MDE DMS 2008

Senin, 07 Desember 2009

1. A 35 y.o. man underwent partial thyroidectomy for hyperthyroidism in which the thyoid failed to take up radioactive iodine. He is noted to have some hoarseness of voice 1 month later. Which of the following nerve is most likely injured?
A. Superior laryngeal nerve
B. Recurrent laryngeal nerve
C. Spinal accessory nerve
D. Hypoglossal nerve
Jawaban : B
Alasan : Hoarseness is the usual sign of unilateral recurrent nerve injury; however, temporary aphonia or disturbance of phonation and laryngeal spasm may also occur (Moore hlm 1087)

2. Which of the following muscle is most important to allow air movement through the larynx?
A. Posterior cricoarytenoid muscle
B. Lateral cricoarytenoid muscle
C. Thyroarytenoid muscle
D. Cricothyroid muscle
E. Vocalis muscle
Jawaban : B
Alasan : fungsi thyroarytenoid adalah untuk relaksasi vocal ligament (Moore hlm 1094)

3. A 40 y.o. female come to hospital with shooting pain down her left leg and worsen when sitting and coughing. There is numbness in the same area. The physician test her sensation on the lateral thigh region. Which of the following nerve roots is most likely being tested?
A. L1 - L2
B. L2 - L3
C. L4 - L5
D. S1 - S2
E. S3 - S4
Jawaban : B
Alasan : hlm 585-586 Moore (dermatome)

4. A 30 y.o. woman complains unable to walk on her tip-toes. Which of the following nerves is most likely damaged?
A. Sural nerve
B. TIbial nerve
C. Deep fibular nerve
D. Common fibular nerve
E. Superficial fibular nerve
Jawaban : D
Alasan : The loss of dorsiflexion of the ankle cause footdrop, which is exacerbated by unopposed inversion of the foot. The toes do not clear the ground during swing phase of walking (hlm 646 Moore)

5. Which of the following ligaments has prevented abduction of the leg at the knee?
A. Anterior cruciate
B. Posterior cruciate
C. Lateral collateral
D. Medial collateral
Jawaban : C
Alasan : ga tau jawaban pasti, tapi cruciate ligament itu fungsi utamanya mencegah sliding femur dari tibia. Kalo collateral posisinya pas di samping patella, fungsinya menjaga stabilitas saat berdiri, jadi mungkin fungsinya memang mengatur abduksi/adduksi patella. Untuk abduksi (menjauhi sumbu tubuh) yang mungkin itu lateral collateral ligament (Moore hlm 687)

6. A 35 y.o. man complaints of the weakness in the ability to flex the knee. This indicates a problem with which of the following nerves?
A. Tibial nerve
B. Femoral nerve
C. Deep fibular nerve
D. Common fibular nerve
E. Superficial fibular nerve
Jawaban : A
Alasan : popliteus muscle berfungsi untuk fleksi lutut (weakly) dan diinervasi oleh tibial nerve (Moore hlm 649)

7. A young athlete has sustained an injury to his right shoulder. Which of the following structure is most likely to maintain the main stability of this joint?
A. Rotator cuff muscle
B. Celenohumeral ligament
C. Coracohumeral ligament
D. Coracoclavicular ligament
E. Acromioclavicular ligament
Jawaban : D
Alasan : Moore hlm 851-852

8. A tennis athlete has shoulder discomfort and you suspect a rotator cuff tear. Which of the following tendos is most likely damaged?
A. Teres major
B. Teres minor
C. Supraspinatus
D. Infraspinatus
E. Subscapularis
Jawaban : C
Alasan : Recurrent inflammation of the rotator cuff, especially the avascular area of supraspinatus tendon, is a common cause of shoulder pain and results in tears of the musculotendinous rotator cuff (Moore hlm 857)

9. A 27 y.o. man comes to outpatient clinic woth chief complaint fall onto outstretched hand. You suspect fracture of carpal bone. Which of the following bone is most likely fractured?
A. Lunate
B. Pisiform
C. Capitate
D. Scaphoid
E. Triquetrum
Jawaban : D
Alasan : A fall on outstretched hand may result in fracture of the scaphoid, generally across its narrow part (Moore hlm 875)

10. A 20 y.o. student comes to the outpatient clinic with chronic sinusitis. From PE revealed purulent drainage arising from the superior nasal meatus. Which of the following sinuses is likely to be infected?
A. Frontal
B. Maxillary
C. Sphenoidal
D. Ethmoid
Jawaban : D
Alasan : Sinusitis merupakan infeksi pada sinus dan posisi ethmoid sinus adalah di middle dan superior nasal meatus diantara nasal cavity dan orbit (moore hlm 1019)

11. A 30 y.o. boxer received a blow to the right eye. Soon after that he was unable to secrete tears from that eye. What is the most likely location of the injury?
A. Lateral superior orbit
B. Lateral inferior orbit
C. Medial superior orbit
D. Medial inferior orbit
Jawaban : D
Alasan : Because of the thinness of the medial and inferior wall of the orbit, a blow to the eye may fracture the orbital wall whle the margins remain intact (hlm 958 Moore)

12. A 85 y.o. woman comes to family practice because she loose weight about 6 kg for the past 2 months. This condition occurred after she has trouble chewing especially elevate the jaws. Which of the following muscles is a pure muscle that involved in above case?
A. Buccinator muscle
B. Geniohyoid muscle
C. Medial pterygoid muscle
D. Lateral pterygoid muscle
E. Posterior fibers of temporalis muscle
Jawaban : C
Alasan : Acts synergistically with masseter to elevate mandible; contributes to protusion; alternate unilateral activity produces smaller grinding movements (hlm 988 Moore)

13. Fractures of the humerus in different regions may potentially damage different nerves. Which muscle innervations may be compromised by a fracture of the humerus at the surgical neck?
A. Subscpularis
B. Pectoralis major
C. Teres major
D. Deltoid
E. Subclavicularis
Jawaban : D
Alasan : Fracture pada humerus di daerah surgical neck biasanya melukai axillary nerve yang mempersarafi deltoid muscle (Moore hlm 734, 755)

14. A one week baby was brought by his parents to pediatric department with left cleft to the upper lip that extends upward toward the left nostril and left nasal anterior cleft of the primary palate just deep to the cleft lip. Which of the following process is most likely fail that explains the above defect?
A. Mandible process to fuse with the lateral nasal process
B. Mandible process to fuse with the medial nasal process
C. Maxillary process to fuse with the lateral nasal process
D. Lateral and medial nasal process to fuse with each other
E. Maxillary process to fuse with the medial nasal process
Jawaban : E
Alasan : Moore embryology hlm 188

For number 15 and 16 refer to scenario below
A 55 y.o. woman comes to the outpatient clinic with a chief complaint of pain on her both knees since week ago. Pain was felt particularly in the morning. The doctor diagnosis is rheumatoid arthritis, and plans to give Diclofenac sodium 50 mg tablets orally 3 times a day 1 hour after meal for 5 days.

15.Which of the following is the most likely inscription and subscription on the prescription order?
A. Diclofenac Na No. XV
B. Diclofenac Na 50 mg No. XV
C. Diclofenac Na tab No. XV
D. Diclofenac Na 50 mg tab No. XV
E. Diclofenac Na 50 mg Dispense No. XV tab
Jawaban : D
Alasan : Inscription  nama dan jumlah dari isi obat; Subscription  penyusunan bahan obat

16. The doctor also gives Diclofenac sodium emulgel 1% tube I 20gr twice a day.
A. S s.d.d applic
B. S b.d.d applic
C. S t.d.d applic
D. S q.d.d applic
E. S d.i.d applic
Jawaban : B
Alasan : agak ga jelas maksud soalnya, mungkin maksudnya di resep gimana cara make obatnya (Signatura)

For number 17 until 19, choose the appropriate preparation
A. ointment
B. cream
C. pasta
D. lotion
E. Solution

17. Male 25 y.o. has dry skin on leg
Jawaban : D
Alasan : ga tau, tapi biasanya dikasih body lotion bukan sih???:D

18. Male 34 y.o. itching on the fingers near nail, scratching
Jawaban :
Alasan :

19. Baby girl 16 months old brought by her mother with oozing eczema at her buttock
Jawaban :
Alasan :

20. A 16 y.o. man goes to gym to build muscle, forcing himself to do strenuous exercise. There is painful muscle cramp at his upper limbs and back. Blood examination reveals increase in both lactate dehydrogenase and creatin kinase. What is cause of the pain?
A. Depletion of ATP
B. Decrease of blood pH
C. Accumulation of CO2
D. Accumulation of lactate
E. Decrease of blood glucose
Jawaban : D
Alasan : Proses metabolism anaerobic akan menghasilkan laktat dan akan menyebabkan muscle fatigue dan bila berkelanjutan akan menyebabkan pain (Interactive physiology video)

21. during such kind of exercise, energy demand depends heavily on anaerobic glycolysis. Which of the following is the mostly explanation?
A. muscles have no storage of lipid
B. exercised muscles need a lot of O2
D. aerobic glycolysis produces less energy
D. aerobic glycolysis needs longer time to start
E. muscle contraction squeezes blood out of the muscle bed
answer: E
A dan B bener tapi ga nyambung , C. salah karena dengan aerobic glycolisis energy yang diproduksi itu besar, tapi pertanyaan ini menyangkut ketika kita dalam keadaan exercised sehingga keadaaan metabolismnya adalah anaerobic. D. sebenernya tidak ketemu statement bahwa aerobic glikolisis lebih cepat dari anaerobic.. tapi berdasarkan guyton dan analisa, bahwa ketika terjadi kontraksi otot, maka akan terjadi peningkatan tekanan di otot dan inter muscular, akibatnya ada squeezing, lalu ketika adanya exercise, harus ada pembebasan sumber energy yang berasal dari glikogen dimana glikogen dipecah menghasilkan asam piruvat dan asam laktat untuk mengubah ADP jadi ATP (dianggap guyton sebagai proses glikolisis) dalam waktu yang cepat sehingga kontraksi otot dapat dipertahankan meski tidak ada supply O2 dalam membentuk ATP.. jadi dalam exercise, proses yang cepat dalam pembentukan ATP ialah anaerobic.. oleh karena itu, analogi yang mendekati adalah yang E.. Ada yang nemu jawaban pastinya?

22. which of the following is the best explanation of the elevated serum enzyme level?
A. synthesized by exercised muscle cells
B. waste product of muscle cells metabolism
C. leaked out through muscle cell membrane
D. needed to produce energy within muscle cells
E. needed to stimulate glucose uptake by muscle cells
answer: sepertinya C, karena apabila adanya exercise, maka jumlah enzyme ini increase untuk merelease phosphate untuk membentuk ATP, dan apabila jumlahnya meningkat maka akan ada leakage ke kapiler. Ada yang menemukan yang pastinya?

