Prescription for no44

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Now I have enough information to write a complete prescription for case No. 44.

Prescription for Case No. 44

Patient: 70-year-old male Diagnosis: Flatulent Dyspepsia

Presenting complaints: Retro-sternal burning pain at night for 6 months, associated with bloating (gabharaman), nausea, and flatulence.

Rx

Date: 14/07/2026

S.No	Drug	Dose	Route	Frequency	Duration
1	Tab. Omeprazole (PPI)	20 mg	Oral	Once daily, before breakfast	4-6 weeks
2	Tab. Domperidone (Prokinetic)	10 mg	Oral	Three times daily, 30 min before meals	4 weeks
3	Tab. Simethicone (Antiflatulent)	40-125 mg	Oral	Four times daily after meals	2-4 weeks
4	Syr. Antacid (Aluminium hydroxide + Magnesium hydroxide)	10 mL	Oral	Three times daily, 1 hour after meals & at bedtime	2-4 weeks

Rationale

Omeprazole (PPI) - The night-time retro-sternal burning strongly suggests acid reflux/GERD component. A PPI suppresses gastric acid secretion and relieves burning.
Domperidone (Prokinetic) - Improves gastric motility and emptying, reduces bloating and nausea. It also helps with the sensation of fullness (gabharaman). It also acts as an antiemetic.
Simethicone (Antiflatulent) - An inert surfactant that collapses gas bubbles in the GI tract, directly addresses flatulence. Standard adult dose is 40-125 mg four times daily after meals (Goodman & Gilman's, p. Flatulence section).
Antacid suspension - Provides immediate symptomatic relief of burning and acid-related discomfort.

Non-pharmacological Advice

Eat small, frequent meals; avoid large meals especially at night
Avoid gas-forming foods (beans, cabbage, carbonated drinks, fried/spicy food)
Do not lie down immediately after meals; elevate head end of bed
Avoid alcohol, smoking, and NSAIDs
Maintain healthy weight
Walk for 20-30 minutes after meals

Follow-Up

Review after 2 weeks. If symptoms persist despite PPI therapy, consider upper GI endoscopy to rule out peptic ulcer disease or H. pylori infection.

Sources: Goodman & Gilman's The Pharmacological Basis of Therapeutics (Flatulence/Simethicone section); Sleisenger and Fordtran's Gastrointestinal and Liver Disease (Functional Dyspepsia)

Renal stone prescription

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Prescription for severe abdominal colic pain with renal stone, vomiting since 2 hrs

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Case no 44 proper prescription

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I now have excellent textbook content. Here is the complete, proper prescription for Case No. 44.

Prescription - Case No. 44

Patient: Female, 20 years Diagnosis: Renal Stone (Ureteric Colic) Presenting complaints: Severe spasmodic pain in left flank radiating to back, vomiting since 2 hours, burning pain during micturition

EMERGENCY / ACUTE PHASE (First 24-48 hours)

1. IV Fluids

Inj. Normal Saline (0.9% NaCl) / Ringer's Lactate
500 mL IV, over 1 hour - to ensure adequate hydration and promote stone passage

2. Analgesic (NSAID - First line for renal colic)

Inj. Diclofenac Sodium 75 mg in 100 mL Normal Saline
IV slowly over 30 minutes - STAT
(NSAIDs are first-line pain medications for renal colic - Brenner & Rector's The Kidney)

3. Antispasmodic

Inj. Hyoscine Butylbromide (Buscopan) 20 mg
IV / IM - STAT
Relieves smooth muscle spasm of ureter

4. Antiemetic (for vomiting)

Inj. Ondansetron 4 mg IV slow push - STAT
OR Inj. Metoclopramide 10 mg IV/IM
To control acute vomiting

5. If pain not controlled - Opioid rescue

Inj. Tramadol 50 mg in 100 mL NS
IV slow infusion over 20-30 minutes
(Opioids are second-line after NSAIDs for renal colic)

DISCHARGE / ORAL PHASE (After stabilization)

6. Oral NSAID

Tab. Diclofenac 50 mg + Tab. Paracetamol 500 mg (combination)
Oral, twice daily after food - for 5 days

7. Antispasmodic oral

Tab. Hyoscine Butylbromide (Buscopan) 10 mg
Oral, three times daily - for 5 days

8. Medical Expulsive Therapy (MET) - to facilitate stone passage

Tab. Tamsulosin 0.4 mg
Oral, once daily at night - for 4-6 weeks
(Alpha-1 blockers decrease ureteral smooth muscle tone, increase stone clearance and shorten expulsion time - supported by Cochrane review of 67 studies, 10,509 participants - Brenner & Rector's The Kidney)

9. Antibiotic (if UTI/dysuria present)

Tab. Norfloxacin 400 mg + Tab. Metronidazole 400 mg
Oral, twice daily - for 5-7 days
(Burning micturition indicates possible concurrent UTI)

10. Alkalinizer (if uric acid stone suspected)

Syr. Potassium Citrate / Sodium Bicarbonate
Oral, as directed - alkalinizes urine, helps dissolve uric acid stones

Non-Pharmacological Instructions

Advice	Details
Hydration	Drink 3-4 litres of water per day to flush the stone
Stone collection	Strain all urine through a filter - collect passed stone for analysis
Diet	Avoid spinach, tomatoes, nuts, chocolates (oxalate-rich foods)
Avoid	Excess salt, protein, vitamin C supplements
Activity	Mild walking helps stone passage
Monitoring	Watch for fever (sign of infection - emergency)

Investigations to order

Urine routine & microscopy (hematuria, pyuria, crystals)
USG KUB (kidney-ureter-bladder) - first-line imaging
Non-contrast CT KUB if USG inconclusive
Serum creatinine, urea (renal function)
Serum calcium, uric acid
24-hour urine after stone passage (calcium, oxalate, citrate, uric acid)

When to Hospitalize

Admit if:

Persistent pain not controlled by oral/IM medications
Intractable vomiting
Fever with obstruction (infected stone - urological emergency)
Stone >6 mm (low chance of spontaneous passage)
Single kidney or bilateral obstruction

Sources: Brenner and Rector's The Kidney, 2-Volume Set - "Management of Renal Colic" & "Medical Expulsive Therapy"; Campbell Walsh Wein Urology - "Medical Expulsion Therapy"; ROSEN's Emergency Medicine - Nephrolithiasis

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