---

What This Guide Covers

Surgery by Stone Size & Location - Quick Answer:

Why each procedure:

• SWL - non-invasive, outpatient, but lower single-session success; fragments must pass
• URS/RIRS - direct vision, active extraction, ideal for distal ureter and <2cm renal stones; avoids percutaneous access
• PCNL - highest stone-free rates for large/complex stones; powerful lithotripsy through skin tract
• Open surgery - <1% of cases; reserved for failed endourology or simultaneous anatomical reconstruction

---

1. Clinical Decision Flowchart Poster

---

2. ESWL vs URS vs PCNL Comparison Table Poster

---

3. Complete Medications Guide (Downloadable HTML)

---

What's Inside the Medications Guide

Section 1 - Analgesia for Renal Colic (9 drugs)

Section 2 - Medical Expulsion Therapy (4 drugs)

• Tamsulosin 0.4mg OD (Urimax, Veltam, Contiflo) - first-line MET, off-label paeds
• Doxazosin 4mg OD (Cardura, Doxcard) - alternative
• Silodosin 8mg OD (Silodal, Urocam) - high alpha-1A selectivity
• Nifedipine 30mg SR (Adalat, Calcigard) - adjunct

Section 3 - Stone Prevention (10 drugs)

• Potassium Citrate (Urocit-K, Potrate, Alkasol) - for uric acid, hypocitraturia
• Allopurinol 100-300mg OD (Zyloric, Uricad, Lopuric) - with HLA-B*5801 warning for South Asians
• Febuxostat 40-80mg (Febucip, Zurig, Febustat)
• Hydrochlorothiazide 25-50mg (Aquazide) - for hypercalciuria
• Indapamide 1.25-2.5mg (Natrilix, Lorvas)
• D-Penicillamine (Artamine) - cystine stones - CONTRAINDICATED in pregnancy

Section 4 - Antibiotics (7 drugs)

• Piperacillin-Tazobactam 4.5g 8hrly (Tazact, Piptaz) - urosepsis first-line
• Meropenem 1g 8hrly (Meromer, Meronem) - MDR/resistant organisms
• Gentamicin 3-5mg/kg OD (single dose prophylaxis) - pre-op PCNL/URS
• Nitrofurantoin 50mg OD (Furadantin) - long-term post-struvite prophylaxis (AVOID if eGFR <45)
• Ciprofloxacin 500mg BD (Ciplox, Cifran) - AVOID in pregnancy
• Cefalexin 500mg QDS (Sporidex, Phexin) - SAFE in pregnancy

Section 5 - Pregnancy Quick-Reference Table

---

Your PDF Poster Collection is Ready

---

What's Inside - Page by Page

---

PDF Poster Collection - Rebuilt (v2)

---

• Rebuilt entirely using PIL (Python Imaging Library) - each page is rendered as a full raster image, then all 5 images are combined into a standard PDF. This format is universally compatible with every PDF viewer (Adobe, Preview, Chrome, Foxit, mobile).
• No complex reportlab flowable objects that can cause layout corruption.

---

---

---

MASTER GUIDE: BASIC GENERAL SURGICAL CASES

For MBBS General Physicians | 10 Complete Cases with Casesheets & Doctor's Orders

---

CASES COVERED

1. Acute Appendicitis
2. Inguinal Hernia (Irreducible/Strangulated)
3. Acute Intestinal Obstruction
4. Superficial Abscess / Perianal Abscess
5. Burns (Minor & Major)
6. Traumatic Wound / Laceration
7. Acute Cholecystitis
8. Hemorrhoids (Symptomatic)
9. Breast Abscess
10. Diabetic Foot Ulcer / Infected Wound

---

CASE 1: ACUTE APPENDICITIS

Master Guide

1. Vague periumbilical pain (visceral, colicky) - first 2-6 hours
2. Nausea, vomiting, anorexia
3. Pain migrates to McBurney's point (RLQ) - after 6-12 hours (parietal peritoneum involvement)
4. Fever (low grade: 37.5-38.5°C; >39°C suggests perforation)

• McBurney's point tenderness - 2/3 from umbilicus to ASIS
• Rovsing's sign - palpating LLQ causes RLQ pain (referred rebound)
• Psoas sign - RLQ pain on right hip extension (retrocecal appendix)
• Obturator sign - RLQ pain on internal rotation of right hip (pelvic appendix)
• Guarding/rigidity - peritonitis; board-like rigidity = perforation

• Score ≤4: Low probability (observe/discharge)
• Score 5-6: Possible appendicitis (imaging ± admit)
• Score ≥7: High probability (surgical consultation)

• FBC: WBC >10,000 in 87-92% (but normal WBC doesn't exclude!)
• CRP: elevated (non-specific but supports diagnosis)
• Urinalysis + urine pregnancy test (women of reproductive age)
• Ultrasound: distended non-compressible appendix >6mm + hypervascularity; sensitivity 78%, specificity 83%
• CT abdomen (preferred adults): sensitivity 94%, specificity 90%; shows periappendiceal fat stranding, appendicolith, free fluid

• Uncomplicated: Appendectomy (laparoscopic preferred) OR antibiotics alone (recent evidence shows non-inferior for uncomplicated; 30% recurrence at 5 years)
• Perforated/gangrenous: Emergency appendectomy + peritoneal lavage + IV antibiotics
• Appendix mass/abscess: Initial conservative (IV antibiotics + percutaneous drainage if needed), interval appendectomy at 6-8 weeks

---

CASESHEET 1: ACUTE APPENDICITIS

PATIENT DETAILS
Name: Mr. Ramesh Kumar        Age/Sex: 22M
Date of Admission: 25/06/2026  Ward: Surgical Emergency
Presenting Complaint: Abdominal pain x 18 hours

