1. Haemorrhoids
Grading of haemorrhoids
Grade 1: only bleeding present, no prolapse
Grade 2: prolapse with spontaneous reduction, bleeding may be present
Grade 3: prolapse, do not reduce spontaneously ( have to be pushed inside)
Grade 4: remains prolapsed, cannot be reduced.
Management of haemorrhoids
Grade 1 haemorrhoids:
• Drink plenty of fluids
• High-fibre diet
• Avoid fatty spicy foods
• Sitz Bath 2-3 times a day
• Syrup Looz 15ml OD HS
• Tablet DICLO 50mg BD for 3 days
• Tablet OMEPRAZOLE 20mg OD BBF
• Ointment LIGNOCAINE LA BD
• Ointment ANOVATE LA BD
Great 2 haemorrhoids:
Same as grade 1 + either Banding or sclerotherapy
Grade 3 haemorrhoids:
Manage like grade two, if no response – surgery (open or stapler haemorrhoidectomy)
Grade 4 haemorrhoids:
Require surgery(in addition to surgery, lifestyle modifications, as well as dietary changes)
2. Anal Fissure
Management of Anal Fissure
• Drink plenty of fluids
• High-fibre diet
• Avoid fatty spicy foods
• Sitz Bath 2-3 times a day
• Syrup Looz 15ml OD HS
• Tablet DICLO 50mg BD for 3 days
• Tablet OMEPRAZOLE 20mg OD BBF
• Ointment LIGNOCAINE LA BD
• Ointment ANOVATE LA BD
If Conservative management fails, then operative management- Lateral Anal Sphincterotomy.
3. Perianal fistula
Management of perianal fistula:
Definitive management: surgery (Fistulectomy, Fistulotomy, Seton treatment)
Conservative management: same as grade 1 haemorrhoids.
4. Hernia
Clinical examination of inguinal hernia:
Pulsatile cough impulse
Deep ring occlusion test
Investigation of choice: USG
Management:
Conservative -
• TRUSS (Compression undergarment) [not curative]
• Weight management- it reduces intra- abdominal pressure
• Manage constipation: high-fibre diet, staying hydrated.
• Avoid Heavy Lifting
• Quit smoking: Chronic cough increases abdominal pressure.
Open surgery-
A) Herniorraphy
B) Hernioplasty (Lichenstein’s Tension free mesh Hernioplasty- surgery of choice)
Laparoscopic surgery-
A) TEP (total extra-peritoneal repair)
B) TAPP( trans abdominal pre-peritoneal repair)
5. Hydrocele
Clinical examination:
• Fluctuation sign positive
• Can get above the swelling
• Transillumination test
- Primary hydrocele: brilliantly transilluminant
- Secondary hydrocele: no transillumination
Management:
Conservative management:
• Wait and Watch: Often small hydrocele are painless and don’t require treatment.
• Scrotal support.
Surgical management
A) Jabouley’s Procedure: Eversion of sac
B) Lord’s Plication: for small hydrocele
6. Lipoma
Examination of lipoma
• Not attached to overlying skin
• Slip sign positive
Diagnosis: FNAC
Management: Surgical removal under LA (only if, there is rapid increase in size, become painful, cosmetic reasons.)
7. Sebaceous Cyst
Examination of Sebaceous cyst:
• Punctum present
• Overlying skin cannot be pinched
• Fluctuation present
Management: Excision of cyst, including skin adjacent to punctum using elliptical incision .
(Whole capsule should be removed properly, otherwise cyst will recur.)
8. Ganglion cyst
Fluid filled lump that commonly develops along the tendon or joints of wrist or hands
Management
• Aspiration (commonly done)
• Excision (if persistent or recurrent symptoms)
9. Varicose Veins
Investigation of choice: Doppler with B mode USG
Management of varicose veins:
A) Adjunctive Management:
• Compression stockings
• Elevate your legs
• Weight management: reduced pressure on the way
• Avoid prolonged sitting or standing. Shift positions frequently or take short walking breaks.
B) Surgery
- For Great Saphenous Veins and SFJ incompetence: Trendelenburg Procedure
- For short Saphenous vein and SPJ incompetence: Flush ligation of SPJ and no stripping is done.
- For Perforator Incompetence: Dodd and Cockett Procedure.
10. Venous Ulcer
Management of Venous ulcer:
BISGARD Regime
• Education of Patient (regarding foot care, correct shoes which are well cushion and cover entire foot, nail care)
• Limb elevation
• Elastic compression stockings
• Four layer bandage technique
- Layer 1 : Orthopedic wool
- Layer 2: cotton crepe
- Layer 3: elastic bandage
- Layer 4: cohesive bandage
• Antibiotics, if infection present
• Pentoxyfylline: reduces blood viscosity, and improve blood flow
• Surgery for varicose veins
11. Arterial Ulcer
Management of arterial ulcer:
- Revascularization
- Regular dressing
- VAC dressing
12. Diabetic Foot
Grades of diabetic ulcer ( Wagner Classification):
Grade 0: intact skin in patients who are at risk
- Management: (Antibiotics, Sugar control, Foot care, correct shoes)
Grade 1: superficial ulcer with exposed subcutaneous tissue
- Management: Antibiotics, Debridement, VAC dressing, Sugar control, Foot care.
