Clinical Log PART 1: Patients PARTICULAT AND PLANNED PROCEDUREKanchi Maya tamang, 22 years unmarried female from Nagarkot presented to Operation Theater today from Surgery ward for Laparoscopic cholecystectomy. Presentation: Patient presented to Surgery OPD with complain of pain on the right upper quadrant since 2 month.Hospital number: 322344Main diagnosis: Acute CholelithiasisHistory of Presenting Complaints and associated featuresPatient was apparent well 1 month back. Then she started feel pain on the right upper quadrant. The pain was of continues type and radiate to back. The pain was aggravated by having the fatty food. It was relieved with lying on the bed. There was no history of fever, nausea, vomiting. Her bowel and bladder habit was normal.Menstruation historyMenarche: 12 years, Regular cycle of 30 days, No history of dysmenorrhea.Systematic enquiryCentral Nervous System: No complainGastro intestinal system: No complainUrinary System: No complainMusculoskeletal system: No complainCardiovascular system: No complainRespiratory system: No complainPast medical and surgical History-There is no significant past medical history. Similarly there is no any previous surgical history. Drug historyShe had taken NSAIDS once one month back beside that there is no other significant drug history.Known drug allergies- There are no known drug allergies in the patient.Social historyShe follows Hinduism. She is non-smoker, non-alcoholic, and non-vegetarian.Family History-No significant family history. No known communicable disease in the family. There is not any history regarding the complication during the surgery. Summary of history22 years female presented to OPD with chief complain of pain on the right upper quadrant which radiates to back and aggravate with the fatty food. There is no history of nausea, vomiting or fever. There is no significant surgical history and any significant allergic history. Summary of ExaminationPatient was lying in the supine position. On general examination Icterus was present. There was no pallor, cyanosis, clubbing, edema, and tremor. Capillary refilling time was less than 2 sec.Vitals: BP: 110/70 mm of Hg, Pulse: 132/min sinus rhythm with normal volume, character, Temperature: 97 degree F, Respiratory rate: 20/minLocal examination:On Cardiovascular examination first and second sound was heard without any murmur. On chest auscultation there was bilateral equal breath sound. There was no added sound. On spinal examination there was no visible deformity, without presence of tenderness over the spinal area. On airway assessment mouth opening was more than 2 fingers size. Thyromental distance was > 6 cm. Neck was freely mobile. Temporomandibular joint was free. On assessing for the Mallampati grade, it was found to be grade 1. There were no loose or any false teeth present. Laboratory InvestigationHCT: 35%TC: 9.5 X 103/microliterDC: N:67%, L:28%, E:05%Platelet: 430 X 103/microliterBlood Group: B positiveRandom Blood sugar: 100 mg/dlSodium: 139Potassium:4.1Urea: 20Creatinine: 0.6Bilirubin: T: 0.5 D: 0.12AGOT:24 SGPT:22Alkaline Phosphate: 72Other InvestigationECG: Sinus rhythm with heart rate 80 bpmChest X-ray: Increased in vascularity on hilar regionUSG: CholelithiasisPatient was planned for laparoscopic Cholecystectomy. For that he was done Pre Anaesthetic Evaluation. On evaluation patient was adviced for midnight NPO. Concent form was also signed on the same day. Patient was adviced to take Tablet Diazepam 5 mg peroral at night and at the morning of the operation. Along with that she was given Rinitidine 150 mg to be taken same dose as Diazepam. On ASA PS grading she was kept on Grade 1.She is planned for operation under general Anesthesia. PART 2: ABOUT GENERAL ANAESTHESIAPreparation for anesthesia monitoring equipment is attached to the patient; IV access is obtained; Patient is preoxygenated.Once all of these have been achieved satisfactorily, the patient is anaesthetized.

Medication used in the process of General AnesthesiaDrug name: - RanitidineDose: - 150 mgRoute: - Oral Indication: -For decreasing the gastric acid secretionClass of drug: - H2 blockerMechanism of action:- It inhibits the H2 receptor in parietal cell of gastric mucosal, thereby it decreases the gastric acid secretionMain side effects and monitoring: Constipation Nausea, vomiting Headaches Insomnia

Drug name: - Tab Diazepam Dose: - 5 mgRoute: - POOnset of action: - 1 to 2 hoursT :- 30 to 60 hourFrequency:-One tablet before 12 hours of surgery and one tablet before 3 hour of surgery Indication and planned duration:- Premedication in anaesthesia for sedation, decrease gastric secretion and anxiety Class of drug: - BenzodiazepinesMechanism of action Act by enhancing pre/post synaptic inhibition through a specific BZD receptor which is an integral part of the GABA receptor Chloride channel complex.Main side effects and monitoring Dizziness, vertigo, ataxia, disorientation, amnesia, dry mouth, blurring of vision