HISTORY OF PRESENTING ILLNESS
Mr. Ramesh Kumar, 22-year-old male, presented with:
- Onset: Vague periumbilical pain 18 hours ago
- Migration: Pain shifted to right lower abdomen 12 hours ago
- Associated: Nausea x2, vomiting x1, anorexia since yesterday
- No passage of flatus/stools in last 12 hours
- Fever: Noticed since 8 hours
- No urinary symptoms, no similar episodes in past

EXAMINATION
General: Ill-looking, flushed, dehydrated (++)
Vitals: BP 118/76, HR 98/min, Temp 38.4°C, RR 18/min, SpO2 99%
Abdomen:
  - Inspection: Flat, moves with respiration (reduced)
  - Tenderness: ++++ at McBurney's point
  - Guarding: + (right iliac fossa)
  - Rebound tenderness: ++ (RIF)
  - Rovsing's sign: POSITIVE
  - Psoas sign: POSITIVE
  - Obturator sign: Negative
  - Bowel sounds: Reduced
  Alvarado Score: 8/10 (High probability)

INVESTIGATIONS
FBC: WBC 14,200/mm³, Neutrophils 84%
CRP: 68 mg/L
Urine: Occasional WBCs (sterile pyuria - proximity of inflamed appendix to bladder)
Urine pregnancy test: NEGATIVE
USS Abdomen: Distended non-compressible appendix 8mm diameter, hypervascularity on Doppler; no perforation seen

DIAGNOSIS: Acute Appendicitis (Uncomplicated, Alvarado Score 8)

MANAGEMENT PLAN: Emergency Laparoscopic Appendectomy

ADMISSION/PRE-OPERATIVE ORDERS

1. NBM (Nil by mouth) IMMEDIATELY
2. IV access x2 (16G cannula both arms)
3. IV fluids: Normal Saline 0.9% 1L over 6 hours (correct dehydration)
4. Monitoring: Vital signs q1hr; urine output hourly (catheterise)
5. ANALGESIA:
   - Inj. Morphine 5mg IV PRN q4h (acute pain management)
   OR Inj. Tramadol 100mg IV 8hrly
   - Do NOT withhold analgesia fearing it masks signs (MYTH - debunked)
6. ANTI-EMETIC: Inj. Ondansetron 4mg IV 8hrly PRN
7. PRE-OP ANTIBIOTICS (single-dose prophylaxis):
   - Inj. Cefuroxime 1.5g IV at induction
   - Inj. Metronidazole 500mg IV at induction
8. Bloods: FBC, U&E, LFT, coagulation, Group & Save, CRP
9. Urine: Dipstick + culture
10. ECG + CXR (pre-anaesthesia)
11. Consent: Laparoscopic appendectomy ± conversion to open
12. DVT prophylaxis: TED stockings; LMWH (Enoxaparin 20mg SC) if BMI >30
13. Inform operating theatre and anaesthetics

POST-OPERATIVE ORDERS (Uncomplicated)
1. Vitals q1hr x 4hrs, then q4hrly
2. Resume oral fluids when bowel sounds return (6-12hrs)
3. IV fluids until tolerating oral
4. Analgesia: Tab. Paracetamol 1g PO q6h + Inj. Morphine PRN
5. Anti-emetic: Ondansetron PRN
6. Wound check at 24hrs; remove drain (if placed) when <30mL/24hr
7. Mobilise Day 1 post-op
8. Discharge when tolerating diet, afebrile, pain controlled (Day 1-2)
DISCHARGE MEDICATIONS:
   - Tab. Co-amoxiclav 625mg PO TDS x 5 days (if no perforation: single dose only)
   - Tab. Paracetamol 1g PO q6h PRN x 5 days
   - Tab. Metronidazole 400mg PO TDS x 5 days (if perforated)
   - Stitch removal: Day 7-10
REVIEW: OPD in 2 weeks

---

CASE 2: STRANGULATED INGUINAL HERNIA

Master Guide

• Indirect (lateral): Through deep inguinal ring → inguinal canal → superficial ring → scrotum; congenital or acquired; most common in young men
• Direct (medial): Through Hesselbach's triangle (inferior epigastric vessels laterally, inguinal ligament inferiorly, rectus laterally); acquired weakness; older men

• Reducible: Contents return to abdomen spontaneously or with pressure
• Irreducible (incarcerated): Cannot be reduced; bowel trapped; tender; obstructive symptoms
• Strangulated: Blood supply cut off → ischemia → gangrene → perforation; SURGICAL EMERGENCY

• Sudden severe pain in hernia + systemic symptoms
• Tense, tender, irreducible swelling
• Overlying skin red/dusky
• Absent cough impulse
• Signs of intestinal obstruction

• Reducible hernia: Elective herniorrhaphy (Lichtenstein tension-free mesh repair)
• Irreducible/Strangulated: Emergency surgery - reduce, assess bowel viability, resect if needed, repair hernia

---

CASESHEET 2: STRANGULATED INGUINAL HERNIA

Patient: Mr. Suresh, 58M
CC: Right groin swelling x 6 years, now painful and irreducible x 12 hours
Nausea, vomiting (x4), abdominal distension
No flatus or stool x 10 hours

EXAMINATION
Vitals: BP 100/70, HR 114, Temp 38.2°C
Abdomen: Distended; high-pitched bowel sounds; generalised tenderness
Groin: Tense, tender, irreducible swelling in right inguinal region 5×4cm
       Overlying skin erythematous; absent cough impulse
       Cannot get above swelling (hernia vs hydrocele distinction)
Scrotum: Swelling extends into right scrotum

