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What is the diagnosis and medication
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Zerodol-P Amoxyclav DSR Udiliv Esotac tablet composition uses India
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laparoscopic cholecystectomy multiple gallbladder calculi fatty liver preoperative workup medication
Diagnosis
Based on the AIIMS Patna General Surgery OPD note:
Symptomatic Cholelithiasis (multiple gallbladder calculi) with Fatty Liver
- Presenting complaint: pain in the right upper abdomen x 10 days, with nausea and weakness
- No history of diabetes/hypertension, no prior surgery
- Abdomen: soft, non-distended, mild epigastric/right upper quadrant tenderness
- USG (OPD): fatty liver + multiple gallbladder (GB) calculi
- Plan: Laparoscopic (converting to open if needed) cholecystectomy
Pre-operative workup ordered: USG whole abdomen, CBC, LFT, RFT, PT/INR, HIV/HBV/HCV serology, RBS (random blood sugar), ECG, and CXR-PA view — this is standard fitness-for-surgery workup before cholecystectomy.
Medications advised
| Drug | Dose/Frequency | Duration | Likely purpose |
|---|---|---|---|
| T. Amoxyclav-DSR (amoxicillin + clavulanate) | 1-0-0 (OD) | 10 days | Antibiotic |
| T. Zerodol-P (aceclofenac + paracetamol) | 1 tab, SOS (as needed) | - | Pain relief |
| Cap Esotac/Pantop-40 (esomeprazole/pantoprazole, PPI) | 1 OD | 10 days | Gastric acid suppression |
| Cap Udiliv (ursodeoxycholic acid) 300 mg | 1 OD | 30 days | Bile acid therapy for gallstones/fatty liver |
| Cap [brand partly illegible, ends "...Gokul"] | 1 OD | 30 days | Likely a liver support/multivitamin supplement - please confirm exact name with the treating doctor or pharmacist |
| Syrup Lactulose | 10 ml TDS, titrate to loose stools (~6 doses/day), continue | Ongoing | Laxative/bowel regimen |
| Advised: Review with reports | - | - | Follow-up once investigation results are back |
Important caveats:
- Two items in the second image (one capsule brand name and part of the follow-up instruction) are only partially legible in the handwriting — I've flagged where I wasn't fully certain. Please verify exact drug name and dose with the prescribing surgeon or a pharmacist before administering.
- This is a photo of a real prescription for a specific patient. Do not adjust doses or substitute drugs without confirming with the treating physician at AIIMS Patna — I'm reading and organizing what's written, not re-prescribing.
Overall picture: this is a patient with gallstone disease (cholelithiasis) and fatty liver being worked up for cholecystectomy, on antibiotics, an analgesic (as needed), a PPI for gastric protection, UDCA for the gallstones/liver, a bowel regimen, and a scheduled review once labs are back.
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