23. exercising muscle actually consist of cyclic attachment and detachment of which of the following structure?
A. globular head region of myosin to F-Actin
B. Globular head region of myosin to G-Actin
C. Helix (tail) region of myosin to F-Actin
D. Helix (tail) region of myosin to G-Actin
E. G-Actin to F-Actin
Answer: B. Guyton Buku Ajar Fisiologi Kedokteran ed 9 hal 96: “pada tiap molekul G-Actin melekat 1 molekul ADP yang diperkirakan berinteraksi dengan jembatan penyeberangan (cross bridge) myosin.

24. Running for long time will decrease ATP level in the muscle. Which is of the following molecule is used as an immediate source of energy?
A. Fatty acid
B. ketone bodies
C. muscle protein
D. Oxygen
E. Creatine phosphate
answer : E. Guyton Buku Ajar Fisiologi Kedokteran ed 9, hal 100.. sumber energy pertama yang digunakan untuk menyusun kembali ATP ialah Creatin phosphate yang membawa ikatan fosfat berenergi tinggi yang serupa dengan ATP. Karena creatine phosphate memiliki energy bebas lebih sedikit dari ATP, maka creatine phosphate segera dipecahkan dan pembebasan energy tersebut menyebabkan terikatnya sebuah ikatan fosfat baru pada ADP untuk membentuk ATP.

For number 25-27, refer to scenario below
Bone mass contains predominantly type I collagen, helix protein which act as a matrix for deposition of calcium.

25. Bone marrow contains type I collagen, helix protein to deposit calcium. Where is the calcium deposited?
A. sulphate
B. oxalate
C. carbonate
D. proteinate
E. phosphate
answer: E. Jancquiera hal 136-137, calcium itu terdeposit membentuk hydroxyapatite Ca10(PO4)6(OH)2

26. Glycine is essential for the formation of protein above because it has the…… needed to be accommodated on the central core of the triple helix.
A. right size
B.right shape
C. strong bone
D. positively charged
E. negatively charged
answer: ?????

27. when is the physical activity best preventing loss of bone mass in osteoporosis?
A. boxing
B. jogging
C. walking
D. swimming
E. weight lifting
answer:E. Frontera essential of physical medicine and rehabilitation 1st ed
hal 649: prevent bone loss= exercise. Bone adapts to physical & mechanical loads placed on it by altering its mass and strength. This occur either by the direct impact of the weight bearing activity or action of muscle attach to the bone
hal 650, rehabilitation; finally therapist can instruct patient about how to exercise to improve strength, flexibility, and balance. All those activity can help prevent falls and weight bearing strengthening exercise may improve bone density

28. damage to peripheral nerve motor neuron in the somatic nerve system produces..
A. high voltage and short duration potentials
B. low voltage and long duration potentials
C. high voltage and long duration potentials
D. low voltage and short duration potentials
E. silent potentials
answer: ??? sory banget, ga ketemu

30. electromyography is a technique to study the electrical activity within muscle. This is accomplished by inserting a needle electrode into muscle. If we record muscles with peripheral neuropathies, which if the following motor unit potentials are most likely to be seen?
A. giant action potentials decline in the amplitude
C. no fasciculation potentials
D.all potentials are of shorter duration
E. reduced number of motor unit action potentials
answer: A. Merrit’s neurology 11th ed, hal 93 fig 19.3
this waveform has a high amplitude of 10 mv, a significantly prolonged duration of 29 milisecond and is highly complex with more than 10 turns.As an individual motor axon dies during denervating injury, the muscle fibers it previously supplied lose all innervations. Surviving nearby axons subsequently branch to supply these muscles, increasing their size and territory resulting in increased MUAP size with higher amplitude, longer duration, and complex morphology.. bandingkan dengan pola MUAP normal pada fig. 15.8

31.which of the following is most likely to the metabolism in white muscle fibers?
A. cross bridge cycling occurs relatively slowly
B. mainly use krebs cycle and oxidative phosphorylation
C. fatigue resistance and high endurance
D. muscles with a high number of myoglobin and mitochondria
E. powerful due to large number of myofillaments and large diameter .
answer: E. Tortora 11th ed. Hal 309. Fast glycolitic fibers: largest in diameter and contain most myofibrils hence they can generate the most powerful contraction, contain large amount of glycogen and generate ATP by glycolisis

32. a period during muscle twitch was a relaxation period. Which of the following is the most important mechanism during this period?
A. sarcomeres shorten as a result of myosin cross bridge cycling
B. tension is reduced, muscle return to original length
C. Calciium is released to cytosol
D.sarcollema and tubules depolarized
answer: B. Tortora hal 309, prosesnya meliputi:
• Calcium is actively transported back into sarcoplasmic reticulum
• Myosin binding site dicovered oleh tropomyosin
• Myosin head detach dari actin
• Tension muscle fiber menurun

33. which of the following mechanism occurs during latent period?
A. calcium actively transported back into terminal cisternae
B. tension is reduced, muscle return to original length
C. calcium is released to cytosol
D. sarcomeres shortened as a result of myosin cross bridge cycling
E. calcium is released into cytosol
answer: C/E. Tortora hal 309, muscle action potential sweep over sarcollema and calcium release dari sarcoplasmic reticulum
34. which of the following mechanism occurs during contraction period?
A. cross bridge begin to cycle but no visible shortening of muscles
B. tension is reduced, muscles return to original size
C.sarcollema and T-tubules depolarized
D. speed depends on weight being lifted and fiber type (?)
E. Calcium actively transported back into terminal cysternae
answer: -
yg terjadi ialah: calcium binds to troponin -> pembukaan myosin binding site -> pembentukan cross bridge-> kontraksi

35. which of the following statement directly trigger the detachment if cross bridge from action?
A. depolarization of T-tubule
B. Hydrolysis of ATP to myosin head
C. calcium ion
D. attachment of ATP to myosin head
E. Depolarization of plasma membrane
Answer: D, tortora hal 300: at the end of power stroke, the cross bridge remains firmly attached to actin until it binds another molecule if ATP. As ATP binds to ATP binding site in the myosin head, myosin head detaches from actin

36. Which of the following is the characteristic of white skeletal muscle?
A.ATP production can be synthesized through krebs cycle and oxidative phosphorilation
B. the muscle cells itself contain numerous mitochondrion and less myosin ATP-ase
C. the muscle cells itself contain numerous of myosin ATP-ase and less myoglobin
D. Fatigue resistant and have high endurance
Answer: C, Tortora hal 312: ciri-cirinya:
• Low myoglobin
• Few blood capillaries
• Few mitochondria
• Contain large amount of glycogen
• Memiliki banyak myofibrils
• Kontraksi yang kuat sehingga membutuhkan banyak ATP, tapi mudah mengalami fatigue

37. which of the following is the most likely term for prolongation of contraction with high frequency?
A. twitch
C. treppe
D. Incomplete titanic contraction
E. complete titanic contraction
answer: E. Berdasarkan pengertian dari guyton, bahwa tetanic contraction adalah prolonged summation yang terjadi secara terus menerus, dan apabila dilihat di grafik, tetanik kontraksi ini memiliki celah antar grafik yang teramat sangat kecil yang menandakan waktu terjadi kontraksi sangatlah singkat. Jika dilihat di tortora hal 310, fig.10.15, maka frekuensi yang singkat dalam stimulasi otot mengakibatkan prolonged contraction without relaxation.

38. what is the sac like regions of the sarcoplasmic reticulum that serve as specialized reservoirs of calcium?
A. T-tubule
B. Sarcoplasmic reticulum
C. myofibril
D. terminal cisternae
E. triad
answer: B. jelas ya..

39. What is the definition for short, rapid contraction/ relaxation cycles due to high frequency of stimulation?
A. treppe
B. temporal summation
C. incomplete tetanus
D. complete tetanus
E. fatigue
answer: C. tortora hal 310, fig. 10.15, bahwa pada unfused tetanus terdapat fase relaksasi pada otot diantara stimulus sehingga hasilnya berupa sustained tapi wavering contraction..

40. which of the following is correct for the action potential of skeletal muscle?
A. it has prolonged plateau phase
B. it spreads inward to all part of the muscle via T-tubule
C. it is caused by immediate uptake of Calcium into lateral sacs of the sarcoplasmic reticulum
D. it is longer than the action potential of the cardiac muscle
E. it is not essential for contraction
answer: B, Tortora hal 294: muscle action potential travel along sarcollema and through T-tubules quickly spreading through muscle fibers. This arrangement ensure that an action potentials excites all parts of the muscle fibers at essentially the same instant

41. What is the function of tropomyosin in skeletal muscle ?
a. Sliding on actin to produce shortening
b. Releasing Ca after initiation of contraction
c. Bending to myosin during contraction
d. Acting as relaxing proteinat rest by covering up the sites where myosin binds to actin
e. Generating ATP, which it passes the contractile mechanism
Answer : D
Tropomyosin melilit F-actin helix. Pada resting state, lilitan molekul tropomyosin terletak diatas active site dari actin, sehingga mencegah kontak antara actin dan myosin yang menyebabkan kontraksi tidak terjadi. (Guyton&Hall page 76)

42. The cross-bridges of the sarcomere in skeletal muscle are made up of
a. Actin
b. Myosin
c. Troponin
d. Tropomyosin
e. Myelin
Answer : B
Cross bridge skeletal muscle adalah arm dan body dari myosin yang menjulur ke arah actin. The protruding arms and heads of myosin together are called cross-bridges. (Guyton&Hall page 75)

43. Which of the following is correct for the contractile response in skeletal muscle
a. It starts after the action potential is over
b. It doesn’t last as long as the action potential
c. It produces more tension in the isotonically contraction muscle than isometrically
d. It produces more tension in the isometrically contraction muscle than isotonically
e. It can increase the magnitude with repeated stimulation
Answer : E

A 13 years old high school student complained about pain and swelling at her right ankle joint after fell down during sport activity at her school. She was still able to walk but painfully
44. What is the most likely problem occur at her ankle joint
a. Bone injury
b. Muscle injury
c. Ligament Injury
d. Tendon Injury
e. Cartilage injury
Answer : C

45. What is the most common mechanism of this injury
a. Inversion type
b. Eversion type
c. Pronation type
d. Supination tipe
e. Extension type
Answer : A
A sprained ankle is nearly always an inversion injury, involving twisting of the weight-bearing plantarflexed foot. (Moore page 706)

46. Physical examination of the ankle revealed
Look : Localized, swelling at lateral aspect
No deformity, no wound, no ecchymosis
Feel : Tenderness only at lateral aspect, below the lateral malleolus
No bony tenderness at all
Further examination is to perform range of motion examination. Which is the most likely joint to exam
a. Tibiotalar joint
b. Talocalcaneal joint
c. Talonavicular joint
d. Calcaneocuboid joint
e. Tarso metatarsal joint
Answer : B
The lateral ligament is injured because it is much weaker than the medial ligament and is the ligament that resist inversion at the talocrural joint (or talocalcaneal joint) (Moore page 706)

