Perianal abscess
IPD admission notes
C/o pain & Swelling in right perianal region x 4days
h/o pain & swelling increasing x 2days
h/o fever +
No h/o nausea&vomiting
No h/o DM/HTN/allergy/seizure/trauma
Sx h/o – if any ?
No h/o bowel/bladder complaints
No h/o tobacco/tapkir/alcohol use
O/E – conscious,oriented to TPP, afebrile
PR- 104/min
BP-120/70 mmHg
SpO2- 99% on RA
PA- soft
Nontender
Nondistended
LoSoKo
BS ++/++
L/E – right perianal 5x6 swelling +, tenderness+, local temp. raised
Fluctuation+
Send
CBC,RFT,LFT,PT/INR,S.Electrolytes,HHH,BSL-R,BG,Urine-R/M,CXR-PA,ECG,USG-local swelling, Fitness &
PAC
Adv
Full diet
TPR/BP-8hrly
OT notes – perianal abscess
Position-lithotomy under SA
Parts P+D done
Stab incision taken over most prominent part of swelling
Pus drained, all loculi broken with finger
Incision converted into crucite incision
Betadine+H2O2 wash given
Cavity packed with betadine+H2O2 soaked gauze
Adequate hemostasis achieved
Dressing done
Procedure uneventful
Pus sent for C/S
Post-OP orders
POD#0
O/C/O Perianal abscess u/w I&D under SA
Pt. seen
-----------------
NMB x 8hrs
Headlow x 8hrs
TPR/BP/BSL-8hrly
I/O charting
Sitz bath with 10% betadine QID
-------------------------
Rx
D1/5-Inj. Xone 1gm iv bd (AST)
D1/3-Inj. Amikacin 500mg iv od
Inj. Pan 40mg iv od
Inj. Dynapar-AQ 75mg iv bd
Inj. Emeset 4mg iv SOS
I/V/F RL/DNS/D5% ALT@100ml/hr iv over 24hrs
c/s/b Dr. under surgery
POD#1
O/C/O Perianal abscess u/w I&D under SA
Pt. seen
C/o pain over Sx site
O/E – conscious, oriented to TPP,afebrile
PR- 82/min
BP-110/70 mmHg
SpO2- 99% on RA
PA- soft
Nontender
Nondistended
LoSoKo
BS ++/++
Flatus- yes
Motion- yes
U/O- adequate
Adv
Full diet
TPR/BP-8hrly
Mobilise
Sitz bath with 10% betadine QID
-------------------------
Rx
D2/5-Inj. Xone 1gm iv bd (AST)
D2/3-Inj. Amikacin 500mg iv od
Inj. Pan 40mg iv od
Inj. Dynapar-AQ 75mg iv bd
Inj. Emeset 4mg iv SOS
I/V/F RL/DNS ALT@60ml/hr iv over 24hrs
c/s/b Dr. under surgery
POD#2
O/C/O Perianal abscess
Pt. seen
C/o pain over Sx site
O/E – conscious, oriented to TPP,afebrile
PR- 82/min
BP-110/70 mmHg
SpO2- 99% on RA
PA- soft
Nontender
Nondistended
LoSoKo
BS ++/++
Flatus- yes
Motion- yes
U/O- adequate
Adv
Full diet
TPR/BP-8hrly
Mobilise
Sitz bath with 10% betadine QID
-------------------------
Rx
D3/5-Inj. Xone 1gm iv bd (AST)
D3/3-Inj. Amikacin 500mg iv od
Inj. Pan 40mg iv od
Inj. Dynapar-AQ 75mg iv bd
Inj. Emeset 4mg iv SOS
c/s/b Dr. under surgery
POD#3
O/C/O Perianal abscess
Pt. seen
C/o mild pain over Sx site
O/E – conscious, oriented to TPP,afebrile
PR- 82/min
BP-110/70 mmHg
SpO2- 99% on RA
PA- soft
Nontender
Nondistended
LoSoKo
BS ++/++
Motion- yes
U/O- adequate
Adv
Full diet
TPR/BP-8hrly
Mobilise
Sitz bath with 10% betadine QID
-------------------------
Rx
D4/5-Inj. Xone 1gm iv bd
T. Pan 40mg od
T. Zerodol-SP 1tab BD
C. Bcomplex 1cap od
Syp. Cremaffin 30ml HS
c/s/b Dr. under surgery
POD#4
O/C/O perianal abscess
Pt. seen
No complaints
O/E – conscious, oriented to TPP,afebrile
PR- 82/min
BP-110/70 mmHg
SpO2- 99% on RA
PA- soft
Nontender
Nondistended
LoSoKo
BS ++/++
Motion- yes
U/O- adequate
Adv
Full diet
TPR/BP-8hrly
Mobilise
Sitz bath with 10% betadine QID
-------------------------
Rx
D5/5-Inj. Xone 1gm iv bd
T. Pan 40mg od
T. Zerodol-SP 1tab BD
C. Bcomplex 1cap od
Syp. Cremaffin 30ml HS
c/s/b Dr. under surgery
POD#5
O/C/O perianal abscess
Pt. seen
No complaints
O/E – conscious, oriented to TPP,afebrile
PR- 82/min
BP-110/70 mmHg
SpO2- 99% on RA
PA- soft
Nontender
Nondistended
LoSoKo
Motion- yes
U/O- adequate
Adv
Full diet
TPR/BP-8hrly
Mobilise
Sitz bath with 10% betadine QID
-------------------------
Rx
D1/5 T. Cepodem 200mg Bd
T. Pan 40mg od
T. Zerodol-SP 1tab BD
C. Bcomplex 1cap od
Syp. Cremaffin 30ml HS
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