Patient: 72-year-old male, referred by GP to anticoagulation clinic.
PC: Unusual bruising and gum bleeding × 3 days.
PMHx: Atrial fibrillation (warfarin 5mg/day, INR usually 2.4), Type 2 diabetes, hypertension.
DHx: Metformin 500mg BD · Amlodipine 5mg OD · Warfarin 5mg OD · Fluconazole 150mg OD × 7 days (started 6 days ago by GP for oral candidiasis).
Social: Retired teacher. No alcohol. Good compliance.

Examination: Extensive ecchymoses bilateral forearms. HR 88 bpm irregular. BP 134/82 mmHg. Gingival oozing noted.

Investigations: INR 7.4 (target 2–3) · Hb 11.2 g/dL · Renal function normal · LFTs normal.

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