47. Based on these physical findings, what is the most likely classification of this injury
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
e. Grade 5
Answer : A

48. Further test to rule out instability of this condition is to examine which if the following ligament
a. superior talofibular ligament
b. inferior talofibular ligament
c. anterior talofibular ligament
d. posterior talofibular ligament
e. medial talofibular ligament
Answer : C
The anterior talofibular ligament is most vulnerable and most commonly torn during ankle sprains, resulting in instability of the ankle joint. (Moore page 706)

49. Which of the following is the most appropriate radiological examination, at minimum requirement to rule out concomitant fracture of this condition
a. AP projection of the ankle joint
b. Lateral projection of the ankle joint
c. AP and lateral projection of the ankle joint
d. AP, lateral, and mortise projection of the ankle joint
e. AP, lateral, and tangential projection of the
Answer : D
Anteroposterior, lateral, and ‘mortise’ (30 oblique) views of the ankle should be obtained in all but the mildest cases (Apley’s page 734)

50. How long is the most sufficient period of immobilization, as a treatment for this condition
a. 1 week
b. 2 weeks
c. 3 weeks
d. 4 weeks
e. 5 weeks
Answer : C
Clinical feature; there is a swelling and marked tenderness. If it’s partial tears then the treatment is immobilization for 2-3 weeks (Apley’s page 737)

51. Which of the following is the most common predisposing factor of this condition
a. Lack of positioning
b. Lack of strengthening
c. Lack of stretching
d. Lack of conditioning
Answer : C

52. A 3-month old girl is taken by her mother for having a red spot since she was 3-days old. Previously, the mother thought it was due to mosquito’s bite. But it slowly enlarges within the last month. Now, the red spot diameter is 0.5 cm, located at the right cheek. What is the possible diagnosis in this patient
a. Birth mark
b. Cavernous hemangioma
c. Capillary hemangioma
d. Port wine stain
e. Nevus flammeus
Answer : C
Hemangioma; the initial sign is hypopigmented blanched macule with or without telangiectasia or an erythematous to ecchymotic patch that is superficial, often with irregular surface and borders. Mostly grow to between 0.5 – 5.0 cm in diameter.
- Cavernous (deep); proliferate in lower dermis and subcutaneous tissue without penetration of the papillary dermis. Present as localized, firm, rubbery, subcutaneous mass that can be slightly raised with a bluish color
- Capillary (telangiectatic); flat or slightly elevated and deep red with an array of superficial dilated capillaries radiating over the surface
Port Wine Stains = Nevus Flammeus; cosmetically disfiguring, congenital capillary and venular malformations that affect up to 0.5 percent of newborns. At birth, lesions are first noted as subtle, light pink patches, commonly appearing on the face. The vessels aren’t proliferate and only grow proportionally with the individual

A 22 year old female came with scald burn due to hot water spill in the whole both arms and part of the chest. The burn wound looked blistered and some of broken blisters showed patchy white and pink and weeping wound base. She felt pain in the wound area. She arrived in the hospital 4 hours after the injury. Her body weight was 50 kg.
53. What is the most likely burn degree in this patient
a. Grade I
b. Grade II A
c. Grade II B
d. Grade III
e. Grade IV
Answer : C
Deep Partial thickness (IIB)
Extend into the reticular layer of the dermis. Blister, wound surface is usually a mottled pink and white color immediately after the injury, because of the varying blood supply to the dermis. (Schwartz page 195)
54. What is the most appropriate burn degree in this patient
a. 18 %
b. 25 %
c. 30 %
d. 45 %
e. 53 %
Answer : B
Each upper extremity = 9% = 18%
Anterior trunk = 18%, hanya chest = 6%
Total 24-25 %

55. What is zone of coagulation in burn wound
a. Area of the worst necrosis
b. Area of local inflammation
c. Area of cellular reaction
d. Area of vasodilatation near static zone
e. Area outside hyperemic zone
Answer : A

56. A 33 year old female had explosion on stove in the kitchen. There was no window. She had burn on face, neck, part of chest. Few hours after injury she had dyspnea. What is the most probable diagnosis
a. Moderate burn
b. Burn and obstructive attack
c. Burn and CO poisoning
d. Burn and foreign body in airway
e. Burn and inhalation injury
Answer : E
Inhalation injury should be suspected in anyone with flame burn, and assumed until proven otherwise. (Schwartz page 202)

57. When the doctor examined him, he was anxious, BP 80/60 mmHg, pulse rate 128 bpm, RR 30/mnt. Which of the following is the most appropriate pathophysiology shock in this patient
a. Increased evaporation
b. Loss off large skin
c. Bleeding from wound
d. Increased capillary permeability
e. Dehydration
Answer : D
Burn shock etiology; hypovolemic or cellular.
Hypovolemic -> multiple mediators causing the microvascular changes via a direct increase in vascular permeability -> disrupsi normal barriers untuk memisahkan intravascular dan interstitial compartments

58. What is inhalation injury
a. Injury of the airway due to trauma
b. Injury due to inhalation of poisonous gas
c. Injury to the lung
d. Burn injury after … the airway
e. Injury to the nasopharynx
Answer : ?

A 3 month old baby girl born with cleft lip and palate. She was born from a term pregnancy and cried immediately after birth
59. When did the disturbance of gestation happen that caused the cleft lip and palate
a. 3rd week of gestation
b. 4th week of gestation
c. 8th week of gestation
d. 9th week of gestation
e. 12th week of gestation
Answer : Cleft lip & palate -> 5-8 minggu (Moore)

60. What is the main problem in this patient
a. Appearance
b. Psychosocial
c. Feeding
d. Speech
e. Choking
Answer : C

61. Her three sisters are normal and both parents as well. What is possible etiology of the congenital anomaly in this patient?
A. genetic
B. malnutrition
C. gen mutation
D. radiation
E. diabetes mellitus
jwb: B
The etiology of cleft lip is regarded as multifactorial. Important potential risk factors include anticonvulsants, parental age, lower socioeconomic class, smoking, alcohol intake, and prenatal nutrition.
Similarly, with cleft lip, there is a plethora of etiologies, including teratogens, alcohol, dietary deficiencies, and maternal epilepsy.
(Schwartz's Surgery 8th Ch.44 Plastic and Reconstructive Surgery, cleft lip & palate)

62. what is the percentage of having another baby with cleft lip and palate in this family?
A. 4%
B. 7%
C. 10%
D. 15%
E. 50%
jwb: A
Concomitantly, parents or siblings with cleft lip and palate predispose future children to an increased risk. In families of a one-cleft parent or sibling, there is a 4% risk of a subsequent child being born with cleft lip/palate.
(Schwartz's Surgery 8th Ch.44 Plastic and Reconstructive Surgery, cleft lip & palate)

63. baby girl 2 m.o lahir dgn cleft lip & palate, lahir cukup bulan dan langsung menangis. Kapan waktu treatment yg tepat?
A. as soon as possible
B. setelah 3 bulan
C. setelah 6 bulan
D. setelah 1 tahun
E. setelah 6 tahun
jwb: B
Surgical closure of a cleft lip is usually performed by 3 mo of age, when the infant has shown satisfactory weight gain and is free of any oral, respiratory, or systemic infection.
(Nelson Pediatrics 17th Ch.291 Cleft Lip and Palate)

For number 64-65
a 6-month-old baby had a bluish lump at her left ear since birth. The last two months, her mother noticed the lump is getting larger slowly.

64. what is the most possible diagnosis in this patient?
A. birth mark
B. cavernous hemangioma
C. capillary hemangioma
D. port wine stain
E. nevus flammeus
Cavernous hemangiomas are deeper, blue masses that if large, may trap platelets and produce disseminated intravascular coagulation or interfere with local organ function.
(Nelson Pediatrics 17th Ch.83 The Newborn Infant)
Hemangiomas are benign vascular neoplasms that arise soon after birth. They initially undergo rapid cellular proliferation and slowly involute through early childhood. Capillary (strawberry) hemangiomas are soft, compressible papular lesions with sharp borders located mostly on the shoulders, face, and scalp. Cavernous hemangiomas are bright red or purple and have a spongy consistency. Histologically, capillary hemangiomas are composed of endothelial cells seen primarily in fetal veins. Cavernous lesions contain large, blood-filled spaces lined by normal-appearing endothelial cells.
The port-wine stain (nevus flammeus) is a flat, dull-red capillary malformation that can be located on the trunk, extremities, and, most commonly, along a trigeminal distribution on the face. Histologically these nevi are composed of ectatic capillaries lined by mature endothelium.
(Schwartz's Surgery 8th Ch.15 Skin and Subcutaneous Tissue, vascular tumors)

65. what is the best therapy for this case?
A. observation until spontaneous regression
B. excision
C. skleroting injection
D. laser
E. corticosteroid
jwb: A
Hemangiomas can enlarge during the first year of life, and more than 90% of them involute over time. Allowing lesions to regress spontaneously usually gives optimal cosmetic results.
(Schwartz's Surgery 8th Ch.15 Skin and Subcutaneous Tissue, vascular tumors)

For 66-67
A 23-year-old female fell off the motorcycle in an accident with her chin hitting the road. There was bleeding from her mouth and she felt pain in her chin. The patient had difficulty in opening her mouth and the doctor noticed deformity at the right chin region.

66. what is the possible diagnosis in this patient?
A. fracture of simphysis of mandible
B. fracture of body of mandible
C. fracture of angle of mandible
D. fracture of ramus of mandible
E. fracture of condylus of mandible
The mandible is the second most commonly injured facial bone and represents 10 to 25% of all facial fractures. The condyle and the angle are the two most frequent regions for mandibular fractures.
(Schwartz's Surgery 8th Ch.44 Plastic and Reconstructive Surgery, mandibular fractures)

67. what is the dominant muscle in above disturb region?
A. m. mentalis
B. m. digastrics
C. m. pterygoid internus
D. m. masseter
E. m. buccinators
Muscle Origin Insertion
Mentalis Mandible Skin
Digastrics Anterior belly from inner side of inferior border of mandible; posterior belly from temporal bone Body of hyoid bone via an intermediate tendon
Medial pterygoid Medial surface of lateral portion of pterygoid process of sphenoid bone; maxilla Angle and ramus of mandible
Lateral pterygoid Greater wing and lateral surface of lateral portion of pterygoid process of sphenoid bone Condyle of mandible; temporomandibular joint
Masseter Maxilla and zygomatic arch Angle and ramus of mandible
Buccinators Alveolar process of maxilla and mandible and pterygomandibular raphe Orbicularis oris
(tortora 11th ch.11 the muscular system)

For number 68-69
A baby boy, 2 months old, born with cleft palate. The pregnancy was at term and the baby cried immediately after birth.