Diagnosis: Right inguinal hernia - STRANGULATED (Emergency)

EMERGENCY ORDERS

1. NBM IMMEDIATELY
2. IV access x2 + Urinary catheter
3. IV Fluids: Hartmann's/Ringer's Lactate 1L STAT; reassess; target UO >0.5mL/kg/hr
4. Nasogastric tube (NG): Insert, free drainage (decompress bowel)
5. ANALGESIA: Inj. Morphine 5-10mg IV titrated
6. IV ANTIBIOTICS (bowel prep for emergency surgery):
   - Inj. Piperacillin-Tazobactam 4.5g IV 8hrly (strangulation = bowel wall breach risk)
   OR Inj. Cefuroxime 1.5g + Inj. Metronidazole 500mg IV (prophylaxis)
7. Bloods: FBC, U&E, creatinine, LFT, coagulation, Group & Crossmatch (2 units)
8. AXR: Dilated bowel loops (obstruction)
9. Inform theatre: Emergency procedure

INTRA-OP NOTE FOR SURGEON:
- Assess bowel viability (pink/peristalsis/bleeding on cut = viable)
- Resect gangrenous bowel if present; anastomosis or stoma
- Repair: Lichtenstein mesh (if no bowel resection); simple repair if contaminated

POST-OP ORDERS:
1. Continue IV antibiotics 48-72hrs then step down
2. NG tube: Remove when bowel sounds return + passing flatus
3. IV fluids until tolerating oral
4. Analgesia: Paracetamol 1g q6h + Morphine PCA
5. DVT prophylaxis: Enoxaparin 40mg SC OD from Day 1
6. Monitor wound for infection
DISCHARGE: Tab. Co-amoxiclav 625mg TDS x 7 days; OPD 2 weeks

---

CASE 3: ACUTE INTESTINAL OBSTRUCTION

Master Guide

• Mechanical (most common):
  • Adults: Adhesions (post-surgery #1) > hernia > malignancy > volvulus
  • Children: Intussusception > congenital bands > Hirschsprung's
• Paralytic ileus: Post-op, peritonitis, electrolyte imbalance, drugs

1. Colicky abdominal pain
2. Distension
3. Vomiting (bilious early = high obstruction; feculent late = low)
4. Absolute constipation (no flatus + no stool = complete obstruction)

• High SI obstruction: Early vomiting, less distension
• Low SI obstruction: Less vomiting, marked distension, late feculent vomiting
• Large bowel obstruction: Gross distension, late or no vomiting, closed-loop if ileocaecal valve competent

• Distension (graded 1-4)
• High-pitched tinkling bowel sounds (mechanical) vs absent (ileus)
• Ladder pattern tenderness (SI loops)
• Check ALL hernial orifices (missed hernia = missed obstruction!)
• Rectal exam (rectal carcinoma, impaction, bloody stool = intussusception)

• AXR: Dilated loops, air-fluid levels, absence of gas in rectum
• Erect AXR: Multiple air-fluid levels (step-ladder pattern)
• CT abdomen (gold standard): Identifies transition point, cause, strangulation

• 70-80% of adhesive SBO resolves conservatively within 24-48 hours
• Water-soluble contrast (Gastrografin) enema: diagnostic + therapeutic in adhesive SBO

• Signs of strangulation (peritonism, fever >38.5, WBC >15,000, tachycardia)
• Complete LBO (risk of caecal perforation if >12cm diameter)
• Closed-loop obstruction
• No resolution after 48hrs conservative management

---

CASESHEET 3: ACUTE INTESTINAL OBSTRUCTION

Patient: Mrs. Priya, 45F, Post-cholecystectomy 3 years ago
CC: Colicky abdominal pain, distension, vomiting x 2 days; no flatus x 1 day

EXAMINATION
Vitals: BP 108/72, HR 106, Temp 37.6°C
Abdomen: Grossly distended; visible peristalsis
        Tinkling high-pitched bowel sounds
        Generalised tenderness (no peritonism)
        Hernial orifices: Intact
Rectal: Empty rectum

AXR: Multiple dilated small bowel loops with air-fluid levels; no gas in colon/rectum
CT Abdomen: Transition point at mid-jejunum; dilated loops proximal; no evidence of
            strangulation; likely adhesive band SBO

DIAGNOSIS: Adhesive Small Bowel Obstruction (non-strangulated)

CONSERVATIVE MANAGEMENT ("DRIP AND SUCK")

1. NBM IMMEDIATELY
2. NGT INSERTION: Free drainage (decompress dilated bowel); chart hourly output
3. IV Access + Urinary catheter
4. IV Fluids: Hartmann's 1L/8hrly + replacement of NGT losses mL-for-mL
5. Monitoring: Vital signs q2hrly; strict fluid balance
6. ANALGESIA: Inj. Morphine 2.5-5mg IV PRN; Inj. Buscopan 20mg IV for colicky pain
7. ANTI-EMETIC: Inj. Metoclopramide 10mg IV 8hrly
8. ELECTROLYTES: Correct K+ (common hypokalaemia in obstruction)
   If K+ <3.2: Add KCl 20mmol/L to IVF; recheck in 4 hours
9. Do NOT give laxatives or enemas without surgical review
10. Serial abdominal examinations q4hrly
11. Repeat AXR at 12 and 24 hours to assess progress

REVIEW TRIGGERS FOR EMERGENCY SURGERY:
- Any peritonism developing
- Temp >38.5°C
- WBC >15,000
- HR >110 or BP falling
- No improvement/worsening at 48hrs

