Ward Prescription

Patient Details

History Summary

• Chief Complaint: Swelling over the occipital region - 10 years duration
• Course: Gradually increasing in size
• Co-morbidities: No history of DM / HTN / Asthma
• Referred as: S/B Dr. (seen by doctor) - 5x1 (likely dimensions 5 x 1 cm, or booked for 5th visit, 1st admission)
• Working diagnosis: Dermoid Cyst (?)

Investigations Advised

1. USG of the occipital swelling - to assess:
   • Size, extent, depth
   • Intracranial connection (sinus tract or dural attachment) -- dermoid cysts at the midline occiput may connect intracranially through a skull defect or attach to the dura
   • Rule out other differentials (lipoma, sebaceous cyst, epidermoid cyst, hemangioma)
2. Routine Pre-operative Workup (for planned surgical excision):
   • CBC (complete blood count)
   • Blood group and Rh typing
   • RBS (random blood sugar)
   • Serum creatinine
   • Coagulation profile: PT / INR, aPTT
   • Chest X-ray (PA view)
   • ECG (12-lead)
   • Urine routine & microscopy
3. CT scan head / skull (if USG suggests intracranial extension or bony defect) -- mandatory to rule out intracranial dermoid before surgery

Ward Orders / Drug Chart

Note: Antibiotics should be prescribed only if there are signs of infection/inflammation. Hold until clinical assessment confirms need.

Pre-operative Orders (if admitted for surgery)

• NBM (nil by mouth) from midnight before surgery
• IV access: 18G cannula, right hand
• IV Fluid: NS / RL 500 mL @ 8 hrly (maintenance)
• Inj. Cefazolin 1 g IV (30 min before incision) -- pre-operative antibiotic prophylaxis
• Inj. Ondansetron 4 mg IV PRN (anti-emetic, post-op)
• Inj. Diclofenac 75 mg IM / IV BD x 2 days (post-op analgesia)
• Head shave (occipital region) prior to surgery
• Informed consent for excision of dermoid cyst, occipital region -- noting possibility of neurosurgical involvement if intracranial extension found

Nursing Instructions

• Monitor vitals (BP, Pulse, SpO2, Temperature) every 4 hours
• Observe swelling for any change in size, redness, discharge, or pulsation
• Bed rest; head end elevation 30 degrees
• Strict input/output charting
• Inform surgeon if fever > 38.5°C or any neurological signs develop (headache, neck stiffness, seizures -- rare but possible if intracranial dermoid)

Clinical Notes

Gentamicin (Inj. Gentamicin) - Assessment for This Patient

Why it is generally avoided here:

When Gentamicin IS used in surgical prophylaxis:

• Beta-lactam allergy (as alternative) -- usually Gentamicin + Metronidazole or Gentamicin + Clindamycin
• Contaminated / dirty wounds with suspected Gram-negative organisms
• Urological / colorectal surgery (bowel flora coverage)
• As part of combination therapy in severe sepsis (not prophylaxis)

Dosing if you must use it (e.g., penicillin allergy in this patient):

Inj. Gentamicin 4-5 mg/kg IV once daily (single daily dose preferred over divided doses -- lower renal tubular accumulation)

For a ~55 kg woman: 240-280 mg IV once, given 30-60 minutes before incision as a single prophylactic dose

Adjust / avoid if serum creatinine is elevated

Bottom line for this patient:

Stick with Inj. Cefazolin 1 g IV as the pre-op prophylactic antibiotic. Gentamicin is not indicated unless she has a documented beta-lactam allergy. Adding it without indication increases nephrotoxicity and ototoxicity risk with no clinical benefit for a clean scalp surgery.

Gentamicin in Acute Appendicitis - YES, it is standard

Ward Prescription - Acute Appendicitis

Antibiotic Regimen Options

Option 1 - Classic Triple Drug Regimen (most common in Indian hospitals)

This triple regimen covers: Gram-negatives (Gentamicin), Anaerobes/Bacteroides (Metronidazole), and Gram-positives/Enterococcus (Ampicillin) -- complete polymicrobial bowel flora coverage.

Option 2 - Gentamicin + Metronidazole (simpler, evidence-based)

This matches the Farahnak et al. 2007 regimen (IV gentamicin + metronidazole, followed by oral amoxicillin-clavulanate) shown effective for non-perforated acute appendicitis (Fischer's Mastery of Surgery, Table 288.1).

Option 3 - Beta-lactam based (if Gentamicin avoided)

Per Current Surgical Therapy 14e: cefoxitin, cefotetan, or cefazolin + metronidazole are first-line for uncomplicated appendectomy prophylaxis.

Full Ward Prescription

Gentamicin Dosing Notes (Important for this patient)

When to escalate antibiotics (perforated / gangrenous appendix):

• Add Inj. Piperacillin-Tazobactam 4.5 g IV q8h, OR
• Switch to Inj. Meropenem 1 g IV TDS for severe peritonitis / sepsis
• Continue for 7-14 days depending on peritoneal contamination

Key Point

Gentamicin + Metronidazole is the backbone of appendicitis antibiotic therapy in Indian surgical practice. It covers the two most important microbial threats: bowel Gram-negatives (E. coli, Klebsiella) and anaerobes (Bacteroides fragilis). Adding Ampicillin completes the triple coverage for Enterococcus. This is the standard regimen in most government / teaching hospitals across India.

Ward Prescription - Acute Appendicitis WITH Fever

What fever tells you clinically

Drug additions for fever

1. Antipyretics (added to existing prescription)

Avoid NSAIDs if perforated appendicitis / sepsis - risk of AKI and masked peritonitis.

2. Escalate antibiotics if fever is high grade / persistent

3. Supportive management for fever

Revised Full Drug Chart

Nursing Instructions (updated for fever)

• Temp charting every 2 hours
• Tepid sponging if temp >38.5°C
• Send blood culture x2 before next antibiotic dose if temp spikes >39°C
• Strict input/output chart - increase IV fluid rate during fever spikes
• Inform surgeon immediately if:
  • Temp >39.5°C (hyperpyrexia)
  • BP drops <90/60 (septic shock)
  • Patient develops rigors, altered sensorium, or worsening abdominal rigidity

Bottom line

Fever = Inj. Paracetamol IV added to the prescription + increased IV fluid rate + closer vitals monitoring. High fever (>38.5°C) with appendicitis means likely perforation or gangrenous appendix - antibiotics should be escalated and surgery should not be delayed. Blood cultures must be sent before changing or escalating antibiotics.