68. when is the best timing for surgery in this patient?
A. as soon as possible
B. after one year old
C. after 2 years old
D. after 6 years old
E. after 8 years old
jwb: B

69. doctor found the third and fourth fingers of his left hand are joined. What is the diagnosis for the anomaly of fingers in this patient?
A. syndactili
B. polydactili
c. brachidactily
D. polisindactily
E. brachisyndactili
jwb: A
A different category of limb abnormalities consists of extra fingers or toes (polydactyly). The extra digits frequently lack proper muscle connections. Polydactyly can be inherited as a dominant trait but may also be induced by teratogens. Abnormal fusion is usually restricted to the fingers or toes (syndactyly).
(langman embryology 9th ch.8 skeletal system, clinical correlates)

70. a 26-year-old man had an accident fell off the motorcycle with the jaws hitting the road. There was massive bleeding from his mouth and pain at the chin. There was deformity at the right lower jaw and the right cheek. What is the first emergency treatment in this patient?
A. put on the barton sling
B. immediate tracheoctomy
C. insert tampon to stop bleeding
D. treat hemorrhagic shock immediately
E. immediate surgery for the facial fractures
jwb: B
Tracheostomy is indicated in the management of patients who require prolonged intubation, assisted ventilation, and pulmonary toilet, and in those patients with neurologic deficits that impair protective airway reflexes. Its use in head and neck surgery is often for the temporary management of the airway in the perioperative period. After surgical resection of oral cavity and oropharyngeal cancers, bleeding into the sublingual and submaxillary soft-tissue spaces may result in airway compromise, and elective tracheostomy is indicated to prevent loss of the airway.
(Schwartz's Surgery 8th Ch.17 Disorders of the Head and Neck, tracheostomy)

For number 71-72
A 25-year-old man had an accident fell off the motorcycle with the force hitting the road. Ther was periorbital hematoma in the left eye, deformity at the left cheek, bleeding form the mouth (+). The patient felt numbness at the left cheek & double vision.

71. what is the possible diagnosis in this patient?
A. nasal fracture
B. mandible fracture
C. maxillozygomatic fracture
D. frontalis fracture
E. maxillary sinus fracture
jwb: C
The zygomatic bones (cheek bones, malar bones), forming the prominences of the cheeks, lie on the inferolateral sides of the orbits and rest on the maxillae.
The frontal bone, specifically its squamous (flat) part, forms the skeleton of the forehead, articulating inferiorly with the nasal and zygomatic bones.
The maxillae form the upper jaw; their alveolar processes include the tooth sockets (alveoli) and constitute the supporting bone for the maxillary teeth. The maxillae surround most of the piriform aperture and form the infraorbital margins medially. They have a broad connection with the zygomatic bones laterally and an infraorbital foramen.
The mandible is a U-shaped bone with an alveolar process that supports the mandibular teeth. It consists of a horizontal part, the body, and a vertical part, the ramus.
Le Fort III fracture: horizontal fracture that passes through the superior orbital fissures and the ethmoid and nasal bones and extends laterally through the greater wings of the sphenoid and the frontozygomatic sutures. Concurrent fracturing of the zygomatic arches causes the maxillae and zygomatic bones to separate from the rest of the cranium.
(moore anatomy 5th ch.7 head)

72. what is the possible cause for numbness in this patient?
A. severe soft tissue injury
B. mental nerve injury
C. facial nerve injury
D. infraorbital nerve injury
E. zygomatic nerve injury
jwb: D
mental nerve supplies the skin and mucous membrane of the lower lip from the mental foramen to the midline, including the skin of the chin.
The zygomatic nerve runs to the lateral wall of the orbit, giving rise to two of the three cutaneous branches of CN V2, the zygomaticofacial and zygomaticotemporal nerves.
Infraorbital nerve supplies mucosa of maxillary sinus; premolar, canine, and incisor maxillary teeth; skin and conjunctiva of inferior eyelid; skin of cheek, lateral nose, and anteroinferior nasal septum; skin and oral mucosa of superior lip.
(moore anatomy 5th ch.7 head)
Facial neve traverses the posterior cranial fossa, internal acoustic meatus, facial canal, stylomastoid foramen of the temporal bone, and parotid gland. After traversing the internal acoustic meatus, the nerve proceeds a short distance anteriorly within the temporal bone and then turns abruptly posteriorly to course along the medial wall of the tympanic cavity.
(moore anatomy 5th ch.9 Summary of Cranial Nerves)

73. a 35-year-old man was admitted to the hospital with a two-month history of pain, swelling and purulent discharge to his left lower leg. This occurred one year after sustaining a fracture to that area. Radiological examination reveals sequestrum. Which of the following is the most likely cause of sequestrum appearance in this case?
A. the radiolucent area
B. periosteal reaction
C. the radioopaque area
D. destroyed bone island
E. the surrounding bone segment
jwb: D
The morphologic changes in osteomyelitis depend on the stage (acute, subacute, or chronic) and location of the infection. Once localized in bone, the bacteria proliferate and induce an acute inflammatory reaction and cause cell death. The entrapped bone undergoes necrosis within the first 48 hours, and the bacteria and inflammation spread within the shaft of the bone and may percolate throughout the haversian systems to reach the periosteum. In children, the periosteum is loosely attached to the cortex; therefore sizable subperiosteal abscesses may form, which can trek for long distances along the bone surface. Lifting of the periosteum further impairs the blood supply to the affected region, and both the suppurative and the ischemic injury may cause segmental bone necrosis; the dead piece of bone is known as the sequestrum. Rupture of the periosteum leads to a soft tissue abscess and the eventual formation of a draining sinus. Sometimes the sequestrum crumbles and forms free foreign bodies that pass through the sinus tract.
(robin cotran pathology 7th ch.26 bones, pyogenic osteomyelitis)

74. a 15-year-old male is admitted with a fracture of his left digital femur. An x-ray reveals abnormal bone density and some soft tissue swelling in the area. A biopsy taken during the operation reveals a monotonous population of “small blue cells”. There is no other symptom or clinical signs. Which of the following is TRUE for the above tumor?
A. primary malignant bone tumor with osteolitic nature
B. affected the epiphyses and metaphyses
C. onion’s skin type periosteal reactions
D. pathologic ossification in soft tissue
E. low tendency of metastasis

75. a plain x-ray photo of skull shows multiple osteolytic lesions. What is the most possible diagnosis?
A. ewing’s tumor
B. osteosarcoma
C. osteochondroma
D. multiple myeloma
E. ewing’s tumor
jwb: D
Ewing sarcoma is a primary malignant small round cell tumor of bone. It has long posed a difficult diagnostic problem because the tumors resemble those of lymphoma, rhabdomyosarcoma, neuroblastoma, and oat cell carcinoma. Current evidence indicates that Ewing sarcoma tumor cells exhibit a neural phenotype. The expression of the oncogene c- myc and the identification of a specific chromosome translocation in both Ewing sarcoma and similar tumors of soft tissue, called primitive neuroectodermal tumors ( PNET), further support this contention.
Osteosarcoma is defined as a malignant mesenchymal tumor in which the cancerous cells produce bone matrix. It is the most common primary malignant tumor of bone, exclusive of myeloma and lymphoma, and accounts for approximately 20% of primary bone cancers.
Osteochondroma, also known as an exostosis, is a benign cartilage-capped outgrowth that is attached to the underlying skeleton by a bony stalk. It is a relatively common lesion and can be solitary or multiple. Multiple osteochondromas occur in multiple hereditary exostosis, which is an autosomal dominant hereditary disease that is genetically heterogeneous.
(robin cotran pathology 7th ch.26 bones)
Multiple myeloma is a plasma cell neoplasm that is characterized by involvement of the skeleton at multiple sites.
Table, clinical feature: Myeloma; older patients with lytic bone lesions, pathologic fractures, hypercalcemia, renal failure, and primary amyloidosis.
(robin cotran pathology 7th ch.14 disesase of white blood cells, multiple myeloma)

76. a 25-year-old man came to an otolaryngologist, with symptoms of chronic rhinitis and frontal type headache. The physician diagnosed the patient with sinusitis maxillaries and asked x-ray photo to confirm the diagnosis. Which of the following is the most appropriate x-ray photo?
A. schuller and stenver photos
B. waters and Caldwell photos
C. towne and submento vertex photos
D. esler and rhese photos
E. anteroposterior and lateral skull photos

77. which of the following is the most specific radiological sign for above case?
A. thining of the antrum maxillary sinus
B. destruction of maxillary sinus wall
C. opacity of maxillary sinus
D. air fluid level in maxillary sinus
E. periosteal reaction of maxillary sinus wall

78. a radiologic appearance of chronic abscess is surrounded by marked sclerosis. What is the most likely term for the abscess?
A. tuberculosis abscess
B. brodie’s abscess
C. granuloma
D. Luetic disease
E. malignant abscess

79. what is radiological signs of tuberculosis at extremities bone?
A. periosteal reaction of the bone
B. calcification of the bone
C. abscess formation
D. gouge effect
E. destruction of subcortical bones

80. a radiological sign of a patient reveals osteoblastic type metastase in bones. Which of the following is the most possible primary tumor origin?
A. skin carcinoma
B. thyroid carcinoma
C. stomach carcinoma
D. prostate carcinoma
E. wilms’ tumor

For number 81 until 83. Refer to scenario below:
A corpse is found without cadaveric rigidity but with cadaveric lividity on the hands and feet. There is also aberration on neck andblood spots on the conjunctiva
81. How much is the body temperature of the corpse?
a. 36.5o C
b. 35 o C
c. 32 o C
d. 28 o C
e. Depending on the surrounding
Answer: A
- Livor mortis (postmortem hypostasis, lividity) is the discoloration of the body after death due to the gravitational settling of blood which is no longer being pumped through the body by the heart. Livor mortis is usually noticeable approximately 1 hour after death and is often apparent earlier, within 20–30 minutes
- Within 1–3 hours following death, the muscles begin to become noticeably increasingly rigid and
the joints immobile (freeze) due to a process known as rigor mortis (postmortem
rigidity, rigor)
Sumber: ebook “Time of Death, Decomposition and Identification - An Atlas”
-dari keterangan diatas dapat disimpulkan bahwa mayat meniggal sekitar 1 jam yang lalu
-dari slide( lecture dr.norman) dikatakan bahwa 6 jam pertama setelah meninggal penurunan suhu tubuh mayat adalah 1’ C tiap jamnya.. karena baru 1 jam jadi 37.5-1= 36.5’C

82. whe is the most likely time of death?
a. Cannot be determined
b. An hour ago
c. 3 hours ago
d. More than 12 hours
e. More than 24 hours
Answer: B
-lihat keterangan soal no 1

83. what is the most color of cadaveric lividity?
a. Brown
b. Purplish
c. Dark red
d. Reddish purple
e. Bright red
Answer: B
- Lividity tends to be violaceous or purple in a light-skinned individual and darker in someone with darker skin. Livor may not be apparent in a darkly pigmented person.
-Certain causes of death, livor mortis may take on a different color.Carbon monoxide poisoning, cyanide poisoning and hypothermia are often associated with livor mortis that appears bright red or pink. Brown lividity has been described in deaths caused by potassium chlorate and in deaths caused by
nitrobenzene poisoning. Sumber: ebook “Time of Death, Decomposition and Identification - An Atlas”

For number 84 until 87 refer to scenario below:
A corpse is found with lividity that is disappeared when pressed and cadaveric rigidity on facial muscle.
84. Which of the following is true for this kind of death?
a. Systemic death
b. Cellular death has occured
c. Death cannot be determined yet
d. Appeared death
e. To be an organ donor is impossible
Answer: A
-systemic death saat dimana jantung telah berhenti,tidak lagi bernafas(tidak ada lagi aliran darah)
-setelah systemic death masih mungkin belum mati celluler. Disaat seperti ini masih memungkinkan untuk donor organ.

