SANS General Clinical Flashcards
Pasien berusia 16 tahun dengan cedera otak berat yang traumatik dalam pemberian profopol IV secara berkelanjutan untuk manajemen ICP/CPP. Pada pasien didapatkan urine output yang rendah, demam ringan dan darah yang diambil untuk pemeriksaan laboratorium berwarna kekeruhan. Diagnosis “Propofol Infusion Syndrome” pun kemudian diusulkan. Manakah hasil laboratorium dibawah ini yang TEPAT menunjukkan diagnosis tersebut ?
A. Serum Potasium 3,4
B. Serum Kreatin kinase 75.000
C. ABG pH 7,35
D. Serum Kreatinin 1,2
E. Serum Trigliserida 100
B. Serum Kreatin kinase 75.000
The answer is serum creatine kinase of 75,000. Propfofol Infusion Syndrome (PIS) has been reported in pediatric and adult patients undergoing prolonged high-dose propofol therapy (>4-5 mg/kg/hr for > 48 hours). The clinical features of this syndrome include rhabdomyolysis, resulting in high creatine kinase, urine myoglobin, or both. The rhabdomyolyis results in renal failure, which is characterized by oligo- or anuria, elevated creatinine, and hyperkalemia. Other important features of the syndrome include cardiac bradyarrhythmias and ventricular arrhythmias with possible cardiac failure and death; lipemia, manifested by high serum triglycerides; hepatomegaly and elevated transaminases, with evidence of fatty liver. Metabolic acidosis is a primary feature and may be the first laboratory evidence of the syndrome. Treatment is to promptly stop the propofol infusion, especially if metabolic acidosis is noted. Dialysis may be required. However, once the full syndrome develops the prognosis for survival is poor. According to the available case reports and series, propofol infusion syndrome has not been seen at dosages below 4 mg/kg/hr. Care should be taken to assure that such dosages are not exceeded. As the safety of propofol for ICU sedation has not been formally studied in the pediatric age group, propofol is not approved for this purpose in patients under the age of 16. High-dose propofol has been used to treat patients with conditions such as severe head injury and refractory seizures. Seizures, per se, have not been reported as part of this syndrome. There is some evidence that patients receiving catacholamines or steroids concomitantly may harbor an increased risk of developing PIS
Seorang wanita sehat berusia 28 tahun yang baru saja melahirkan anak keduanya 10 hari lalu datang dengan gejala nyeri kepala baru, letargi dan resah/kebingungan. Tidak didapatkan defisit fokal. Hasil CT-scan tanpa kontras didapatkan dan terlihat seperti di gambar. Manakah dibawah ini yang merupakan terapi definitif pada pasien tersebut?
A. Embolisasi endovaskuler
B. Recombinant activated factor VII
C. Intravenous heparin infusion
D. Craniotomy untuk evakuasi hematoma
E. Observation
C. Intravenous heparin infusion
The scenario depicted above is indicative of intracerebral hemorrhage from cerebral sinus thrombosis, making anticoagulation with continuous intravenous heparin infusion the most appropriate answer. Small hemorrhages are evident on CT (white arrows), as well as a hyperdense superior sagittal sinus, likely representing sinus thrombosis. The diagnosis of sinus thrombosis is reinforced by the clinical history of a recent childbirth; cerebral sinus thrombosis is more likely in patients with a hypercoagulable state, such as the peripartum period (within 16 days of childbirth). Intracerebral hemorrhage often secondarily occurs in patients with cerebral sinus thrombosis due to venous hypertension. Treatment goals for a patient with sinus thrombosis are prevention of further thrombosis and recanalization of the occluded sinus. Initial treatment should be administration of anticoagulation with a continuous intravenous heparin infusion. Administration of potent pro-thrombotic agents such as recombinant activated Factor VII will worsen the sinus thrombosis, likely leading to increased hemorrhage and worsening clinical outcome. Emergent craniotomy and evacuation of the hematoma is not indicated in this scenario as the hemorrhages are small and producing little mass effect. Hematoma evacuation may be indicated if the hemorrhage is large and actively contributing to increased intracranial pressure and herniation. While a cerebral angiogram is useful in establishing the correct diagnosis and evaluating the extent of the sinus thrombosis, it does not need to be obtained emergently and it should not delay the administration of intravenous anticoagulation. Endovascular therapy for sinus thrombosis (i.e. transvenous thrombolysis) is generally reserved for patients who are refractory to medical management.
