Prescription for Right-Sided Abdominal Pain with 6mm Right Renal Calculus + LUTS

PATIENT ASSESSMENT SUMMARY

1. Right renal calculus (6 mm, USG confirmed) with renal/ureteric colic
2. Lower urinary tract symptoms (LUTS) - burning micturition (dysuria) + increased urinary frequency - likely concurrent cystitis / urinary tract irritation secondary to calculus

INVESTIGATIONS BEFORE PRESCRIBING

℞ PRESCRIPTION

Dr. [Name], MBBS / MD
[Clinic Name & Address]
Date: 14-July-2026                     Reg. No.: ______

Patient: ________________   Age/Sex: __/M or F
Wt: ___ kg                 Allergies: NKDA

Diagnosis: Right renal calculus (6mm, USG), Renal colic, LUTS (dysuria + frequency)

💊 GROUP 1 - ANALGESICS (Pain Relief for Renal Colic)

• Dose: 1 tablet twice daily (after food)
• Duration: 5-7 days
• Instructions: Take with a full glass of water. Do NOT take on empty stomach.
• Caution: Check serum creatinine before use. Avoid if eGFR < 30 mL/min.

NSAIDs are the first-line analgesic for renal colic, with evidence showing superiority over opioids for pain control with fewer side effects. (Brenner and Rector's The Kidney)

• Dose: 1 capsule every 8-12 hours as needed (SOS) for severe pain
• Duration: Max 3-5 days
• Instructions: Do not drive/operate machinery. Do not exceed 200 mg/day.

💊 GROUP 2 - ANTISPASMODIC (Ureteral Smooth Muscle Relaxation)

• Dose: 1 tablet three times daily
• Duration: 5-7 days
• Instructions: May be combined with the analgesic. Reduces ureteral spasm-related colicky pain.

💊 GROUP 3 - ALPHA BLOCKER / MEDICAL EXPULSIVE THERAPY (MET) - MOST IMPORTANT

• Dose: 1 capsule once daily at bedtime (after food)
• Duration: 4-6 weeks (continue until stone passes or surgical decision made)
• Instructions: Take at the same time every night. May cause postural hypotension - sit up slowly on waking. Do NOT stop abruptly.
• Mechanism: Blocks α1a/α1c receptors in distal ureter smooth muscle → ureteral dilation → facilitates stone expulsion

The AUA and EAU both recommend alpha-blockers for ureteral stones <10 mm as MET. Tamsulosin was shown in a Cochrane review (67 studies, n=10,509) to significantly increase stone clearance and reduce expulsion time. It is especially beneficial for stones >5 mm. AUA recommends 4-6 weeks of observation with MET. (Brenner and Rector's The Kidney; Campbell-Walsh Wein Urology)

💊 GROUP 4 - ANTIBIOTIC (For Dysuria/Frequency - Presumptive UTI Coverage)

• Dose: 1 capsule twice daily (with food)
• Duration: 5 days
• Instructions: Take with food to reduce GI side effects. Urine may turn yellow/brown - this is normal. Avoid if eGFR < 30 mL/min.
• (If culture results show resistant organism, switch based on sensitivity)

Nitrofurantoin is a preferred first-line agent for uncomplicated cystitis/lower UTI. Effective against E. coli and Enterobacterales. A 5-day course is as effective as 3-day TMP-SMX. (Harrison's Principles of Internal Medicine 22E; Goodman & Gilman's Pharmacology)

• Ciprofloxacin 500 mg twice daily x 7 days (if complicated UTI/pyelonephritis is suspected)
• Fosfomycin 3g single sachet (excellent for uncomplicated cystitis)

💊 GROUP 5 - URINE ALKALINIZER + HYDRATION SUPPORT

• Dose: 10 mL in a glass of water three times daily after meals
• Duration: Continue for 4-6 weeks
• Purpose: Alkalinizes urine, reduces irritation, helps prevent further stone formation (especially calcium oxalate and uric acid stones), reduces dysuria

💊 GROUP 6 - ANTIEMETIC (If Nausea Present)

• Dose: 1 tablet as needed (max 3x daily) for nausea/vomiting
• Duration: As required, up to 5 days

💊 GROUP 7 - PROTON PUMP INHIBITOR (GI Protection with NSAIDs)