85. When is the most likely time of death?
a. ¼ hours
b. ½ - 6 hours
c. > 8 hours
d. > 12 hours
e. Cannot be determined
Answer: B
-The stiffening becomes noticeable in the smaller muscle groups before the larger groups, giving the appearance that rigor mortis proceeds at different rates in the various muscle groups. Stiffness is usually apparent first in the jaw(facial muscle), then the elbows and finally the knees
-Within 1–3 hours following death, the muscles begin to become noticeably increasingly rigid
- satu sampai tiga jam pertama kematian adalah saat-saat awal dimulainya Rigor Mortis dimana prosesnya bertahap dimulai dari otot wajah.

86. A 1 mm maggot was found on corpse. How long did the corpse dead?
a. On the 1st day
b. On the 2nd day
c. On the 3rd day
d. On the 1st week
e. On the 3rd week
Answer: B
-maggot = belatung. Belatung ini terbentuk setelah proses decomposition sempurna. Decomposition mulai tampak jelas setelah 24-36 jam. Kemungkinan waktu yang paling tepat untuk proses pembentukan belatung itu setelah labih dari 3 hari. Jadi jawaban yang paling mendekati adalah 1 minggu setelah kematian.
87.what is the most possible cause of rotting smell?
a. Ammonie and sulphide gases
b. Sulphate gas
c. Sulphide gas
d. Ammoniac gas
e. No rotting smell yet

For number 88 until 91. Refer to thescenario below:
In a remote village a corpsewas found without any clothes. The stomach skin and face was dark green.
88. which of the following is the most likely identification method for examination?
a. Odontogram
b. Finger print
c. DNA
d. Nothing/difficult to do
e. Blood
Answer: B
- At room temperature, the right lower abdomen turns green at about 24 hours after death and the entire abdomen is green by 36 hours and Skin begin slips off but the hands and fingers will contain the decedent’s fingerprints.
-Since the fingerprint pattern is actually based in the dermis which remains on the body, the fingers from which the outer layers of the skin are absent can be printed.
-mayat masih cukup baik untuk diidentifikasi dengan menggunakan finger print

89.The visum reveals teeth were intactand there were 24 permanent teeth. Which of the following isteh most appropriate age? (Approximately)
a. 7 year old
b. 8 year old
c. 9 year old
d. 10 year old
e. 11 year old
90. The corpse was sent to Hospital by village official then the identification examination is the?
a. Competency and responsibility of doctor/hospital
b. Competency and responsibility of police
c. Competency of police and responsibility of doctor/hospital
d. Competency of doctor/hospital and responsibility of police
e. Competency of doctor/hospital and responsibility of village official
Answer: D
-bisa dipahami sendiri

91. At the crime scene. A red spot was found. From the blood examination revealed negative result for benzidine and teichmann tests and positive result for the presipitine test. Which of the following is the most likely?
a. Animal blood
b. Human blood
c. Animal and human blood
d. Animal body tissue
e. Human body tissue
Answer: B
- Benzidine reactions detect the presence of blood components, notably hemoglobin, within the bone matrix.
- Teichmann test for hemoglobin . Also called the Teichmann crystal, this is a test that is used on dried stains to determine whether or not blood is present. His microcrystalline test remains in use today as a means of identifying whether or not dried stains at a crime scene, on clothing or other fabric, or elsewhere at the site of a forensic investigation contain (human) blood.
-dua test diatas digunakan untuk melihat apakah darah tersebut mengandung darah manusia atau tidak. Karena kedua test diatas menunjukan hasil negative maka bisa dipastikan darah tersebut bukan darah manusia.

92. a parent who lost a child sent passport picture of the child to hospital.Which of the foolowing is the most likely identification method that can be conducted?
a. Facial reconstruction
b. Superimposition via the recent X-ray image of the victim
c. The victim photograph
d. Matching is not possible
e. An older X-ray image should be also used
-Facial reconstruction is a method used in forensic anthropology to aid in the identification of skeletal remains
-dibuat sketsa wajah mayat dengan menggunakan tulang-tulang wajah yang tersisa untuk dicocokan dengan foto asli mayat tersebut ketika masih hidup.

93.a 58 year old woman was admitted to hospital with a two month history of pain, swelling, and purulent discharge to her left lower leg. This occurred one year after sustaining a compuud fracture to that area. Colloning grown from the purulent discharge an blood agar were convex and appeared golden yellow. Which of the following is the most probable diagnosis?
a. Arthritis caused by Neisseria gonnorhoeae
b. Osteomyelitis caused by Haemophilus influenza
c. Wound infection caused by Sporothrix schenckii
d. Arthritis caused by Streptococus pneumonia
e. Osteomyelitis caused by Stapylococcus aureus
Answer: E
-Infection: Osteomyelitis/ostitis
-Most important pathogens:Staphylococcus aureus. Other: Coagulase negative. staphylococci. Streptococcus spp. Enterobacteriaceae Pseudomonas spp. Gram-positive and Gram negative
anaerobes (rare)
-Laboratory diagnosis:Microscopy and culture for bacteria, preferably based on biopsy or surgical material.Swab from fistular duct not useful for diagnosis
- S. aureus:Coagulase-positive; colonies golden yellow. Local purulent infections

For number 94 and 95. Refer to the scenario below:
A 33 yearold woman who is known intravenous drug user. Present with an acutely painful left ankle. On examination she is febrile with a swollen and red ankle. Her white cell count is 19.000/mm3.
94. what is the most likely causative organism?
a. Staphylococcus aureus
b. Streptococcus pyogenes
c. Candida albicans
d. Pseudomonas aerigenosa
-Infection: Septic arthritis
-Most Importnat Patogen:Staphylococcus aureus. Other:Streptococcus pyogenes. Streptococcus pneumonia. Haemophilus influenza. Neisseria gonorrhoeae. Enterobacteriaceae . Pseudomonas spp.
-Laboratory diagnosis :Microscopy and culture from synovial fluid with parallel blood culture

95. this patient has an aspiration of synovial fluid from her inflamed joint which shows turbidity,gram positive cocci in a gram stain of the joint fluid,and growth opaque cream colonies on the blood agar culture of the joint fluid.
The systemic infection inthis patient has most likely come from which of the following?
a. An infected needle-sharing contact
b. Contamined drug supply
c. The patient own skin
d. Contamined injecting equipment
-dengan ciri diatas kemungkinan bakterinya adalah Staphylococcus aureus. Dimana bakteri ini meruapakan flora normal dikulit.

96. A 14 year old girl was admitted to the hospital for the treatment of burn wound on her left foot. After four days of admission,pus stared oozing from the wound. Her body temperature was 39’C. A pus sample from the wound showed gram positive cocci arranged in clusters, and the culture showed beta hemolytic colonies on blood agar which were resistant to penicillin. What is the most likely causative organism in this case?
a. Streptococcus mutans
b. Staphylococcus epidermis
c. Staphylococcus aureus
d. Streptococcus pyogenes
e. Streptococcus faecalis
Answer: C
- Gram-positive cocci: Staphylococcaceae¬Cluster-forming cocci. Gram-stained S. aureus: This is a facultative anaerobe that is readily cultured on normal nutrient mediums. Hemolytic zones are frequently observed around the colonies.

97.A 70 year old man present to hospital with a fever 40.1’ C and painful cellulitis of the right buttock. The skin appears necrotic, and there are several fluid-filled bulla.Crepitus can be felt,indicating gas in the tissue. A gram stain of the exudates reveals large gram-positive bacilli.
Which of the following statement is CORRECT?
a. The patient has tetanus
b. His condition has treatable with topical antibiotics
c. The patient has shingles
d. This is a vaccine-preventable disease
e. Surgical debridement and systematic antibiotic are mandatory
Answer: E
-Anaerobic cellulitis. Infection restricted to the fascial spaces that does not affect musculature. Gas formation in tissues causes a cracking, popping sensation under the skin known as crepitus. There is no toxemia.
- The most frequent causative organism in anaerobic cellulitis and gas gangrene (clostridial myonecrosis) is C. perfringens

98. a 58 year old woman was admitted to hospital with a two month history of pain, swelling, and purulent discharge to her left lower leg. This occurred one year after sustaining a compound fracture to that area. Colloning grown from the purulent discharge an blood agar were convex and appeared golden yellow. What is the most possible organism?
a. Neisseria gonnorhoeae
b. Streptococus pneumonia
c. Haemophilus influenza
d. Staphylococcus aureus
e. Sporothrix schenckii
Answer: D
-lihat keterangan soal nomor 93

99. A 9 year old girl is broufht by her mother because itching on her finger. This itching is worsening at night. Her friend at school also have similar disease. On physical examination reveals small and red vesicle resemble tunnels under the skin between her fingers
Which one of the following is the most likely causative parasite?
a. Trichodectes canis
b. Phthirus pubis
c. Pediculosis humanus
d. Cutaneus larva migrans
e. Sarcoptes scabiei

Answer: E
- Clinical manifestations of Sarcoptes scabiei. An early sign of an initial infestation with Sarcoptes
mites is the primary efflorescence with mite tunnels up to 2–4mm and
sometimes 10mmlong—threadlike, irregularly winding burrows reminiscent
of pencil markings

100. some bacteria produce an internal structure known as endospore. This structureis produced bythe vegetative cells by process called sporogenesis. Which of the following is the most likely produce such structure?
a. Mycobacterium tuberculosis
b. Chlamidya trachomantis
c. Pseudomonas aerugenosa
d. Clostridium tetani
e. Proteus vulgaris
Answer: D
- Bacterial spores (endospores) are purely dormant life forms. Their development from bacterial cells in a “vegetative” state does not involve assimilation of additional external nutrients. They are spherical to oval in shape and are characterized by a thick spore wall and a high level of resistance to chemical and physical noxae. Among human pathogen bacteria, only the genera Clostridium and Bacillus produce spores