IF CONSERVATIVE FAILS (48hrs):
- Gastrografin (water-soluble contrast) 100mL via NGT → AXR at 8h (therapeutic + diagnostic)
- If no improvement → Theatre: Adhesiolysis ± bowel resection

DISCHARGE: When fully resolved, tolerating diet, bowel sounds normal, passing flatus
Advice: High-fibre diet; return if recurrence

---

CASE 4: SUPERFICIAL ABSCESS / PERIANAL ABSCESS

Master Guide

1. Cellulitis (no pus yet): Antibiotics alone
2. Abscess formation (fluctuant): Incision and Drainage (I&D) - antibiotics are adjunctive only
3. Spreading cellulitis: Antibiotics + urgent surgical review

• Redness, warmth, swelling, tenderness (rubor, calor, tumor, dolor)
• Fluctuance (fluctuation test positive)
• Pointing (skin thinning over abscess)
• Systemic: Fever, rigors, raised WBC

• Most arise from infected anal glands (cryptoglandular theory)
• Types: Perianal (50%), Ischiorectal (25%), Intersphincteric, Supralevator
• URGENT drainage required - can spread rapidly to perineum (Fournier's gangrene!)
• Never give antibiotics alone for perianal abscess without drainage

1. LA infiltration (lignocaine 1% with adrenaline) OR GA for large/deep abscess
2. Cruciate/elliptical incision over point of maximum fluctuance
3. Break loculi with finger/forceps
4. Irrigate with normal saline
5. Pack loosely with ribbon gauze (or leave open for secondary intention)
6. Send pus for culture and sensitivity

---

CASESHEET 4: PERIANAL ABSCESS

Patient: Mr. Vijay, 34M, Diabetic (Type 2)
CC: Severe perianal pain x 4 days, worse on sitting and defecation
    Unable to sit comfortably; low-grade fever

EXAMINATION
Vitals: BP 126/82, HR 92, Temp 38.1°C, BSL: 14.2 mmol/L
Perianal: 4×3cm tender, erythematous, fluctuant swelling at 3 o'clock position
          No external fistula opening seen
          Fluctuation test: POSITIVE
PR examination: Tender; no internal opening palpated on digital exam

DIAGNOSIS: Left perianal abscess (Cryptoglandular origin)
Note: Diabetes increases risk of spread — urgent drainage required

EMERGENCY I&D ORDERS

1. Consent for I&D under LA ± GA (counselled on fistula risk ~30-50%)
2. IV access; FBC, BSL, HbA1c, coagulation
3. Control blood sugar: Actrapid insulin sliding scale pre/peri-procedure
4. IV ANTIBIOTICS (diabetic patient — risk of spreading infection):
   - Inj. Co-amoxiclav 1.2g IV 8hrly (Augmentin)
   OR Inj. Piperacillin-Tazobactam 4.5g IV 8hrly (if immunocompromised/severe)
   Start 1 hour before procedure; continue 48hrs
5. PROCEDURE (I&D):
   - Position: Left lateral or lithotomy
   - LA: Lignocaine 1% + Adrenaline 1:200,000 — ring block around abscess
   - Cruciate incision over point of maximum fluctuance
   - Drain pus; break loculi with finger; irrigate with saline
   - Pus for C&S (critical in diabetic)
   - Pack with ribbon gauze (2cm width); leave wound OPEN
6. Post-procedure:
   - Sitz baths BD (warm water 5-10 min after each bowel movement)
   - Wound packing changed Daily by nurse until wound heals from base
   - Lactulose 15mL BD (prevent constipation/straining)
   - Paracetamol 1g QDS + Ibuprofen 400mg TDS (pain)
   - Continue antibiotics → switch to oral Co-amoxiclav 625mg TDS x 7 days on discharge
7. REVIEW: In 48 hours for wound check; 6 weeks for fistula assessment
NOTE: Counsel patient that fistula-in-ano may develop in 30-50% — further surgery may be needed
DISCHARGE MEDICATIONS:
   - Tab. Co-amoxiclav 625mg TDS x 7 days
   - Tab. Paracetamol 1g QDS PRN
   - Lactulose 15mL BD

---

CASE 5: BURNS

Master Guide

Total fluid (first 24 hrs) = 4 mL × Weight (kg) × %TBSA burned
(Only count 2nd and 3rd degree burns)

Give:
- First HALF in first 8 hours (count from time of burn, NOT admission)
- Second HALF in next 16 hours
- Use Ringer's Lactate (Hartmann's)
- ADD maintenance fluids on top
- Target: Urine output 0.5-1 mL/kg/hr (adults); 1 mL/kg/hr (children)

• Total = 4 × 70 × 30 = 8400 mL
• First 8hrs = 4200 mL (525 mL/hr)
• Next 16hrs = 4200 mL (262 mL/hr)

• 15% TBSA partial thickness (adults); >10% (children)

• Any full thickness burn >5%
• Burns of face, hands, feet, genitalia, perineum, major joints
• Chemical/electrical burns
• Inhalation injury

---

CASESHEET 5: BURNS

Patient: Mrs. Kavita, 35F, Housewife
CC: Flame burns to both arms and chest while cooking (LPG cylinder fire) x 2 hours ago

EXAMINATION
Vitals: BP 106/68, HR 118, Temp 36.2°C (hypothermia risk), SpO2 97%
Airway: Patent; no singed nasal hair; no stridor; voice normal (NO inhalation injury)
Burns Assessment:
  - Right arm (partial thickness, blistered): 9%
  - Left arm (partial thickness, blistered): 9%
  - Anterior chest (partial thickness): 9%
  - Total TBSA: 27% (2nd degree, partial thickness)
Weight: 55 kg