Grade 2: exposed tendon and deep structures
- Management: Same as Grade1
Grade 3: ulcer extends to deep tissue and have either associated soft tissue abscess or osteomyelitis
- Management: Same as grade 1, debridement and abscess drainage
Grade 4: ulcer include feet with partial gangrene
- Management: Antibiotics, Debridement, Sugar control, Eventually land up with Amputation
Grade 5: feet ulcer with more extensive gangrenous tissue
- Management: Amputation, Antibiotics, Sugar control.
13. Abscess
Management:
• Incision and Drainage
• Antibiotics for 5 days
(Tab Amoxicillin 500mg TDS x 5days
+
Tab Pantop 40mg OD BBF x 5days)
14. Mastalgia
a) Cyclical:
Fibroadenosis ( pain during beginning of cycle, breast lump may be present)
Management:
• Lifestyle changes
• Weight Reduction
• Reduce Tea/ Coffee intake
• Tab Vit E x 2 months
• Primrose oil Capsule x 2 months
After 2 month, if pain persists, Low dose Tamoxifen
b) Non-cyclical:
Costochondritis ( Tietze Syndrome):
Management:
• Intralesional Triamcinolone
Mondor’s Disease
(Superficial Thrombophlebitis of Chest Veins)
M/c vein involved: Lateral Thoracic Vein
Management:
• Analgesics
15. Breast Lump
• Detailed history and examination
• Mammography (If Age >40 years)
• USG B/L Breast + Axilla (If age < 40 years)
Management based on BIRADS Score
16. Acute Cholecystitis
Investigation: USG abdomen
Management:
• Advise Hospitalisation
• Conservative treatment initially
- IV fluids
- Analgesics and Antispasmodics
- Broad Spectrum Antibiotics
(Ceftriaxone, Ceftazidine, Cefotaxime + Amikacin, Tobramycin + Metronidazole)
- Observation and Follow up USG.
• Elective Interval Cholecystectomy: After 6 weeks.
17. Cholelithiasis
Investigation: USG Abdomen
Management: Laparoscopic/open Cholecystectomy
18. Acute Appendicitis
Investigation: USG abdomen
Management: Immediate Surgery (Laparotomy or through classic approaches)
19. Appendicular Lump
Investigations:
- USG abdomen
- CBC (TLC raised)
Treatment:
Ochsner-Sherren Regimen
• Temp, BP and Pulse charting
• Mark the mass (to check it’s Regressing/ progressing)
• Antibiotics (Ampicillin, Metronidazole, Gentamicin or other, depending on severity and requirement)
• IV fluids
• Analgesics
• Initial Nasogastric Aspiration.
(Response: Usually by 48-72 hours, mass reduces in size, Temp and pulse becomes normal, Appetite regained.)
• Patient is advised Interval appendicectomy, after 6 weeks
If Patient become more toxic, persistent vomiting, Increase in size, pain increase, Abscess formation in mass,
Ochsner-Sherren Regimen is discontinued and Immediate Surgery done (Laparotomy or classic approach)
20. Keloid
Treatment:
• IntraKeloidal Triamcinolone (at regular intervals, once in 7-10 days, 6-8 injections)
21. Corn
Treatment:
• Excision of corn
• Local application of Salicylic acid Or mixture of salicylic acid/ lactic acid / Colloidion.
• Eliminating Pressure , to prevent recurrence.
22. Phimosis
Causes:
A) Congenital: child with pinhole meatus.
B) Balanitis: Inflammation of glans, prepure and sac, Common in diabetics
Treatment:
• Circumcision
23. Burns (Follow up case)
Management:
• After cleaning with Povidone Iodine solution, Silver Sulfadiazine Ointment is used
• Regular dressing
• Regular slough Excision
24. UTI
C/o Burning micturition
Investigation:
• Urine- Routine and Microscopy
• Urine- Culture and sensitivity
Treatment:
• Tab Nitrofurantoin 100mg BD
• Or specific antibiotic according to Urine - Culture sensitivity report
25. Renal Stone
c/o flank pain, burning micturition (may ne present)
Investigation: Ultrasound
Treatment:
A) Operative management:
- Percutaneous Nephrolithotomy
- Extracorporeal shock wave Lithotripsy
B) Conservative management:
• IV Fluids
• Inj Frusemide 60-80mg IV
• Anti-inflammatory and anti spasmodic agents (to relieve pain)
• Flush Therapy: mainly for lower ureteric stones