Sumber 93-100: e-book “Medical Microbiology (F.H.Kayser et al., Thieme 2005, ISBN 1588902455)”

121. A 25-year-old woman was diagnosed as burn injury 1% grade II at left arm caused by flame. Which is the deepest layer that is affected by the injury?
A. Stratum corneum
B. Stratum lucidum
C. Stratum granulosum
D. Stratum basale
E. Stratum papillary
Jawaban : E.
Penjelasan :
1st degree burn  sampai epidermis (+ erythema, pain, peeling)
2nd degree burn :
 Superficial Partial Thickness  sampai upper dermis / papillary layer (+ blister, pain, moist)
 Deep Partial Thickness  sampai lower dermis / reticular layer (+ mottled, less sensation, hypertrophic scar result)
3rd degree burn  sampai subcutaneous tissue, bahkan sampai bone / muscle (+ painless, white/cherry-red/black, dry, leathery, skin graft is needed)

122. A 65-year-old woman complained of insidious onset of low back pain during standing and walking. There is no history of trauma. From physical examination revealed pain at spine process of L-4 vertebrae. X-ray revealed of compression fracture of L-4. Which of this following bone cell activity imbalance in above condition?
A. Osteoblast-osteocyte
B. Osteoblast-osteoclast
C. Osteoblast-osteogenic
D. Osteoclast-osteogenic
E. Osteoclast-osteocyte
Jawaban : B.
Penjelasan :
Compression fracture = fraktur tulang akibat tekanan
Axial compression fracture = fraktur vertebra akibat gaya vertikal berlebih, sehingga ada bagiannya yang keluar secara horizontal, yang seringkali bisa melukai spinal cord
Osteoblast  bone deposition
Osteoclast  bone absorption

123. A 50-year-old man suffered from erythroderma came to the Emergency Room with chill as prominent complaint. Which of the following disturbance can cause his complaint?
A. Bacterial protection
B. Mechanical barrier
C. Chemical barrier
D. Thermo-regulator
E. Evaporation
Jawaban : D.
Penjelasan :
Salah satu fungsi kulit adalah sebagai thermo-regulator.
Pada erythroderma terjadi erithema secara universal di seluruh tubuh, yang artinya terjadi vasodilasi pembuluh darah pada kulit secara luas. Hal ini menyebabkan aliran darah ke kulit meningkat, sehingga kehilangan panas juga akan meningkat. Hasilnya adalah pasien merasa dingin dan menggigil.

For number 124 until 126, refer to scenario below :
A 60-year-old man came to your clinic with chief complaint swelling and ulceration accompanied with difficulty in opening his left eyelid of the last 6 months. He noticed hyperpigmentation skin lesion on the outer aspect of the eyelid. The skin lesion was sometimes itching and easily glued. He works as a farmer in the mountainous and works from 7am to noon daily for more than 20 years without any sunlight protection. Microscopic finding revealed that the tumor cells were growth hyperplastic in solid arrangement, tumor cells were oval to spindle which have the appearance of forming island.
124. Which layer of skin is damaged because of sunlight from case above?
A. Stratum corneum
B. Stratum lucidum
C. Stratum granulosum
D. Stratum spinosum
E. Stratum basale
Jawaban : E.
Penjelasan :
Sunburn  1st degree burn  epidermis
Radiasi sinar UV matahari memiliki efek terhadap melanosit yang terdapat pada stratum basale.

125. Which layer of the skin is damaged from case above?
A. Epidermis
B. Dermis
C. Subcutis
D. Subcutaneous fat
E. Muscle
Jawaban : B.
Penjelasan :
Excoration  kelainan kulit akibat kehilangan jaringan sampai ke papillary layer.
Apabila kerusakan belum sampai papillary layer ( epidermis), disebut erosion.
Apabila kerusakan melebihi papillary layer ( dermis), disebut ulceration.

126. Which layer is damaged that causing difficulties in opening the eye?
A. Epidermis
B. Dermis
C. Subcutis
D. Subcutaneous fat
E. Muscle
Jawaban : E.
Penjelasan :
Otot merupakan organ yang mampu berkontraksi / berelaksasi untuk melakukan suatu pergerakan / aksi.

For number 127 and 128, refer to scenario below :
A 25-year-old man comes to your clinic with chief complaint of reddish plaques pruritus on his entire body and chillness. This comlaint has already happened for the last month that was started on his knees, elbows, and buttocks. The lesion has large scaling that exfoliated profusely. Microscopic finding from skin biopsy was containing marked epithelial hyperplasia, hyperkeratotic, parakeratotic and spongiosis.
127. Which layer of the skin damaged for large scales from above case?
A. Epidermis
B. Dermis
C. Subcutis
D. Subcutaneous fat
E. Fascia
Jawaban : A.
Penjelasan :
Parakeratosis & spongiosis merupakan ciri khas dari psoriasis.
Psoriasis adalah hiperproliferasi dari keratosit (yang terdapat pada epidermis).

128. Which part of the nerve stimulated cause pruritus in the case above?
A. Meissner
B. Pater Pacini
C. Free nerve endig
D. Krause
E. Rufini
Jawaban : C.
Penjelasan :
Itch merupakan sensasi gatal yang disebabkan oleh rangsangan free nerve ending oleh zat kimia / stimulus permukaan kulit secara lembut, dihantarkan oleh C fiber pada spinothalamic tract.

129. A 17-year-old girl comes to dermatologist with chief complaint of red pimples on both cheeks for the last two years. She rarely wears cosmetics. On physical examination, comedo, papules, and pustules are found mostly on forehead, cheeks, and jaws area. What type of gland is causing above symptoms on the face?
A. Apocrine
B. Holocrine
C. Eccrine
D. Sitocrine
E. Paracrine
Jawaban : B.
Penjelasan :
Acne = peradangan pilosebaceous unit
Sebaceous (oil) gland  holocrine  jenis sekresi glandular dengan cara akumulasi secretory product pada cytosol, kemudian terjadi disintegrasi seluruh bagian sel.

130. A 7-year-old girl brought to dermatologist with chief complaints of small vesicles and itchy on her back. What type of gland is causing above symptoms on this patient?
A. Paracrine
B. Holocrine
C. Eccrine
D. Sitocrine
E. Endocrine
Jawaban : C.
Penjelasan :
Miliaria = retensi keringat akibat oklusi sweat gland
Sudoriferous (sweat) gland  eccrine/merocrine  jenis sekresi glandular dengan cara exocytosis melalui vesikel-vesikel berisi secretory product.

131. A 35-year-old man had discrete, coin-shaped, erythematous patches from 20-40 mm wide, in which papules and papulovesicles and exudation occurred. The lesions were itchy and appeared on his legs. Which of the following is the most likely diagnosis?
A. Circumsribed neurodermatitis
B. Nummular dermatitis
C. Seborrhoic dermatitis
D. Chronic lichen simplex
E. Erythroderma
Jawaban : B.
Penjelasan :
B  dermatitis berbentuk nummular (coin-shaped), biasanya menghasilkan eksudat (=exudative neurodermatitis)
A = D  dermatitis berbentuk lichen (papul kecil, padat, berdekatan) akibat garukan yang berulang-ulang pada kulit
C  dermatitis kronis, dengan sisik kering / berminyak, terutama pada scalp ditandai dengan ketombe
E  erithema abnormal secara universal

132. A 32-year-old man is diagnosed of having erythroderma. The doctor gives him intravenous glucose 5%, 20 glt/mnt and topical vaseline ointment for the skin. Which of the following is the most likely reason of giving intravenous glucose 5%?
A. Patient couldn’t drink or eat
B. For antibiotics preparations
C. To overcome the excessive water loss
D. Standard procedure
E. For calorie requirement
Jawaban : C. / E. (?)
Penjelasan :
(IV glucose untuk asupan kalori/energi.. tapi di kasus ini kayanya ditekenin untuk treatment eritroderma nyaprevent water loss… tapi gatau…)

For number 133 and 134, refer to scenario below :
A 35-year-old man complained of thick scaling at his elbow and knee area accompanied by mild itching and reddish.
133. Which of the following is the most likely diagnosis for this particular condition?
A. Psoriasis
B. Erythroderma
C. Sunburn
D. Lichen planus
Jawaban : A.
Penjelasan :
Psoriasis adalah kelainan kulit akibat hiperproliferasi keratosit pada epidermis, dengan ciri lesi erythrosquamous (kemerahan & pengelupasan sisik).

134. Which of the following test is appropriate to diagnose this disease?
A. Auspitz test
B. Prick test
C. Skin test
D. KOH test
E. Woods Lamp test
Jawaban : A.
Penjelasan :
Auspitz’s sign  gambaran titik perdarahan halus bila sisik diangkat dari plak psoriasis, disebabkan oleh penipisan epiddermis di atas dermal-papilae.

135. A 30-year-old woman came to the doctor with complaint many dandruffs since last 2 months. She only complained about mild itching. The doctor found scales in te border of her scalp. Which of the following is the most likely diagnosis for this patient?
A. Seborrheic dermatitis
B. Pityriasis versicolor
C. Secondary syphilis
D. Pityriasis rubra
E. Parapsoriasis
Jawaban : A.
Penjelasan :
Seborrheic dermatitis  dermatitis kronis, dengan sisik kering / berminyak, terutama pada scalp ditandai dengan ketombe & rasa gatal.

136. A 60-year-old man came to the doctor with chief complaint his finger nails at both hands became yellowish and pitted since 3 months ago. He also complained about pain and swelling at his finger joints. He did not have history of trauma or diabetes mellitus. Which of the following disease is the most likely caused pitting nail in this patient?
A. Mycosis
B. Rheumatoid arthritis
C. Vascular disease
D. Allergic
E. Psoriasis
Jawaban : E.
Penjelasan :
Psoriasis memiliki manifestasi klinis pada kuku berupa :
-nail pitting (cekungan kecil pada kuku akibat keratinisasi yang abnormal)
-oil spot (macula kekuningan di bawah nail plate)
-onychodystrophy (bentuk kuku yang abnormal)
-onycholysis (terlepasnya kuku dari matrixnya)
-anonychia (kuku tidak tumbuh)

137. A 25-year-old woman had small clear and superficial vesicles on her back. The lesions were asymmetric and appeared after she had bedridden due to fever. Which of the following is the most likely diagnosis?
A. Miliaria rubra
B. Miliaria pustulosa
C. Miliaria crystalline
D. Occlusion miliaria
E. Milia
Jawaban : C.
Penjelasan :
Miliaria crystalline  bentuk : vesikel superfisial yang kecil, akibat bedrest yang lama
Miliaria rubra  bentuk : papulovesikel kemerahan yang gatal, pada daerah lipatan tubuh
Miliaria pustulosa  bentuk : pustule, diawali oleh bentuk dermatitis lainnya
Miliaria profunda  bentuk ; papule putih tanpa gatal, letaknya di lapisan kulit yang dalam

For number 138 until 140, refer to scenario below :
A 60-year-old man came to the hospital with breathing difficulty and poor condition. He said his weight loss about 10 kg in the last 3 months. Cough without sputum occurred last month. Physical examination was found normal vital sign, anemic conjunctivae, lung auscultation, : ronchi (+) in the left chest. In the left extremity, the doctor found 3 black nodules, 2x3x1 cm in diameter, painless, well-border, left inguinal lymph node just palpable.
138. Which of the following is the most possible diagnosis for this patient?
A. Keratoacanthoma
B. Melanoma maligna
C. Basal cell carcinoma
D. Epidermoid carcinoma
E. Squamous cell carcinoma
Jawaban : B.
Penjelasan :
Melanoma maligna adalah tumor ganas dari melanosit.
Manifestasi klinis : variasi warna pada lesi & peningkatan diameter, kedalaman, ketidak-simetrisan dari lesi, bisa juga disertai perdarahan / gatal / ulkus.