DIAGNOSIS: 27% TBSA Partial Thickness Burns - MAJOR BURN
Parkland Formula: 4 × 55 × 27 = 5940 mL Ringer's Lactate/24hrs
  First 8hrs (from time of burn): 2970 mL (~370 mL/hr)
  Next 16hrs: 2970 mL (~185 mL/hr)
  Time of burn: 1900hrs. Patient arrived 2100hrs.
  Already 2hrs elapsed: Remaining first 8hrs = 6hrs
  → Give 2970mL over 6hrs = 495 mL/hr

MAJOR BURNS MANAGEMENT ORDERS

1. ABC FIRST:
   - Airway: Assess for inhalation injury (stridor, hoarse voice, singed hair)
     If inhalation injury: Early intubation BEFORE airway swells shut
   - O2: 100% via non-rebreather mask x 4 hours
   - Remove all clothing and jewellery

2. IV ACCESS: Two large-bore (14-16G) IVs (avoid burned areas; use femoral if needed)
3. URINARY CATHETER: Strict hourly urine output (target 0.5-1 mL/kg/hr = 28-55 mL/hr)

4. FLUID RESUSCITATION (Parkland Formula):
   Ringer's Lactate (Hartmann's) 5940 mL total
   - Next 6 hours: 495 mL/hr (remaining first half)
   - Hours 8-24: 185 mL/hr
   ADD Maintenance: 5% Dextrose 35 mL/hr separately

5. ANALGESIA (burns are extremely painful):
   - Inj. Morphine 5mg IV titrated PRN q2-4hrly
   - Cover burns temporarily with cling film (NOT cold water on large burns — hypothermia)
   - Inj. Morphine 2mg/hr IV infusion if pain inadequate

6. WOUND CARE (after resuscitation stable):
   - Clean gently with chlorhexidine solution
   - Silver sulfadiazine 1% cream (Flamazine) to all partial thickness burns
   OR Non-adherent dressings (Mepitel, Jelonet)
   - Daily dressing changes

7. TETANUS PROPHYLAXIS:
   - If immunised: Tetanus toxoid 0.5mL IM
   - If not immunised: Tetanus toxoid + Immunoglobulin

8. IV ANTIBIOTICS: NOT routinely for burns
   Give ONLY if signs of wound infection (fever >38.5°C after 48hrs, wound colonisation)
   - Inj. Piperacillin-Tazobactam 4.5g IV 8hrly if infected

9. NUTRITIONAL SUPPORT:
   - Nasogastric feeding: Start within 6 hours (burns = hypermetabolic state)
   - High-protein diet: 1.5-2g/kg/day protein
   - Vitamin C 1g OD, Zinc 50mg OD, Vitamin E (antioxidants reduce oxidative stress)

10. MONITORING:
    - Urine output HOURLY
    - Vitals q1hrly
    - Daily FBC, U&E, blood sugar (burns cause hyperglycaemia)
    - Check for compartment syndrome (circumferential burns → escharotomy needed)

REFERRAL: Burns unit if >15% TBSA, facial/hand/genital burns, inhalation injury

---

CASE 6: TRAUMATIC WOUND / LACERATION

Master Guide

• Clean: Elective surgical wound; no contamination; primary closure; infection rate <2%
• Clean-contaminated: GI/GU tract entered; infection rate 5-15%
• Contaminated: Acute inflammation, traumatic wounds <6hrs old
• Dirty/Infected: >6hrs, fecal contamination, pus; delayed primary/secondary closure

1. Depth: Skin only vs subcutaneous vs muscle/tendon vs bone/joint
2. Contamination level and time since injury
3. Neurovascular status distal to wound
4. Mechanism: Blunt vs sharp vs crush vs avulsion vs bite
5. Tetanus status

• Non-absorbable (skin): Prolene/Nylon 3-0 (face/hand), 2-0 (trunk), Ethilon
• Absorbable (deep/subcutaneous): Vicryl 2-0/3-0, Monocryl
• Staples: Scalp, trunk (fast; avoid face)

• Face: 5-7 days
• Scalp: 7-10 days
• Upper limb: 7-10 days
• Trunk: 10-14 days
• Lower limb: 12-14 days
• Joints: 14 days

---

CASESHEET 6: TRAUMATIC LACERATION

Patient: Mr. Arjun, 28M
CC: Deep cut to left forearm after glass injury x 1 hour
    Profuse bleeding controlled with direct pressure

EXAMINATION
Vitals: Stable; BP 124/80, HR 88, Temp 36.8°C
Wound: 7cm linear laceration, left volar forearm
       Depth: Subcutaneous tissue; no tendon exposure
       Contamination: Glass particles visible; wound edges clean
       Neurovascular: Sensation intact; radial and ulnar pulse palpable; fingers moving fully
Tetanus status: Last tetanus 6 years ago

DIAGNOSIS: Traumatic laceration, left forearm — clean, <6hrs, primary closure appropriate

WOUND MANAGEMENT ORDERS

1. ANALGESIA: Tab. Paracetamol 1g PO + Ibuprofen 400mg PO STAT
   OR Local anaesthetic: Lignocaine 1% without adrenaline (volar forearm — avoid adrenaline near digits/end arteries)

2. WOUND IRRIGATION (most important step):
   - 200-300mL Normal Saline under pressure (20mL syringe through 19G needle)
   - Remove glass fragments (explore systematically under good light)
   - Debride devitalised edges if needed with scissors