Seorang pria 48 tahun dengan “right middle cerebral artery distribution infarction”. Walaupun telah dilakukan terapi medikamentosa dan endovaskuler yang agresif, sampai saat ini arteri tetap tersumbat. Dua hari kemudian, pasien mengalami penurunan status mental. Hasil CT-Scan terlampir. Apakah penjelasan yang paling mungkin untuk penyebab kerusakan neurologis pasien?
A. Hiperemia oklusif
B. Sindroma referfusi
C. Konversi perdarahan
D. Edema serebral
E. Breakthrough dari tekanan perfusi normal
D. Edema serebral
The most likely cause of acute deterioration 2 days after a completed large territory stroke is cerebral edema. The CT demonstrates a large right MCA infarct associated with mass effect and midline shift from cerebral edema. No sign of hemorrhage is present on the CT scan. The patient presented outside the window for intravenous recombinant tissue plasminogen activator (tPA) or endovascular therapy. Therefore, hemorrhagic conversion and reperfusion injury are unlikely causes of his mental status change.
Pemantauan fungsi nervus Hipoglossus selama operasi dilakukan dengan penempatan elektroda pada bagian otot :
A. palatoglossus
B. genioglossus
C. geniohyoid
D. stylopharyngeus
B. genioglossus
The hypoglossal nerve is a purely motor nerve that supplies all the muscles of the tongue except the palatoglossus muscle which is supplied by the Xth cranial nerve. Hypoglossal nerve monitoring is performed by placing electrodes into the ipsilateral genioglossus muscle after intubated. The palatoglossus muscles are supplied by the Xth cranial nerve and the stylopharyngeus muscle is supplied by the IXth nerve. The geniohyoid muscle is innervated by C1.
Penyakit aterosklerosis intrakranial dan stenosis adalah penyebab utama dari stroke iskemik. Etnis manakah dibawah ini yang memiliki insiden tertinggi penyakit aterosklerosis intrakranial?
A. Caucasian
B. Asian
C. African America
D. Hispanic
C. African America
Patients of African American descent are epidemiologically at the highest risk of having intracranial atherosclerotic disease. Atherosclerotic stenosis of the major intracranial arteries (ICA, MCA, vertebral artery, and basilar artery) is an important cause of ischemic stroke. Previous studies have shown an increased risk of stroke in patients of African American descent, followed by Asian, Hispanic, and Caucasian. Several studies suggest that atherosclerosis of intracranial large arteries is more likely to develop in African Americans than Caucasians. In one series of patients with anterior circulation ischemia, cerebral angiography identified MCA occlusion in 90% of African American males compared to 12% in Caucasian males.
Jumlah cairan IV yang sesuai untuk dosis pemeliharaan pada anak berusia 2 minggu adalah?
A. 4 ml/kg/jam
B.10 ml/kg/jam
C. 2 ml/kg/jam
D. 20 ml/kg/jam
E. 1 ml/kg/jam
A. 4 ml/kg/jam
The appropriate maintenance IVF rate for a hospitalized infant from 3 days to 3 months old is 4 ml/kg/hour. 2 ml/kg/hour may be appropriate on the first day of life, but not after three days of life. The other rates are not appropriate for infants under standard circumstances.
Sistem sensorik manakah yang paling sering terpengaruh pada reseksi dari lesi di girus post-sentral?
A. Suhu
B. Nyeri
C. Propiosepsi
D. Perabaan halus
E. Tekanan
C. Propiosepsi
The most common sensory deficit seen postoperatively is a deficit in proprioception. Resection of lesions in the postcentral gyrus patients have been shown to display immediately postoperative deficits with complete recovery of function in 2-3 months. Functional studies indicate that somatosensory cortex activation originates primarily from proprioception. The results of these studies can possibly explain the origin of this postoperative sensory deficit.
