Clinical Log

PART 1: Patients PARTICULAT AND PLANNED PROCEDURE

Kanchi 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: 322344
Main diagnosis: Acute Cholelithiasis
History of Presenting Complaints and associated features
Patient 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 history
Menarche: 12 years, Regular cycle of 30 days, No history of dysmenorrhea.
Systematic enquiry
Central Nervous System: No complain
Gastro intestinal system: No complain
Urinary System: No complain
Musculoskeletal system: No complain
Cardiovascular system: No complain
Respiratory system: No complain
Past medical and surgical HistoryThere is no significant past medical history. Similarly there is no any previous
surgical history.
Drug history
She had taken NSAIDS once one month back beside that there is no other
significant drug history.
Known drug allergiesThere are no known drug allergies in the patient.
Social history
She follows Hinduism. She is non-smoker, non-alcoholic, and non-vegetarian.

Family HistoryNo significant family history. No known communicable disease in the family. There is
not any history regarding the complication during the surgery.

Summary of history
22 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 Examination
Patient 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/min
Local 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 Investigation
HCT: 35%
TC: 9.5 X 103/microliter
DC: N:67%, L:28%, E:05%
Platelet: 430 X 103/microliter
Blood Group: B positive
Random Blood sugar: 100 mg/dl
Sodium: 139
Potassium:4.1
Urea: 20
Creatinine: 0.6

Bilirubin: T: 0.5 D: 0.12

AGOT:24
SGPT:22
Alkaline Phosphate: 72
Other Investigation
ECG: Sinus rhythm with heart rate 80 bpm
Chest X-ray: Increased in vascularity on hilar region
USG: Cholelithiasis
Patient 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 ANAESTHESIA

Preparation 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 Anesthesia

Drug name: - Ranitidine
Dose: - 150 mg
Route: - Oral
Indication: -For decreasing the gastric acid secretion
Class of drug: - H2 blocker
Mechanism of action:

It inhibits the H2 receptor in parietal cell of gastric mucosal, thereby it

decreases the gastric acid secretion

Main side effects and monitoring:

Constipation
Nausea, vomiting
Headaches
Insomnia

Drug name: - Tab Diazepam

Dose: - 5 mg
Route: - PO
Onset of action: - 1 to 2 hours
T :- 30 to 60 hour
Frequency:-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: - Benzodiazepines

Mechanism 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/kg
Route: - IV
Onset of action: - 30 to 60 seconds
T :- 2 to 3 hour
Indication and planned duration:-Sedation, anterograde amnesia and hypnosis for
general anaesthesia
Class of drug and mechanism of action:-Benzodiazepam
MOA:-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:-Pethidine
Dose: - 0.2 -0.5 mg/kg
Route:-IV
Indication: - Analgesia for General anaesthesia
Class 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 thiopentone

Dose:-175 mg (5mg/kg)
Route: - IV
Onset of action: - Rapid onset of action (about 15sec. - arm to brain circulation)
T :- 10 to 12 hours
Indication: -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 alkalinity

Drug name:- Vecoronium

Dose:- 5 mg+ 1mg+ 1mg
Route: - IV
Onset of action: - 2 to 3 minutes
Duration of effects:- 15 to 20 minutes
Indication: -For skeletal muscle paralysis/ relaxation
Class of drug: - Non depolarizing skeletal muscle relaxant
Mechanism of action:

It is competitive antagonists with acetylcholine at Ach receptors and binds at

same site at which acetylcholine binds relaxation of skeletal muscle

Main side effects and monitoring:

Bradycardia and hypotension

Hyperkalaemia
Increases intracranial tension
Arrhythmias

Drug name:- Halothane

Dose:- 1-1.2%
Route: - Inhalation
MAC :-0.74%
Indication: -For maintenance of anaesthesia
Class of drug: - Inhalational General anaesthetic agent
Mechanism of action:

Block Na + channel
Enhance GABA mediated inhibition
Directly bind to cellular proteins altering their enzymes
Decreases release of adrenaline, noradrenaline

Main side effects and monitoring:

CVS depression
Respiratory depression

Increase in intracranial tension

Halothane hepatitis
Postoperative shivering

Drug name: - Neostigmine

Dose: - 0.04 to 0.08 mg/kg
Route: - IV
Onset of action: - 5 to 10 minutes
Indication: -For reversal of muscle relaxation
Class of drug: - Anticholinesterase
Mechanism 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: - Glycopyrrolate

Dose: - 0.01 mg/kg
Route: - IV
Duration of action : 4-6 hours
Indication: -For physiological reversal
bradycardia, increased secretion.

of

undesired

effect

of

atropine

like

Class of drug: - Anticholinergic

Mechanism 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 atropine

Main side effects and monitoring:

Tachycardia, palpitation
Dry skin and mucosa
Blurred vision

Urinary retention

PART 3: Reflection
This 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.