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Explain it
analyse_media
Reading File
This is a hospital prescription from Hopewell Hospital, Sonkatch, M.P., India. Here is a full breakdown:
Patient Details
| Field | Value |
|---|---|
| Name | Vishnu Prajapat |
| Age | 28 years |
| Sex | Male (M) |
| Date | 16-07-26 (July 16, 2026) |
| BP | 90/60 mmHg (low - hypotension) |
| Pulse | 99/min (slightly elevated) |
| Weight/vitals | ~96 F (temperature noted) |
Doctor: Dr. B. Dabhawer Sulale (or similar)
Presenting Complaints (History)
- Pain and swelling over the scapula (shoulder blade region), persisting for approximately 14 years
- Aching pain that worsens at night
- Needling type of sensation
- No history of surgery or trauma
MRI Findings (Left Side)
- MRL (MRI Left) - Shoulder region involving the scapula
- Finding noted as: "shoulder region at scapula"
Physical Exam Notes
- Obesity noted (circled, marked as present)
- Left shoulder/scapula area - Graded/coded finding to mid/lateral scapula
- Accidents not present / No previous surgery (CA - no surgery/trauma history)
- ASU (Ayurvedic/alternate system note, possibly)
Diagnosis
RA factor - 1 in 21 (RA = Rheumatoid Arthritis factor positive, titer noted as 1:21)
This suggests a possible Rheumatoid Arthritis or connective tissue disorder presentation with shoulder/scapular involvement.
Prescription (Rx)
Given for 3 days:
-
Inj. Methylprednisolone - 40 mg in 100 mL Normal Saline (NS), given slowly (IV infusion) - this is a corticosteroid injection used for inflammation/autoimmune conditions.
-
Tab./Syrup (oral medication) - likely an analgesic or anti-inflammatory (written as "every, pantop 40g & Stab" - probably:
- Pantoprazole 40 mg (gastric protection alongside steroids)
- Another tablet (possibly a NSAID or muscle relaxant)
Summary
This is a 28-year-old male with a 14-year history of shoulder/scapular pain (aching, worse at night, with needling sensation), found to be RA factor positive (1:21). MRI of the left shoulder shows scapular involvement. He was prescribed a 3-day course of IV Methylprednisolone (anti-inflammatory steroid) along with a gastric protector (Pantoprazole), suggesting an acute flare management approach.
Note: The handwriting is partially illegible in some areas, so some readings above are best interpretations. For exact medication details, always confirm directly with the treating doctor or pharmacist.
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This is also along with
analyse_media
This is a follow-up OPD prescription for the same patient (Vishnu Prajapat), written the very next day after the hospital admission note. Here is the full breakdown:
Visit Details
| Field | Value |
|---|---|
| Visit Type | OPD - Revisit |
| Date | 17/07/26 (July 17, 2026 - next day follow-up) |
| BP | 100/60 mmHg (slightly improved from 90/60 the day before) |
| SpO2 | 97% (oxygen saturation - normal) |
| Pulse | 84 bpm (improved, was 99 bpm yesterday) |
| Temperature | 97°F (normal) |
Clinical Note
"Soft Cervical Collar" - prescribed/recommended, indicating possible cervical spine involvement alongside the shoulder/scapular complaint.
Prescription (Rx) - for 5 Days
1. Tab. Defcort 6 mg - tapering dose schedule:
This is Deflazacort, an oral corticosteroid (steroid). The dose is written as a taper:
- 1-1-1 (3 times/day) → for a few days
- Then 1-0-1 (twice/day)
- Then 0-1-0 or 1-0 (once/day)
This is a classic steroid taper to reduce inflammation while minimizing side effects.
2. Tab. Zenoodel TH-BD - 10 AM & 10 PM
This is likely Thiocolchicoside + Diclofenac (or similar muscle relaxant + NSAID combination), taken twice daily (BD = Bis Die = twice a day) at 10 AM and 10 PM.
3. Tab. Pauden (Pantoprazole/PAN-D) - Once Daily (OD) in the morning
A proton pump inhibitor (PPI) - given to protect the stomach lining from the steroids and NSAIDs.
All 3 medications above are prescribed for ×5 days.
Additional Injections - for 2 Weeks
4. Inj. Neurokind Gold - 1 ampoule IV/IM, twice daily × 2 weeks
Neurokind Gold is a Mecobalamin + Alpha Lipoic Acid + Pyridoxine + Thiamine injection - used for neuropathic pain and nerve repair. This targets the "needling/numbness" type sensation the patient reported.
Long-Course Medications - for 15 Days
5. Tab. Gabapentin 300 mg - once at night (HS)
A neuropathic pain agent used for nerve-related pain, tingling/needling sensations, and chronic pain syndromes.
6. Tab. SLDS (likely Sulfasalazine or similar DMARD) - Once a week (Sundays)
Written as "once a week (Sundays)" - possibly a Disease Modifying Anti-Rheumatic Drug (DMARD) given the RA factor positive result, OR could be Methotrexate weekly (a common RA treatment given once weekly on the same day each week). The "SLDS" abbreviation likely refers to a specific brand.
Final Note at Bottom
"DFO Adv. MA - TRR" - likely a referral note or advice to "DFO" (possibly another department/specialist), with "MA" = Medical Advice and "TRR" = likely an abbreviation for a further referral or review.
Putting Both Prescriptions Together - Clinical Picture
| Day | Action |
|---|---|
| Day 1 (16/07) | IV Methylprednisolone 40 mg in 100 mL NS (hospital/acute anti-inflammatory) + Pantoprazole |
| Day 2 (17/07) | Switched to oral Deflazacort taper + NSAID/muscle relaxant + Pantoprazole (stomach protection) + Neurokind Gold injections + Gabapentin (nerve pain) + weekly DMARD |
Working diagnosis: RA factor positive, chronic shoulder/scapular pain with neuropathic features - likely Rheumatoid Arthritis or an autoimmune connective tissue disorder with cervical spine/nerve involvement (hence the cervical collar and nerve-targeted medications).
Disclaimer: This interpretation is for informational purposes only. Always follow the treating doctor's instructions and confirm any medication details with your pharmacist or physician.
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