• Dose: 1 tablet once daily (before breakfast)
• Duration: While taking NSAIDs (7-10 days)
• Purpose: Prevents NSAID-induced gastritis/peptic ulceration

LIFESTYLE & NON-PHARMACOLOGICAL INSTRUCTIONS

1. Hydration - CRITICAL: Drink 3-4 liters of fluids daily (water preferred). Aim for urine output >2 liters/day. Dilute urine reduces stone growth and facilitates passage. (Brenner and Rector's)
2. Strain urine: Use a fine strainer/gauze to filter urine with every voiding - to capture the stone if it passes (bring stone for analysis).
3. Activity: Moderate walking/physical activity may help stone passage. Avoid strenuous exercise during colic episodes.
4. Diet: Reduce oxalate-rich foods (spinach, nuts, chocolate, tea), reduce salt and animal protein. Do NOT restrict calcium - low dietary calcium paradoxically increases stone risk.
5. Avoid: Carbonated drinks, excess tea/coffee.
6. Monitor: Note any fever >38°C, chills, inability to pass urine, worsening pain - go to Emergency immediately (may indicate infected obstruction requiring urgent intervention).

RED FLAGS - REFER / ADMIT URGENTLY IF:

FOLLOW-UP PLAN

DOCTOR'S SIGNATURE & SEAL

Dr. __________________ 
MBBS, MD [Urology / Internal Medicine]
Reg. No: ______________
Date: 14-July-2026
Next Appointment: ____________

Why I Didn't Use It - and Why You CAN Use It

Component-by-Component Analysis

1. Aceclofenac 100mg (the NSAID)

• A prodrug - partially converted to Diclofenac in the body (~20-30% conversion)
• Has its own COX-2 preferential inhibition
• Effective for ureteral colic - reduces prostaglandin-mediated ureteral spasm and renal pelvic pressure
• Better GI tolerability than Diclofenac (COX-2 preference means less gastric mucosal damage)
• Widely used in Indian practice for musculoskeletal and visceral pain

2. Paracetamol 325mg

• Additive analgesic effect via central mechanisms
• Safe, well-tolerated, no renal hemodynamic effects at standard doses

3. Serratiopeptidase 15mg - THIS IS THE ISSUE

• A proteolytic enzyme with claimed anti-inflammatory and anti-edema properties
• Evidence is very weak - no high-quality RCTs proving benefit in renal colic specifically
• Not mentioned in any major urology guideline (AUA, EAU, or any Harrison's/Campbell-Walsh chapter)
• Cochrane database and international pharmacopeias do not endorse it
• Its addition is largely a commercial/marketing component, not evidence-based
• Not harmful per se, but adds cost without proven benefit

When Zerodol SP is Fine vs. When to Reconsider

Bottom Line

Two Ways to Write It

Option 1 - Generic (INN) Writing

Tab. Diclofenac Sodium 50mg + Paracetamol 325mg
1 tab BD x 5 days (after food)

Option 2 - Brand Name (How most Indian doctors write in practice)

Tab. Voveran Plus / Tab. Diclomol
1 tab BD x 5 days (after food)

Important Note on Strengths

• Diclofenac 50mg - standard oral dose, BD (twice daily)
• Diclofenac 75mg - mostly in sustained release (SR) formulations, OD or BD
• For acute renal colic → 50mg BD or 75mg SR OD is standard

Recommendation for Your Prescription

Tab. Voveran Plus (Diclofenac 50mg + Paracetamol 500mg)
1 tab twice daily x 5-7 days
(To be taken after food)

Tab. Diclofenac Sodium 50mg + Paracetamol 325mg
1 tab BD x 5-7 days pc (after food)

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Dr. [Full Name], MBBS, MD
Registration No.: MCI/NMC Reg. No. ____________
[Clinic/Hospital Name]
[Address, City, Pin Code]
Contact: ____________
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Date: 14 / 07 / 2026

Patient Name: _______________________________
Age / Sex: _____ / M / F
Weight: _____ kg
Address: ___________________________________

Known Allergies: NKDA (No Known Drug Allergies)
                 [ ] Penicillin  [ ] Sulfa  [ ] NSAIDs  [ ] Other: ____

Diagnosis:
1. Right Renal Calculus - 6 mm (USG confirmed)
2. Renal / Ureteric Colic - Right sided
3. Lower Urinary Tract Symptoms
   (Dysuria + Urinary Frequency) - ?Cystitis
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℞

--- ANALGESIC (Pain Relief) ---

1. Tab. Diclofenac Sodium 50 mg
   + Tab. Paracetamol 500 mg
   (To be taken TOGETHER as one dose)
   Sig: 1 tab of each, twice daily (BD)
   Duration: 5 days
   Instructions: Take AFTER food.
                 Take with a full glass of water.
                 Do NOT take on empty stomach.