3. HAEMOSTASIS: Direct pressure; identify and ligate/tie any bleeding vessel

4. PRIMARY CLOSURE:
   Deep layer: Vicryl 3-0 interrupted (close dead space)
   Skin: Prolene 3-0 interrupted sutures; approximate edges without tension
   Dressing: Non-adherent (Jelonet) + gauze + crepe bandage

5. TETANUS PROPHYLAXIS:
   - Tetanus Toxoid 0.5mL IM (booster; last dose >5 years ago)
   - No immunoglobulin needed (contaminated wound >10 years: add immunoglobulin)

6. ANTIBIOTICS:
   - NOT routinely required for clean lacerations
   - Give if:
     * Dirty/heavily contaminated wound
     * Bite wounds (human/animal) — Augmentin (Co-amoxiclav) 625mg TDS x 5 days
     * Grossly contaminated
     * Immunocompromised/diabetic

7. ELEVATION: Elevate arm above heart level (reduces oedema)

DISCHARGE INSTRUCTIONS:
   - Keep wound dry x 48hrs, then clean daily with soap and water
   - Return if: Increasing pain, redness, discharge, fever
   - Suture removal: Day 10-12 (forearm)
   - Tab. Paracetamol 1g QDS PRN x 5 days
   - OPD review in 48hrs for wound check

---

CASE 7: ACUTE CHOLECYSTITIS

Master Guide

• USS: Gallstones + thickened gallbladder wall (>4mm) + pericholecystic fluid + sonographic Murphy's
• FBC: WBC elevated; LFT: elevated ALP/GGT (mild) - markedly elevated if CBD stone
• CT abdomen if diagnosis unclear or suspect complication

• Conservative (initial): NBM, IV fluids, IV antibiotics, analgesia
• Definitive: Laparoscopic cholecystectomy - ideally within 72hrs of admission (early lap chole is now standard; better than interval)
• Cholangitis: Urgent ERCP + stone extraction ± stenting before cholecystectomy

---

CASESHEET 7: ACUTE CHOLECYSTITIS

Patient: Mrs. Fatima, 48F (5F: Fat, Female, Forty, Fertile, Fair — classic profile)
CC: Severe RUQ pain x 12 hours, radiating to right shoulder; fever; nausea; vomiting
    Ate fatty meal 14 hours ago; previous similar mild episodes

EXAMINATION
Vitals: BP 128/84, HR 96, Temp 38.6°C
Abdomen:
  - RUQ tenderness ++++ with guarding
  - Murphy's sign: POSITIVE
  - No jaundice; no Courvoisier's gallbladder
  - No peritonism

Investigations:
  FBC: WBC 13,800; Neutrophils 82%
  LFT: Bilirubin 24 (mild); ALP 210; ALT 68; GGT 188
  Amylase: Normal
  USS: Multiple gallstones; thickened gallbladder wall 7mm; pericholecystic fluid
       Sonographic Murphy's sign positive; CBD 6mm (normal)

DIAGNOSIS: Acute Cholecystitis (Tokyo Grade II - Moderate)

ACUTE CHOLECYSTITIS MANAGEMENT ORDERS

1. NBM
2. IV fluids: Normal Saline 0.9% 1L/8hrly
3. ANALGESIA:
   - Inj. Diclofenac 75mg IM STAT (NSAID - effective for biliary colic)
   OR Inj. Morphine 5mg IV PRN (do NOT withhold — myth that morphine worsens Oddi's spasm)
4. ANTI-EMETIC: Inj. Metoclopramide 10mg IV TDS
5. IV ANTIBIOTICS:
   - Mild (Grade I): Inj. Cefuroxime 1.5g IV TDS + Inj. Metronidazole 500mg IV TDS
   - Moderate-Severe (Grade II-III): Inj. Pip-Tazobactam 4.5g IV 8hrly
6. Urinary catheter + strict fluid balance
7. Monitoring: Vitals q4hrly; daily LFT (watch for worsening jaundice = CBD stone)

DEFINITIVE TREATMENT:
- Plan: Laparoscopic cholecystectomy within 72 hours of admission (early surgery)
- Pre-op: FBC, U&E, coagulation, G&S, consent

INDICATIONS FOR URGENT SURGERY/ERCP:
- Worsening jaundice (CBD obstruction) → ERCP FIRST
- Gallbladder empyema or gangrene (no improvement in 24-48hrs)
- Suspected Mirizzi syndrome

DISCHARGE MEDICATIONS (after lap chole):
- Tab. Co-amoxiclav 625mg TDS x 5 days
- Tab. Paracetamol 1g QDS PRN
- Tab. Omeprazole 20mg OD
- Low-fat diet advice
- OPD: 2 weeks

---

CASE 8: SYMPTOMATIC HEMORRHOIDS (HAEMORRHOIDS)

Master Guide

---

CASESHEET 8: SYMPTOMATIC HAEMORRHOIDS

Patient: Mr. Mohan, 42M, Software engineer (sedentary job)
CC: Bright red PR bleeding x 6 months; prolapse after defecation x 3 months
    Prolapse requires manual reduction; no pain except after prolonged sitting
    Constipation (straining at stool); fibre-poor diet

EXAMINATION
PR Examination:
  - External: No thrombosed external piles
  - Internal: Grade III hemorrhoids at 3, 7, 11 o'clock positions (left lateral,
              right anterolateral, right posterolateral — classic positions)
              Reducible with gentle pressure
Proctoscopy: Confirmed Grade III internal hemorrhoids; no fissure/fistula/malignancy