Drug name:-Midazolam Dose: - 0.01-0.1 m/kgRoute: - IVOnset of action: - 30 to 60 secondsT :- 2 to 3 hourIndication and planned duration:-Sedation, anterograde amnesia and hypnosis for general anaesthesia Class of drug and mechanism of action:-BenzodiazepamMOA:-Inhibit the actions of glycine & facilitate the actions of the inhibitory neurotransmitter gamma aminobutyric acid (GABA)Main side effects and monitoring Respirations depression Hypotension Abuse

Drug name:-PethidineDose: - 0.2 -0.5 mg/kg Route:-IVIndication: - Analgesia for General anaesthesiaClass of drug: - Opioid Mechanism of action: Pethidine binds with opoid receptor (GiPCRs) inhibit adenylyl cyclase and reduce intracellular cAMP content decrease protein phosphorylation decrease in synthesis and release of major neurotransmitters. Ultimate effect: increase pain tolerance by decreasing perception and reaction to pain.Main side effects and monitoring: - Bradycardia, nausea, vomiting, itching, Respiratory depression, Convulsion

Drug name:-Sodium thiopentoneDose:-175 mg (5mg/kg)Route: - IVOnset of action: - Rapid onset of action (about 15sec. - arm to brain circulation)T :- 10 to 12 hoursIndication: -For induction of loss of consciousness (reversible) Class of drug: - Barbiturate Mechanism of action:- It has GABA facilitatory action at clinical doses there by it increases the membrane conductance to chloride ion causing hyperpolarization of membrane.Main side effects and monitoring: - Respiratory depression Transient apnea CVS depression Laryngospasm and bronchospasm Hypotension, Allergy Locally tissue necrosis because of high alkalinityDrug name:- Vecoronium Dose:- 5 mg+ 1mg+ 1mg Route: - IVOnset of action: - 2 to 3 minutesDuration of effects:- 15 to 20 minutesIndication: -For skeletal muscle paralysis/ relaxationClass of drug: - Non depolarizing skeletal muscle relaxantMechanism of action:- It is competitive antagonists with acetylcholine at Ach receptors and binds at same site at which acetylcholine binds relaxation of skeletal muscleMain side effects and monitoring: Bradycardia and hypotension Hyperkalaemia Increases intracranial tension Arrhythmias

Drug name:- Halothane Dose:- 1-1.2%Route: - InhalationMAC :-0.74%Indication: -For maintenance of anaesthesiaClass of drug: - Inhalational General anaesthetic agentMechanism of action:- Block Na + channel Enhance GABA mediated inhibition Directly bind to cellular proteins altering their enzymes Decreases release of adrenaline, noradrenalineMain side effects and monitoring: CVS depression Respiratory depression Increase in intracranial tension Halothane hepatitis Postoperative shivering

Drug name: - NeostigmineDose: - 0.04 to 0.08 mg/kgRoute: - IVOnset of action: - 5 to 10 minutesIndication: -For reversal of muscle relaxationClass of drug: - AnticholinesteraseMechanism of action:- It blocks the cholinesterase enzymes in neuromuscular junction cause increase concentration of Ach.Main side effects and monitoring: Hypotension and bradycardia Increase body secretion (salivation)

Drug name: - GlycopyrrolateDose: - 0.01 mg/kgRoute: - IVDuration of action : 4-6 hoursIndication: -For physiological reversal of undesired effect of atropine like bradycardia, increased secretion.Class of drug: - AnticholinergicMechanism of action:- It inhibits the Ach receptors and blocks the action of Ach. The advantage over atropine is that it is a quaternary ammonium compound, does not crosses the blood brain barrier and so central side effects are not seen. Its antisialagogue action is better than atropineMain side effects and monitoring: Tachycardia, palpitation Dry skin and mucosa Blurred vision Urinary retentionPART 3: ReflectionThis is the case that helped me to learn about the anesthesia. It helped me to understand all the procedure that has to be came across during the procedure of anesthesia. From this case I came operation theater know that anesthesia is not only the procedure that is done only at the operation table it is a continuous process that include from the pre-anesthetic evaluation to the end of the operation even after the surgery is completed. The degree of pre anesthetic is directly related to the success of the intraoperative anesthetic care as well as postoperative care. I think by being on this posting I have known all these including all the procedure that is carried on anesthetic procedure. Knowing this procedure might help in any time in the future. Most important thing that I learnt is to intubate the patient. That will be helping in emergency in the future.