Thread by @ojayfemi

Script Analysis ( A 🧵)

Disclaimer; i DON'T know this patient, doctor or pharmacist personally.
I have only analysed the script to bring out teachable medical tutes.
This thread speaks mainly to medics and its not a substitute for any patient management.
Every case is unique.

https://twitter.com/flexigenius/status/1205205581352591360

A poor handwriting kills ~7,000 patients worldwide annually. this is a good and legible handwriting with clear patient instructions on the script.
A cursory look at the script reveals a diagnosis of Atrial fibrillation, heart failure and hypercholesterolemia in this patient.

-The presence of a beta blocker, ARB (angiotensin receptor blocker), diuretics, a rythm control medication for AF and an anticoagulant makes that obvious.
- Treating HF without having done an ECHO at any stage is suboptimal treatment. Its necessary in disease classification.

- Beta blockers are very important in all forms of heart failure, its generally started when HF is stable and not in acute HF. Cardiac selective ones have mortality benefits aside the heart rate control.
- Theyre generally well tolerated, but care must be taken in asthmatics.

- Younger people generally complain of tiredness and occasionally erectile dysfunction.
- An ARB e.g Losartan is important in HF and hypertension, it has prognostic benefit especially when the E.F is less than 45%.(HFrEF)
- An added benefit in diabetics is the slowing of CKD.

- Care must be taken due to risk of hyperkalemia and regular UEC is needed in ongoing management.
- A sudden drop in renal function after starting an ARB should trigger a thought of renal artery stenosis. A renal ultrasound is key.
- ARB are generally avoided with ACEI combined.

- Aldactone a diuretic is important moreso in the management of HF with reduced EF. Always consider hyperkalemia and gynaecomastia in males. Its a good add on with furosemide for better diuresis.
- It also has a mortality benefit in HF not just symptom control.

- Furosemide (frusemide) a diuretic helps with volume control of fluid in HF, it can trigger hypokalemia, hence its combo with aldactone can help. However always consider risk of dehydration and kidney injury and especially when an ARB is on board.
-Best give morning and midday.

rather than night to help prevent excessive diuresis at night and poor sleep.
- It has no mortality benefit in HF and just helps with symptoms.
- Rash is a very common neglected side effect.
- Amiodarone is used in AF, for rhythm control, its good but problematic in long term.

- Its half life ~60 days hence prescription should take that in consideration. Combination with beta blockers worsens bradycardia.
- Its unique as a drug in that it can cause both hypo and hyper thyroidism, lung fibrosis and affect liver function test also.

- Atorvastatin and most statins are best taken at night as most peoples body make cholesterol at night hence its effect can be maximal.
- Muscle aches and pains especially in females remains a common side effect.

Xarelto (Rivaroxaban)an anticoagulant helps to prevent strokes in patients with A.F as it thins the blood sufficiently. However, the risk of severe bleeding post injuries are important to note. Its a substitute to warfarin, but useless against valvular AF.

If occult anemia develops whilst on this medication, always consider its from the GIT, ask about dark stools and investigate accordingly.
- It has no antiplatelet effect and bleeding risk increases when combined with aspirin.

- Im summary, this script contains a cocktail of needed medications to comprehensively manage stable HF and atrial fibrillation. An exam check of pulse rate, volume status and BP is important and care must be taken in this script to prevent hyperkalemia and kidney injury.

frequent renal function assessment, a continual check of blood count for evidence of anemia, liver and thyroid function test, daily weights of the patient for volume status and an annual ECHO will help this patient live longer and symptom free.

End.