DIAGNOSIS: Grade III Internal Haemorrhoids

HAEMORRHOID MANAGEMENT ORDERS

CONSERVATIVE (All grades — cornerstone):
1. High-fibre diet: >30g/day (fruits, vegetables, whole grains)
2. Fluid intake: >2.5L water/day
3. Sitz baths: Warm water 10 min TDS (reduces spasm)
4. Avoid straining; elevate toilet seat/footstool (squatting position reduces straining)
5. Topical treatment:
   - Xylocaine 5% ointment (Lignocaine) TDS PRN (local anaesthesia/anti-inflammatory)
   OR Proctosedyl ointment (hydrocortisone + cinchocaine) TDS x 2 weeks
6. Laxatives: Tab. Lactulose 15mL BD OR Ispaghula husk (Isabgol/Fybogel) sachets BD

DEFINITIVE PROCEDURE (Grade III — Clinic):
Rubber Band Ligation (RBL) / Banding:
  - Outpatient procedure; no anaesthesia needed
  - Apply rubber band at base of internal haemorrhoid (above dentate line)
  - Band causes ischaemia → haemorrhoid sloughs off in 5-7 days
  - Treat one pile per session; repeat every 3-4 weeks
  - Success rate: 70-80% for Grade II-III
  - WARN: Post-procedure discomfort 24-48hrs; discharge in 5-7 days
  - Give: Sitz baths; Paracetamol 1g QDS; Lactulose

SURGICAL (Grade III not responding to RBL / Grade IV):
Milligan-Morgan Haemorrhoidectomy (open) or Stapled Haemorrhoidopexy (PPH)
  Pre-op: FBC, coagulation, consent; phosphate enema evening before

POST-PROCEDURE MEDICATIONS:
- Tab. Lactulose 15mL BD (prevent constipation) x 4 weeks
- Tab. Ibuprofen 400mg TDS with food x 1 week
- Sitz baths TDS x 4 weeks
- Proctosedyl ointment TDS x 2 weeks

LIFESTYLE COUNSELLING: Dietary changes are mandatory to prevent recurrence
REVIEW: 4 weeks post-banding for assessment; repeat banding if needed

---

CASE 9: BREAST ABSCESS

Master Guide

1. Lactational (puerperal): During breastfeeding; Staph aureus most common; outer upper quadrant
2. Non-lactational: Periareolar (young women, smokers); Duct ectasia related; anaerobes common

1. Mastitis (cellulitis): Fever + tender red breast; antibiotics may suffice; continue breastfeeding
2. Abscess: Fluctuant; requires drainage; DO NOT stop breastfeeding (unless directly over incision)

• Early mastitis/cellulitis: Flucloxacillin 500mg QDS x 7 days + continue breastfeeding + analgesia
• Abscess: I&D or ultrasound-guided aspiration (preferred) + antibiotics
• Ultrasound-guided aspiration: Serial aspirations q48hrs; less scarring; preferred for small abscesses
• I&D: For large/multiloculated abscesses; radial incision (preserves breast ducts)

---

CASESHEET 9: BREAST ABSCESS

Patient: Mrs. Ananya, 26F, Lactating (baby 6 weeks old)
CC: Painful, red right breast x 1 week; worsening x 3 days; fever; lump developing
    Continuing breastfeeding; baby feeding well

EXAMINATION
Vitals: BP 118/76, HR 98, Temp 38.8°C
Breasts: Right breast: 5×5cm area of erythema, oedema, tender; outer upper quadrant
         Fluctuant mass 3×3cm at centre of inflamed area
         POSITIVE fluctuation — abscess formed
         Nipple: No discharge; no skin changes; no axillary lymphadenopathy
USS Breast: 3.2×2.8cm unilocular fluid collection; no internal septations

DIAGNOSIS: Lactational Breast Abscess, Right, Unilocular

BREAST ABSCESS MANAGEMENT

1. IV access; FBC, CRP, blood cultures (if temp >38.5°C)
2. IV ANTIBIOTICS:
   - Inj. Flucloxacillin 1g IV QDS (Staph aureus)
   OR (if penicillin allergic): Inj. Clindamycin 600mg IV TDS
   - Add Inj. Metronidazole 500mg IV TDS if non-lactational/periareolar
     (anaerobic organisms common)
3. ANALGESIA: Tab. Paracetamol 1g QDS + Ibuprofen 400mg TDS (anti-inflammatory)
4. DRAINAGE (Unilocular — USS guided aspiration preferred):
   PROCEDURE: Ultrasound-guided needle aspiration
   - USS guidance to locate collection
   - 18G wide-bore needle; aspirate all pus
   - Send pus for C&S
   - Repeat aspiration q48hrs until dry (usually 2-3 sessions)
   - If fails/multiloculated → formal I&D under GA with radial incision

BREASTFEEDING:
- CONTINUE breastfeeding from BOTH breasts (including affected side)
- Breastfeeding from infected side is SAFE (antibiotics pass into milk but safe for baby)
- Expressing milk helps clear infection and maintains supply
- Only pause if drainage wound directly over nipple/areola

STEP-DOWN TO ORAL (after 48hrs IV):
- Cap. Flucloxacillin 500mg PO QDS x 14 days total course
- (Empty stomach — absorbs better when fasting)

DISCHARGE CRITERIA: Afebrile >24hrs; wound healing; no re-accumulation on USS
REVIEW: 48hrs for repeat aspiration; 2 weeks OPD
IMPORTANT: Histology of abscess wall on formal I&D specimen (exclude inflammatory carcinoma)

---

CASE 10: DIABETIC FOOT ULCER / INFECTED WOUND

Master Guide

• Neuropathic ulcer: Plantar (pressure areas); painless; good pulses; warm foot
• Ischaemic ulcer: Margins (heel, toes); painful; absent pulses; cold foot
• Neuroischaemic: Mixed features (most common in practice)

