basal insulin. Giving it IV isn't the standard route - it's only licensed for subcutaneous use. For acute glucose management, wouldn't we use Actrapid (soluble insulin) IV or a variable rate insulin infusion?
His glucose is 14.2 - not critically high, so maybe SC Detemir is what you intended?"
[Looks at you carefully - not challenging, just clarifying]
On the Creatinine / Lisinopril question:
"Hmm... so his creatinine went from 160 to 198. Could it be the Lisinopril? Or..."
[Thinking out loud]
"Actually - he's in acute decompensated heart failure with poor cardiac output. Could this be cardiorenal syndrome rather than Lisinopril-induced AKI? The reduced renal perfusion from the heart failure itself could explain the creatinine rise. Though Lisinopril does reduce efferent arteriolar tone and can worsen GFR acutely..."
"Should we hold Lisinopril for now and reassess after diuresis?"
On Aspirin for DVT prophylaxis:
[Gently]
"Dr. Khan - I think there may be a small mix-up here. Aspirin is not recommended for DVT prophylaxis in medical inpatients.
- Aspirin is an antiplatelet - it works on arterial clots
- DVT prophylaxis requires anticoagulation - typically LMWH (e.g. Enoxaparin)
- In fact, given his CKD (eGFR 32), the enoxaparin dose would need renal adjustment
His Aspirin 75mg is most likely a long-term cardiovascular medication - possibly for a prior CV event or primary prevention. Do you know his cardiac history, Dr. Khan?"
[Looks up from clipboard with genuine curiosity]
"So Dr. Khan - overall plan so far: Stop Metformin, start SC Detemir, hold or review Lisinopril, review Amlodipine, clarify the Aspirin indication, and start LMWH for DVT prophylaxis - with a renally adjusted dose. Does that sound right to you?"
Yeah , I mean detemir sc only I mentioned IV by mistake,
[Nods and corrects notes immediately]
"Of course, Dr. Khan - SC it is, noted and corrected on the chart."
[Looks back at the medication review summary so far]
"So just to consolidate what we've decided for Mr. Tariq:
| Drug | Decision | Reason |
|---|---|---|
| Metformin 1000mg BD | ❌ STOP | eGFR 32 - risk of lactic acidosis |
| Insulin Detemir 10u SC | ✅ START | Replace Metformin for glucose control |
| Amlodipine 5mg OD | ⚠️ Review | Contributing to peripheral oedema |
| Lisinopril 5mg OD | ⚠️ Hold | AKI on CKD, K+ already 5.1 |
| Aspirin 75mg OD | ⚠️ Clarify indication | Not for DVT - likely CV history |
| LMWH | ✅ START | DVT prophylaxis - renally adjusted dose |
| IV Furosemide 40mg | ✅ Continue | Acute decompensated heart failure |
[Pauses thoughtfully]
"Dr. Khan, I have a few follow-up questions if you don't mind..."
1. For Insulin Detemir 10 units SC - his glucose is 14.2. Should we also prescribe a short-acting correction dose alongside? Or monitor first and reassess?
2. For the Amlodipine - since he still needs BP control and his BP is 158/96 - are we switching it, or just holding it while we diurese him and see if the oedema improves?
3. His SpO₂ is 91% - are we doing anything beyond the furosemide for that? Positioning, oxygen therapy?"
[Looks at you attentively, pen ready]
Yeah we can start rapid acting insulin inj llispro 1st we have to recess weather edema is due to Amlodipine or chf Ventilation is needed stat Oxygen 2-4L/min
[Writing quickly, nodding]
"Understood, Dr. Khan - Insulin Lispro for corrections, reassess oedema cause after diuresis, and oxygen started now."
[A small flag goes up - raises hand politely]
"Dr. Khan - just one clinical point on the oxygen..."
"His SpO₂ is 91% and he's in acute heart failure - so yes, oxygen is needed. But the current guidelines (BTS/ESC) actually recommend targeting SpO₂ 94-98% in non-COPD patients. At 2-4 L/min via nasal cannula that should be achievable."
"However - he also has CKD and likely longstanding hypertension - we don't have a confirmed COPD history. If there's any suspicion of CO₂ retention or COPD, we'd want to be more cautious and target 88-92% instead."
[Pauses]
"Do we have an ABG on him yet? That would tell us:
- Whether he's retaining CO₂
- Acid-base status - especially important given his AKI and metformin history
- Confirm if the hypoxia is purely cardiac in origin"
[Updates the summary sheet]
Revised Plan so far:
| Issue | Action |
|---|---|
| Hyperglycaemia | Detemir 10u SC OD + Lispro correction doses |
| Hypoxia | O₂ 2-4 L/min, target SpO₂ 94-98%, get ABG |
| Acute heart failure | Continue IV Furosemide, fluid balance monitoring |
| AKI on CKD | Hold Lisinopril, monitor U&E daily |
| Oedema | Reassess after diuresis before deciding on Amlodipine |
| DVT prophylaxis | Start renally-adjusted LMWH |
[Looks up]
"Dr. Khan - should we also think about whether this patient needs a cardiology review? BNP of 1240 is significantly elevated. And has an echo been ordered to assess his cardiac function?"
Let's start with new case
[Flips to next page on clipboard, walks to the next bed]
"Dr. Khan, next patient - Bed 7."
Patient: Mrs. Nadia, 45-year-old female
Admitted: This morning via GP referral
Presenting Complaint: Severe headache, blurred vision, and nausea for the past 24 hours
PMH:
- Hypertension (diagnosed 8 years ago, poorly controlled)
- Asthma (on inhaled salbutamol PRN)
- Depression (on medication)
Current Medications:
- Atenolol 50mg OD
- Hydrochlorothiazide 25mg OD
- Fluoxetine 20mg OD
- Salbutamol inhaler PRN
Observations:
- BP: 210/130 mmHg (confirmed on repeat)
- HR: 88 bpm
- SpO₂: 97% on room air
- Temp: 37.1°C
- RR: 16/min
Bloods:
- Creatinine: 145 µmol/L (baseline unknown)
- K⁺: 3.2 mmol/L
- Na⁺: 141 mmol/L
- Blood glucose: 5.8 mmol/L
Urine dipstick: 2+ protein
Fundoscopy: Papilloedema present
[Looks up at you with wide eyes]
"Dr. Khan... BP of 210/130 with papilloedema and headache. This looks serious. Where do we even begin with her medications?"
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