--- PROTON PUMP INHIBITOR (Gastric Protection) ---

2. Tab. Pantoprazole 40 mg
   Sig: 1 tab once daily (OD)
        Take 30 minutes BEFORE breakfast
   Duration: 7 days (cover entire NSAID course + 2 days)
   Purpose: Protects stomach lining while on Diclofenac

--- ANTISPASMODIC (Ureteral Spasm Relief) ---

3. Tab. Hyoscine Butylbromide 10 mg
   Sig: 1 tab three times daily (TDS)
        Take after meals
   Duration: 5 days
   Purpose: Reduces colicky, cramping pain from
            ureteral spasm

--- RESCUE ANALGESIC (Breakthrough / Severe Pain) ---

4. Tab. Tramadol Hydrochloride 50 mg
   Sig: 1 tab every 8-12 hours AS NEEDED (SOS)
        Only when pain is not controlled by above
   Duration: Maximum 3-5 days, use minimum required
   Instructions: Do NOT drive or operate machinery.
                 Do NOT exceed 3 tablets in 24 hours.
                 Do NOT take with alcohol.

--- ALPHA BLOCKER / MEDICAL EXPULSIVE THERAPY ---
         *** MOST IMPORTANT FOR STONE PASSAGE ***

5. Cap. Tamsulosin Hydrochloride 0.4 mg
   Sig: 1 cap once daily (OD) at BEDTIME
        After dinner, before sleeping
   Duration: 4 to 6 WEEKS
             (Continue until stone passes or
              urology review at 4 weeks)
   Instructions: Take at the SAME time each night.
                 Rise slowly from bed in the morning
                 (may cause dizziness on standing).
                 DO NOT stop without doctor's advice.
   Purpose: Relaxes distal ureter smooth muscle
            to facilitate stone passage naturally.

--- ANTIBIOTIC (For Dysuria / Urinary Frequency) ---

6. Cap. Nitrofurantoin 100 mg
   (Monohydrate / Macrocrystalline)
   Sig: 1 cap twice daily (BD)
        Take WITH food
   Duration: 5 days
   Instructions: Urine may turn yellow-brown in colour
                 - this is NORMAL and harmless.
   Caution: Do NOT use if eGFR < 30 mL/min.
            Review and change if urine culture
            shows resistance.

--- URINE ALKALINISER (Reduces Burning + Stone Prevention) ---

7. Syr. Potassium Citrate + Citric Acid 10 mL
   Sig: 10 mL diluted in half glass of water
        Three times daily (TDS) after meals
   Duration: 4 to 6 weeks
   Purpose: Alkalinises urine, reduces burning
            sensation, prevents further stone
            formation (calcium oxalate / uric acid)

--- ANTIEMETIC (If Nausea / Vomiting Present) ---

8. Tab. Ondansetron 4 mg (ODT - oral dissolving)
   Sig: 1 tab as needed (SOS) for nausea
        Place on tongue, dissolves without water
        Maximum 3 times in 24 hours
   Duration: As required, up to 5 days

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INVESTIGATIONS ADVISED:

1. Urine Routine & Microscopy     - TODAY
2. Urine Culture & Sensitivity    - TODAY (before antibiotic)
3. Serum Creatinine + eGFR        - TODAY
4. Serum Calcium + Uric Acid      - TODAY
5. CBC with Differential          - TODAY
6. X-Ray KUB (Plain)              - TODAY
7. Non-Contrast CT KUB            - If pain not
                                    settling in 48 hrs

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DIETARY & LIFESTYLE INSTRUCTIONS:

FLUID INTAKE (CRITICAL):
- Drink minimum 3 to 4 litres of water daily
- Target urine output more than 2 litres per day
- Pale yellow urine = adequate hydration

