Lecture notes for medical students

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2. Introduction

3. Introduction
Our cases fall in one of the three categories.
Viz.
• 1.Diagnosis is immediately obvious.
• 2.Diagnosis is immediately excluded.
• 3.Diagnosis is unclear.

4. • I want to discuss today this third category in
which most of the patients we see fall.

5. • When diagnosis is not clear we order further
investigations and keep the patient under
observation. Repeat examinations over a
period of time clarify the diagnosis. The
question is what treatment should be given
during observation

6. • The question is what treatment should be
given during observation

7. • I want to discuss today this third category in
wLet us look at some typical cases that we
often see.
• 1.Acute Abdominal Pain.
• 2.Head Injury.
• 3.Acute Testicular Pain.
• 4.Blunt abdominal

8. • In all of the above the two extremes ie.
Absence of a lesion requiring operative
intervention and presence of a lesion
requiring operative intervention present no
particular difficulty in choosing line of
management.

9. • How about a patient
• Who may or may not have acute
appendicitis.
• May or may not have middle meningeal
artery hemorrhage.
• May or may not have testicular torsion.
• May or may not have visceral injury.

10. • A typical protocol for ?Acute Appendicitis that we
use is
• Nill orally
• Inj. Xone 1gm. Iv 12 hourly
• Inj.Metrogyl 100ml. Iv.8 hourly
• Inj. Gentamicin 80 mg.iv 8 hourly
• Inj. Diclofenac 75mg.im stat &
12hourly
• Inj.Tramazac 2ml.iv. sos.
• Inj.Ringer’s Lactate 2000 ml.

11. • A typical prescription for suspected head injury is
• No sedation
• Nill orally
• Inj.Xone 1gm. Iv.12hourly
• Inj.Mannitol 300ml.iv. 12 hourly fast.
• Inj.Decadron 8mg. Iv. 6hourly
• Inj.Dextrose 50% 50 ml. Iv 6hourly
• Inj. Dextrose 10% 1000ml.
• Inj. Dextrose 5% 1000ml

12. • A typical prescription for Acute Testicular
Pain is
• Nill orally
• Inj. Ciplox 100 ml.iv. 12 hourly
• Inj.Diclofenac 75mg. Im. 12
hourly
• Inj. Ringer’s Lactate 2000ml.
• Scrotal Support.

13. • The rationale seems to be that mild degree
of these diseases are to be treated
conservatively and if conservative
management fails then only patient should
be operated.

14. • These protocols have served us well over
the years and most of the patients who are
treated in this way do well, recover fast and
need no surgery. Only a small a percentage
of cases requires surgical intervention.

15. • But I beg to differ.
• The very purpose of observation is to
identify that small minority of patients who
will need surgery.

16. • Majority of patients who do well on the
above regimen never needed surgery and
their course would have been the same if
they were not treated at all.

17. • Let us discuss effect of our regimen on
those who need surgery.
• Drug therapy masks their symptoms which
leads to delay in surgery hence increasing
the mortality and morbidity.

18. • 1.In case of head injury giving of mannitol or
dextrose
• I Serves to enhance intracranial hemorrhage.
• II. Delays the development of alarming signs
and symptoms thus delaying referral to
neurosurgeon.
• III.Had dehydration therapy not been given we
could give it now to buy time for shifting the
patient to neurosurgical centre.

19. • In case of Acute Appendicitis giving of
antibiotics leads to masking of symptoms
which delays operation increasing mortality
and morbidity. We should not forget that
pathology of acute appendicitis is
obstruction and it is not helped by
antibiotics .

20. • . In acute testicular pain we must exclude
torsion which is not possible clinically.
Giving of conservative treatment gives us a
false sense of security while the testis is
becoming gangrenous.

21. • Hence I suggest following regimen:
• 1.Head injury
• No Sedation.
• Nil orally.
• Inj. Ringer’s Lactate 1 litre/24hours.
• Antibiotics and Tetanus Prophylaxis if
external injury.

22. • .Abdominal Pain
• NO ANTIBIOTICS NO ANALGESICS
• Nil orally
• Inj. Ringer’s Lactate 2 litre/24hours.
• Inj. Ranitidine 1amp. iv. 8 hourly.
• Inj. Buscopan 1amp. iv. on pain.
•

23. Acute Testicular Pain.
• Exploration.

24. • Blunt abdominal trauma.
• Nil orally.
• Inj Ringer’s Lactate 1 litre/24hours.

25. •Thanks

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