139. In this patient, black nodules occurred due to which of the following?
A. Hemorrhagic crust
B. Increase of melanocyte
C. Inflammation
D. Necrotic tissue
E. Disturbance of lymph system
Jawaban : B.
Penjelasan :
Melanocyte adalah sel khusus pada epidermis dan folikel rabut yang memberikan pigmen gelap / hitam (melanin) pada kulit dan rambut.

140. Considered of enlargement of inguinal lymph node, which of the following process is the most likely to occur in this patient?
A. Metastasis
B. Secondary infection
C. Inflammation of lymph node
D. Lymph system disturbance
E. Defense mechanism of the body
Jawaban : A.
Penjelasan :
Melanoma bisa bersifat invasif.
Staging I & II  localized cutaneous disease
Staging III  apabila telah bermetastasis ke regional lymph node
Staging IV  apabila telah bermetastasis ke viscera, skeleton, CNS

For questions 141 – 142 :
A 56-year-old man complained about a mole in his nose that bleeds easily. He said that the lesion occurred about 10 years ago, was like a dark mole, and became larger and now it is as big as a bean. Three years ago, the lesion started to itch and darken, and now it bleeds so easily that even a touch by a finger can cause it to bleed. The doctor found hyperpigmented lesion with ulcer, ill-bordered, 2 x 2 cm in diameter. Hemorrhagic crust covers a part of the ulcer.

141. Which of the following is the most possible diagnosis ?
A. keratoacanthoma
B. melanoma maligna
C. epidermoid carcinoma
D. basal cell carcinoma
E. squamous cell carcinoma
Jawab : D
Pembahasan :
Keratoacanthoma ditandai secara klinis dengan adanya nodule berwarna kulit (flesh-colored), berbentuk seperti kubah, dan memiliki keratin plug di tengah-tengah, sehingga bentuknya seperti kawah.
Pada melanoma maligna, secara klinis, dalam satu lesi terdapat variasi dalam pigmentasi (ada hitam, coklat, biru, abu-abu); kadang ditemukan pula zona hipopigmentasi (kadang putih atau berwarna kulit). Terkadang ada rasa gatal. Batas lesi biasanya jelas, dan terkadang “notched” (membentuk suatu depresi).
Basal cell carcinoma ditandai secara klinis dengan adanya papule berwarna keperakan (pearly papule) yang mengandung pembuluh darah subepidermal yang terdilatasi dan terlihat jelas (telengiectasis). Lesinya bisa mengalami ulserasi. Selain itu, jika merupakan varian superficial basal cell carcinoma, lesinya merupakan plaque erythema atau terpigmentasi, yang jika diobservasi, pada tepinya terlihat pearly papule. Lesi BCC tumbuh secara lambat.
Squamous cell carcinoma ditandai secara klinis dengan adanya lesi berbentuk plaque yang berwarna merah, berbatas jelas, dan bersisik (scaling) pada tahap in situ. Pada tahap lanjut, lesinya berbentuk nodular, menunjukkan hyperkeratosis, dan memiliki ulserasi. Jika terjadi pada membran mukosa, ada leukoplakia.
Sumber : Robbins & Cotran Pathologic Basis of Disease, edisi 7, hal.1234, 1239, 1241-1244
Jadi, pada kasus di atas, kemungkinan besar jawabannya adalah (D) basal cell carcinoma, karena lesinya mudah berdarah. Kemungkinan besar ini adalah karena telangiectasis yang terbentuk.
142. Which of these is the most likely to have a correlation with the above disease ?
A. chronic trauma
B. chronic infection
C. chronic sun exposure
D. cryosurgery
E. topical cytostastic preparation
Jawab: C
Faktor risiko untuk basal cell carcinoma :
- Paparan terhadap sinar matahari secara kronis
- Orang yang pigmentasinya rendah (berkulit terang)
- Orang yang mengalami immunosuppresion
- Orang yang memiliki defek herediter pada mekanisme DNA repair-nya
Note :
pada squamous cell carcinoma, faktor risiko :
- Paparan terhadap matahari secara kronis
- Paparan terhadap karsinogen industri (tar, minyak)
- Ulkus kronik
- Osteomyelitis kronik
- Bekas luka bakar
- Paparan terhadap radiasi ionisasi (ionizing radiation)
- Pernah mengkonsumsi arsenik
- Pada rongga mulut : tobacco dan betel nut
- Orang dengan immunosuppresion (pada chemotherapy atau transplantasi organ)
- Orang dengan defek herediter pada DNA repair
Sumber : Robbins and Cotran Pathologic Basis of Disease, edisi 7, hal. 1241-1244

143. Which of the following treatment is the first choice in this patient ?
A. surgery
B. radiotherapy
C. cauterization
D. cryosurgery
E. topical cytostatic preparation
Jawab : A
Pembahasan :
Beberapa pilihan terapi untuk basal cell carcinoma :
1. Surgery
Ada dua metode, yakni Mochs Micrographic Surgery dan Standard Excision.
Pada teknik Mochs Micrographic Surgery, dilakukan eksisi sedikit demi sedikit; setiap selesai eksisi, jaringan dilihat melalui mikroskop apakah ada sel tumor atau tidak. Eksisi dilakukan terus hingga jaringan menunjukkan negatif untuk sel tumor. Indikasinya : lokasi tumor pada tempat yang risiko tinggi (misal: mask area dari wajah, kulit kepala, anatomic fusion plane, daerah periorbital), tumor > 2 cm, secara histologis tergolong agresif, tumor berulang, tumor yang sudah dieksisi tapi tidak komplit, lokasi di kulit yang sebelumnya pernah diradiasi, pasien yang mengalami immunosuppression, batas klinis tak jelas, situasi membutuhkan preservasi jaringan untuk fungsi dan/atau kosmetik)
Dengan teknik Standard Excision, dilakukan eksisi pada tumor secara umum.
2. Electrodessication and Currettage (ED & C)
Prinsip : menggunakan arus listrik untuk memotong/menghancurkan jaringan dan mengkauterisasi pembuluh darah.
Indikasi : tumor primer dengan batas jelas, lokasi di tempat yang jarang terjadi rekurensi, sub tipe BCC superficial atau sub-nodular, diameter < 1 cm pada wajah dan < 2 cm pada ekstremitas atau trunk, memiliki kontraindikasi terhadap prosedur eksisi, tidak bisa melakukan follow-up teratur.
3. Cryosurgery
Prinsip : menggunakan cryogen (freon, oksigen, NO, atau nitrogen cair) untuk menghancurkan jaringan melalui perusakan langsung terhadap sel, menginduksi stasis pada pembuluh darah, dan menginisiasi respon inflamasi lokal.
Kontraindikasi : memerlukan diagnosis histopatologi, kanker kulit non-melanoma yang berulang, lokasi lesi pada tempat yang berisiko terjadi scarring dengan retraksi.
4. Photodynamic therapy
Prinsip : generasi reactive oxygen species (ROS) dengan mengeksitasi photosensitizer menggunakan cahaya dan oksigen, sehingga ROS bisa memberi efek cytotoxic secara langsung maupun tak langsung pada sel target.
5. Radiation therapy
Keuntungan : bisa rawat jalan, tidak sakit, atraumatik, jaringan sehat bisa terproteksi, memiliki kontraindikasi terhadap operasi.
Kerugian : tidak bisa dilakukan verifikasi histopatologis, perawatan lama, secara kosmetik bisa memburuk, ada kecenderungan tumor berulang secara agresif dan ekstensif.
6. Topical treatment
Ada 2, menggunakan imiquimod atau 5-fluorouracil (FU).
Imiquimod diindikasikan untuk kutil anogenital eksternal, superficial BCC < 2 cm pada trunk, ekstremitas, leher; dan actinic keratosis. Kerugiannya : terjadi iritasi berupa erythema dan erosi terutama dengan penggunaan harian. Komplikasi : irritant contact dermatitis, ulserasi, treatment tidak komplit.
5-FU diindikasikan untuk actinic keratosis, superficial BCC, dan BCC pada umumnya. Efek samping ada yang sistemik (misal : mual, anorexia, stomatitis, diare, myelosuppression, alopecia, toksis terhadap jantung dan saraf), lokal (iritasi lokal, erythema, nyeri, bengkak, pruritus, dyspigmentasi, allergic contact dermatitis, photosensitivity), dan efek samping yg tidak biasa, seperti onycholysis, onychodystrophy, dan telangiectasis.
Sumber : Case Review DMS angkatan 2006 hal. 149 – 151
Jadi, pada kasus di atas, karena tumornya 2 x 2 cm dan terletak di wajah, sebaiknya tidak dilakukan ED & C maupun cryosurgery. Radiotherapy dan topical treatment sebaiknya tidak dilakukan karena kemungkinan tumor berulang cukup tinggi. Maka, terapi terpilihnya adalah surgery (kemungkinan terutama yg metode Mochs Micrographic Surgery).

For number 144 – 145, refer to the scenario below :
A 20-year-old female medical student came to dermatologist because she had reddish lesion on both of her elbows. She said that the lesion appeared about 2 months ago, after she played tennis. Physical examination found that they are covered by thick scaling with erythematous macules on the base. The doctor found the same lesions on both of her knees.