---

CASESHEET 10: DIABETIC FOOT ULCER

Patient: Mr. Krishnamurthy, 64M, Diabetic x 20 years (poorly controlled), Hypertensive
CC: Non-healing ulcer right big toe x 6 weeks; worsening x 1 week
    No pain (neuropathy); noticed wound while bathing
    Fever for 3 days; not eating well

EXAMINATION
Vitals: BP 146/92, HR 98, Temp 38.4°C, BSL: 18.6 mmol/L
Right foot: Wagner Grade 3 ulcer (2×2cm) at plantar surface right big toe
            Base: Yellow slough + granulation tissue; bone visible on probing
            Surrounding cellulitis 5cm perimeter; erythema, oedema, warmth
            Malodorous (anaerobic infection)
            Pulses: Dorsalis pedis palpable bilaterally; posterior tibial palpable
            Sensation: Reduced (monofilament test failed); vibration absent
            Temperature: Warm bilaterally (neuropathic > ischaemic)

Investigations:
  FBC: WBC 18,400; neutrophils 88%
  HbA1c: 11.2%
  X-ray right foot: Bony erosion at head of right first metatarsal (osteomyelitis)
  Wound swab: Pending C&S
  eGFR: 62 (mild CKD — adjust antibiotic doses)

DIAGNOSIS: Wagner Grade 3 Diabetic Foot Ulcer; Osteomyelitis; Poorly-controlled DM

DIABETIC FOOT MANAGEMENT ORDERS

1. DIABETIC CONTROL (Priority #1 — infection cannot heal without control):
   - Stop oral hypoglycaemics (metformin hold in eGFR<45; stop all during infection)
   - Insulin sliding scale + Basal insulin (Lantus 10 units SC at night)
   - Target BSL: 6-10 mmol/L
   - Endocrinology review

2. IV ANTIBIOTICS (osteomyelitis — minimum 6 weeks total):
   EMPIRICAL (broad-spectrum, cover MRSA, anaerobes, Gram-negatives):
   - Inj. Piperacillin-Tazobactam 4.5g IV 8hrly
   + Inj. Vancomycin 15mg/kg IV 12hrly (MRSA cover; check trough levels 15-20mg/L)
   + Inj. Metronidazole 500mg IV TDS (additional anaerobic cover)
   ADJUST when C&S results available (Day 3-5); step down to oral when clinically improving
   ORAL STEP-DOWN (osteomyelitis — 6 weeks minimum):
   - Co-amoxiclav 625mg TDS + Metronidazole 400mg TDS (if sensitive)
   OR Clindamycin 300mg QDS + Ciprofloxacin 500mg BD (bone penetration)

3. WOUND MANAGEMENT:
   - Debridement (bedside): Remove all slough and necrotic tissue with blade/scissors
   - Saline irrigation (pressure irrigation via 20mL syringe)
   - Dressing: Alginate (Kaltostat)/Silver-containing dressing (Mepilex Ag) daily
   - OFFLOADING: Total contact cast or special diabetic footwear (most important)
     DO NOT bear weight on ulcerated foot
   - Assess daily for worsening/spreading cellulitis

4. VASCULAR ASSESSMENT:
   - Doppler USS + ABI (Ankle-Brachial Index): ABI <0.5 = critical ischaemia → urgent vascular surgery
   - If ischaemia: Angioplasty/bypass needed before wound healing

5. SURGICAL PLANNING:
   - Orthopaedic/Vascular/Plastic surgery MDT review
   - Sequestrectomy/debridement of infected bone
   - Consider toe amputation if bone non-viable / gangrene spreading
   - Wound VAC therapy (negative pressure) post-debridement

6. SUPPORTIVE:
   - Nutritional assessment; high-protein diet
   - Albumin check (hypoalbuminaemia impairs healing)
   - Physiotherapy
   - Podiatry referral for long-term foot care

DISCHARGE PLAN:
- 6 weeks IV/oral antibiotics (guided by C&S)
- Strict offloading continued at home
- Daily dressing by community nurse
- BSL diary + endocrinology OPD
- HbA1c recheck in 3 months
- Educate on foot care, daily inspection
- OPD surgery review 2 weeks

---

SUMMARY: QUICK REFERENCE TABLE — ALL 10 CASES

---

GENERAL PRINCIPLES FOR ANY SURGICAL ADMISSION

SURGICAL CLERKING ORDER (ALWAYS DO THESE):

HISTORY:         Site, Onset, Character, Radiation, Associated symptoms,
                 Timing, Exacerbating/Relieving factors, Severity (SOCRATES)
                 PMH, Drug history, Allergy, Social (smoking, alcohol)
                 Family history, Last menstrual period (women)

EXAMINATION:     Full systemic exam; ALL hernial orifices; rectal exam if abdominal pain
                 Neurovascular exam distal to any limb injury

MANDATORY INITIAL ORDERS FOR ANY SURGICAL PATIENT:
1. NBM if surgery likely
2. IV access + IV fluids (correct dehydration)
3. Urinary catheter if major case (monitor UO)
4. Analgesia (DO NOT withhold — modern surgery does not delay diagnosis)
5. Bloods: FBC, U&E, LFT, coagulation, G&S/crossmatch, BSL, HbA1c (diabetics)
6. ECG + CXR (pre-anaesthesia in >40yr or comorbid)
7. DVT prophylaxis: TED stockings + LMWH (Enoxaparin 20-40mg SC OD from admission)
8. Tetanus status for all wounds
9. Consent documented before any procedure
10. Post-op analgesia written up (not just PRN — prescribe regular paracetamol as minimum)

---