STRAIN YOUR URINE:
- Use a fine sieve / muslin cloth to filter urine
  every time you pass urine
- Collect any stone/grit that passes
- Bring it to the clinic for stone analysis

DIET:
- REDUCE: Spinach, tomato, nuts, chocolate,
          excess tea/coffee, red meat, salt
- DO NOT restrict dietary calcium
  (restriction paradoxically worsens stones)
- AVOID carbonated / aerated drinks

ACTIVITY:
- Gentle walking daily is encouraged
- Avoid strenuous exercise during colic episodes

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COME TO EMERGENCY IMMEDIATELY IF:

[!] Fever above 38.5°C with chills / rigors
[!] Complete inability to pass urine (anuria)
[!] Vomiting that does not stop
[!] Pain becoming unbearable despite medicines
[!] Blood in urine increasing significantly

These may indicate INFECTED OBSTRUCTION -
a urological emergency requiring immediate
hospital admission.

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FOLLOW-UP SCHEDULE:

Review 1: After 48-72 hours
          - Check urine C&S report
          - Assess pain control

Review 2: After 1 week
          - Repeat urine routine microscopy
          - Assess LUTS improvement

Review 3: After 4 weeks
          - Repeat USG KUB
          - Check stone passage / position
          - Continue or stop Tamsulosin

Review 4: After 6 weeks (if stone not passed)
          - REFER TO UROLOGY
          - For ESWL (Extracorporeal Shock Wave
            Lithotripsy) OR Ureteroscopy with
            Holmium Laser Lithotripsy

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Next Appointment: ___________________________

Signature: _________________________________
Dr. [Name]
Stamp / Seal of Doctor

(Prescription valid for 30 days from date of issue)
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Why This Format Is Legally Compliant

• All drugs written by generic/INN names - as mandated by NMC Regulations on Graduate Medical Education and the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002, amended 2016
• Diagnosis clearly stated - medicolegal requirement
• Dose, frequency, duration, and route all specified for every drug - standard legal requirement for a valid prescription
• Doctor's registration number included - mandatory per NMC and State Medical Council rules
• Allergies documented - standard of care
• Any pharmacist in India is legally bound to dispense the generic molecule written; they may offer a brand but cannot substitute without consent

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Dr. [Name]  MBBS, MD
Reg. No.: ____________
[Clinic Name & Address]
Ph: ____________
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Date: 14/07/2026

Name: ______________________  Age/Sex: ___/M/F
Wt: ___ kg    Allergies: NKDA

Dx: Rt. Renal Calculus 6mm (USG), Rt. Renal Colic,
    Dysuria + Frequency (?Cystitis)
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℞

1. Tab. Diclofenac 50mg + Tab. Paracetamol 500mg
   1-1-0   x 5 days   (pc)

2. Tab. Pantoprazole 40mg
   1-0-0   x 7 days   (ac)

3. Tab. Hyoscine 10mg
   1-1-1   x 5 days   (pc)

4. Tab. Tramadol 50mg
   SOS - 1 tab if pain unbearable
   (Max 3 tabs/day, not more than 5 days)

5. Cap. Tamsulosin 0.4mg
   0-0-1   x 4-6 weeks   (hs)
   *** Do not stop without advice ***

6. Cap. Nitrofurantoin 100mg
   1-0-1   x 5 days   (pc)

7. Syr. Potassium Citrate 10mL
   1-1-1   x 4 weeks   (pc)
   (Dilute in half glass water before taking)

8. Tab. Ondansetron 4mg
   SOS - for nausea/vomiting
   (Max 3 times/day)

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Inv. Advised:
- Urine R/M + C/S (before starting antibiotics)
- S. Creatinine, S. Calcium, S. Uric Acid
- CBC
- X-Ray KUB
- NCCT KUB (if pain not settling in 48 hrs)

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Advice:
- Drink 3-4 L water/day
- Strain urine, collect stone if passed
- Low oxalate, low salt diet
- Avoid aerated drinks
- Report immediately if fever/chills/anuria/
  worsening pain

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R/V after 1 week / earlier if needed
R/V after 4 weeks with USG KUB report
If stone not passed in 6 wks → Urology ref.
(ESWL / URS + Laser lithotripsy)

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Signature: _______________
Stamp:
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Key to Shorthand Used