🩺 1. CC (Chief Complaint)
হাতে লেখা অনুযায়ী সম্ভবত:
- C/C: Cold + nasal/ear symptoms
- পাশে লেখা আছে: “Hx RET of both ear (20 d)”
👉 অর্থ:
- উভয় কানে blocked/ear trouble ~20 days
- সাথে upper respiratory symptom (cold)
🧾 2. Probable Diagnosis
Prescriber ENT → ওষুধ দেখে সবচেয়ে logical diagnosis:
👉 Acute Rhinosinusitis with Eustachian tube dysfunction ± Otitis media
Evidence from prescription:
- Nasal drop (Oxymetazoline)
- Antihistamine (Montelukast combo)
- Ear drop
- Antibiotic (Clavurox)
📚 Reference
- Davidson’s Principles & Practice of Medicine
- Chapter: Ear, Nose and Throat Disorders
- Topic: Rhinosinusitis & Otitis media
- (23rd edition, approx p. 720–735)
💊 3. Prescribed Medicines (Generic + Use)
1. Tab Clavurox 250/500
👉 Generic: Amoxicillin + Clavulanic acid
👉 Dose: 1+0+1 (10 days)
Use:
- Bacterial sinusitis
- Otitis media
📚 Reference:
- Harrison’s Internal Medicine
- Chapter: Upper Respiratory Infections
- (21st ed, p. ~185–190)
2. Tab Bilastine (20 mg likely)
👉 Generic: Bilastine (Antihistamine)
Use:
- Allergic rhinitis
- Nasal congestion
3. Tab Montelukast (10 mg)
👉 Generic: Montelukast
Use:
- Allergic component
- Nasal blockage
📚 Reference:
- Katzung Pharmacology
- Chapter: Antihistamines & Leukotriene inhibitors
- (14th ed, p. ~300)
4. Candibac Ear Drops
👉 Generic (likely combo):
- Clotrimazole ± Beclomethasone ± Antibiotic
Use:
- Otitis externa / fungal infection
5. Oxynex Nasal Drop (0.05%)
👉 Generic: Oxymetazoline
Use:
- Nasal decongestant
⚠️ Note: max 3–5 days ideally
📚 Reference:
- Goodman & Gilman
- Nasal decongestants section
6. Cap Gas/acid control (likely PPI/antacid)
👉 Generic unclear (probably Omeprazole/Esomeprazole)
7. Tab Esoral-M
👉 Generic: Esomeprazole + Domperidone
Use:
- Gastric protection
⚖️ 4. Rationality Analysis (Guideline Based)
✔️ According to guideline (Acute Rhinosinusitis):
📚 IDSA Guideline + Davidson
Recommended:
- ✔ Analgesic
- ✔ Nasal saline
- ✔ Short-term decongestant
- ❌ Antibiotic ONLY if:
- 10 days symptoms OR severe
🔍 Evaluation of this prescription:
✔ Rational points:
- Nasal decongestant → ✔
- Antihistamine → ✔ (if allergic component)
- Ear drop → ✔ (if ear involvement)
⚠️ Questionable / Irrational points:
❌ 1. Antibiotic (Clavurox)
- No clear indication written
- Dose & duration aggressive
👉 Guideline says:
- Not first-line in mild viral URI
❌ 2. Montelukast + Bilastine combo
- Dual therapy often unnecessary in simple cold
❌ 3. Multiple symptomatic drugs
- Polypharmacy present
❌ 4. PPI (Esoral-M)
- No strong indication unless gastritis
🧠 Final Clinical Judgment
👉 Diagnosis likely:
Acute rhinosinusitis + ear blockage (ET dysfunction)
👉 Prescription nature:
⚠️ Partially rational but OVER-TREATED
Key issue:
- Unnecessary antibiotic + polypharmacy
Md.Rafiqul Islam Lipu,Date:-04-05-2026 Monday,Time:-09-18-39 Pm