144. Which of the following procedure will help to make the diagnosis ?
A. KOH examination
B. Nikolsky’s sign
C. Tzank smear
D. Gram stain
E. Biopsy
Jawab : E
Pembahasan :
Diagnosisnya Psoriasis.
Untuk mendiagnosis psoriasis, biasanya dilakukan secara klinis, yakni ada tanda-tanda :
- Lesi klasik psoriasis adalah plaque berwarna kemerahan, berbatas jelas, dengan permukaan sisik keperakan.
- Auspitz sign positif (ketika sisik diambil, ada bleeding point/titik-titik perdarahan karena pengambilan sisik telah mengakibatkan trauma pada kapiler di bawahnya).
- Lesi psoriasis biasanya bersifat simetris dan banyak terjadi di bagian ekstensor (siku, lutut).
Jika secara klinis tidak jelas, maka bisa dilakukan biopsi. Dari hasil biopsi, akan ditemukan :
- Pada tahap awal : edema dan infiltrasi round cell pada bagian upper dermis, terutama pada dermal papilla. Bagian epidermisnya menjadi spongiotic, menunjukkan adanya focal loss pada stratum granulosum. Vena pada upper dermis mengalami dilatasi, dan dikelilingi infiltrate mononuclear.
- Pada tahap lanjut :
o Untuk chronic (plaque-type) psoriasis, terlihat peningkatan massa epidermis 3-5 kali lipat, tidak adanya stratum granulosum di atas dermal papilla, tebalnya granulosum di daerah rete ridge. Di lapisan basal, ada banyak mitotic figure. Pada dermis, papilla terlihat tipis, panjang, dan prominent. Kapilernya terdilatasi dan tortuous. Ada infiltrasi sel inflamasi (makrofag, limfosit, neutrofil, mast cell). Ada juga PMN terutama di atas dermal papilla.
o Untuk eruptive (guttate) psoriasis, hyperplasia epidermis lebih tidak prominent. Ada area spongiosis di atas dermal papilla. Ada discharge serum dari ujung papilla menuju ke epidermis, dimana neutrofil akan berakumulasi. Sel-sel ini akan berkumpul di area sub-corneum, membentuk subcorneal pustule. Kadang ada eritrosit yang ikut ekstravasasi.
Opsi A-D tidak dilakukan untuk psoriasis.
Sumber : Fitzpatrick edisi …, hal. 176; edisi …, hal. 415-417

145. Thick scaling with erythematous macules. Which of the following medication is the first choice for topical treatment in this patient ?
A. topical antihistamine
B. cytostatic agent
C. topical steroid
D. moisturizer
E. keratolytic
Jawab : C
Pembahasan :
Topical glucocorticoids biasanya merupakan terapi first-line pada psoriasis bentuk ringan atau sedang dan pada psoriasis yang terjadi pada flexure dan genitalia.
Sumber : Fitzpatrick edisi … hal. 185

146. A 50-year-old man complains resistant dandruff for the last 2 years. His wife has passed away. Itching in scalp with thick dandruff, thick scales, greasy, red macules with well border. KOH exam shows hyphae (-). What is the pathogenesis ?
A. hyperkeratosis
B. orthokeratosis
C. hypertrophy of epidermis
D. hyperplasia of keratinocyte
E. hypertrophy of basal layer
Jawab : C
Pembahasan :
Diagnosisnya adalah psoriasis pada scalp (kulit kepala). Maka patofisiologinya adalah hyperplasia dari keratinosit. Patient’s symptoms : chillness, redness over most of the body, thick scales on the elbow and knee.

147. Which of the following complication must we consider in this patient ?
A. electrolyte imbalance
B. renal failure
C. circulation disorder
D. hematopoietic disorder
E. bleeding disorder
Jawab : A/B
Pembahasan :
Diagnosis pada pria ini adalah exfoliative dermatitis, kemungkinan karena psoriasis.
Pada exfoliative dermatitis, terjadi pengelupasan secara besar-besaran dari sisik yang terbentuk. Hal ini menyebabkan penurunan fungsi kulit sebagai barrier tubuh, salah satunya berakibat pada peningkatan penguapan air. Penguapan air yang meningkat bisa menyebabkan ketidakseimbangan elektrolit dan renal insufficiency.
Sumber : Fitzpatrick edisi … hal. 439-440.

148. Site of predilection :
A. sun-exposed site
B. traumatic sites
C. flexor sites
D. extensor sites
E. neck
Jawab : C/D
Pembahasan :
Bingung! Flexor site = cubital fossa dan popliteal fossa atau siku dan lutut ?
Yang jelas, ED karena psoriasis terjadinya sering di siku dan lutut.

149. A 17-year-old came with chief complain of red pimples on both cheeks for 2 years. She rarely wears cosmetics. Physical findings : comedo, papules, and pustules on cheeks, forehead, and jaws. What is the diagnosis ?
Diagnosis : acne vulgaris 

For question 150 – 151 :
A 19-year-old is hospitalized with a fever, headache, and neck stiffness. According to his mother, 3 days ago he had pimples on his nose, was given a cream by his friend, after which his nose became reddish and swollen. Physical examination reveals decreased alertness, BP 120/90, HR 100 bpm, RR 24/min, temperature 40.3°C, swelling, reddish, pustules, and neck stiffness.

150. Which one is the most likely first choice of antibiotics ?
A. broad spectrum
B. bacteriostatic
C. bactericidal
D. antibiotic which goes through blood-brain barrier
E. antibiotic with resistance test
Jawab : A
Pembahasan :
Untuk mengobati acne, diberikan broad-spectrum antibiotic, misalnya tetracycline.
Sumber : Fitzpatrick edisi …, hal. 680.

151. Without antibiotics, what is the most likely prognosis ?
A. very good
B. good
C. bad
D. worse
E. unexpectable
Jawab : D
Pembahasan :
Pada kasus di atas, acne-nya sudah termasuk pustular; sehingga lesinya merupakan lesi inflammatory. Karena itu, diperlukan antibiotik untuk mengontrol lesi.

152. A woman is brought by her husband because of paralysis of her right arm. She has had this complain since a month ago. She said that her husband was initially worried she had stroke, but her extensive neurological work-up results were entirely within normal limit. The onset of paralysis was sudden after she punished her 15-year-old daughter who had been involved in drugs. What is the most likely diagnosis ?
A. panic disorder
B. mood disorder
C. anxiety disorder
D. somatization disorder
E. conversion disorder
Jawab : D
Pembahasan :
Panic disorder merujuk pada suatu serangan kecemasan (anxiety) yang bentungnya akut dan intens, bersamaan dengan adanya perasaan sesuatu yang jelek akan terjadi (sense of impending doom).
Mood disorder adalah suatu kelompok kelainan dimana mood patologis dan gangguan yang dialami mendominasi gambaran klinis (e.g. major depression, bipolar disorder.. review NBSS  )
Anxiety disorder  g ada. Disorder dari anxiety itu = panic disorder…
Somatization disorder adalah konversi dari faktor psikis menjadi gejala fisik dan biasanya bereaksi dengan manifestasi somatic daripada psikis.
Conversion disorder adalah sama dengan somatization disorder, namun gejalanya berjangka pendek.

153. A 35-year-old female came to the obstetrics ward. This woman is known to like doctor-shopping. She complained of back pain, dyspareunia, excessive menstruation, constipation, and chest pain. What is the most likely diagnosis ?
A. Pain disorder
B. Malingering disorder
C. Hysterical personality disorder
D. Somatization disorder
E. Conversion disorder
Jawab : A
Pembahasan :
Pain disorder biasanya ditandai secara klinis sbb : pasien memiliki riwayat medis dan operatif yang panjang, dan riwayat medisnya tidak terdiri atas gejala yg konsisten, misalnya memiliki sakit punggung bawah, nyeri kepala, nyeri wajah, nyeri pelvis, dan nyeri lainnya.
Malingering dibedakan dari pain disorder dengan kelainan yang dipura-purakan. (Pada pain disorder, pasien benar-benar yakin bahwa dia menderita nyeri)
Major depressive disorder memiliki gejala berupa perubahan nafsu makan dan berat badan, perubahan siklus tidur, penurunan energy, perasaan bersalah, kesulitan dalam berpikir dan membuat pilihan, serta memiliki pikiran untuk mengakhiri hidup selama paling tidak 2 minggu.

154. A 40-year-old female believes she has breast cancer. Mammogram and biopsy is negative.
A. somatization disorder
B. conversion disorder
C. hypochondriasis
D. malingering disorder
E. pain disorder

155. A 50-year-old man who has poorly-controlled diabetes is referred to you due to non-compliance to medication. You learn that he cannot fell asleep at night and has no energy during the day. His appetite is good and he does not enjoy activities as he once did overall, he feels depressed. Additionally, he has been experiencing chronic pain in his feet, which is not relieved by analgesics.
A. alprazolam
B. citalopram
C. amitriptyline
D. bupropion
E. trazodone

For questions 156 – 157 :
A 66-year-old man came to the ENT clinic, complaining about hoarseness and slight dyspnea for 6 months. Physical examination showed tumor in his vocal cord with impaired mobility. A 4-cm nodule is found on the neck, at mid-jugular region. No node enlargement in other parts of the body.

156. What TNM classification ?
A. T is
B. T 1
C. T 2
D. T 3
E. T 4

157. The location level of the node enlargement in the above case (the mid-jugular region) :
A. I
E. V

158. A 40-year-old male came to ENT clinic with a mass in the lower part of his neck that moved upward on swallowing. He had no pain nor tenderness in that area, no fever, no bruit. The mass is about 4 cm in diameter, firm, and hard, located a little bit to the left. There is hoarseness recurrently.
Which of the following is the possible diagnosis ?
A. Lymph node enlargement
B. Thymus persistence
C. Abscess of the lower neck
D. Tuberculosis of the upper mediastinum
E. Thyroid mass
Jawab : A
Pembahasan :
Bukan thyroid mass karena tidak ada fever dan bruit.
Bukan abscess karena tidak ada tenderness, massanya firm dan hard.
Bukan thymus karena tidak congenital.

For number 159 until 161, refer to the scenario below :
A 60-year-old man visited the ENT clinic with difficulty of swallowing because he feels a mass in his throat. The doctor in clinic says that he is suspected to have nasopharyngeal carcinoma.

159. Which neck node enlargement below shows the possibility of that carcinoma ?
A. anterior compartment
B. jugulodigastric
C. mid jugular
D. posterior triangle
E. low jugular
Jawab :
Pembahasan :

160. Which of the following is the most likely therapy to the patients ?
A. Chemotherapy
B. Operating
C. Cryosurgery
D. Radiation
E. Photodynamic therapy
Jawab : D
Pembahasan :
Radiotherapy is the standard modality of treatment, yieliding about a 50%-70% 3-year survival rate.
Sumber : Robbins & Cotran Pathologic Basis of Disease, edisi 7, hal. 785
161.C.Tumor infiltration to th middle ear
Pembahasan: serous otitis media merupakan salah satu complikasi yang sering terjadi ialah pada nasopharingeal tumor. Selain itu jga sering terjadi diplopia karena gangguan CN VI.

162.A.Mixed tumor
Pembahasan: Parotif duct tumor umumnya mix tumor yakni derived dari mixture of ductal dan sel-sel myoepitel.

-Coldwell (anteroposterior): sinus frontal dan ethmoid anterior
-Schuller : proyeksi lateral kepala
-Water: proyeksi radiograpic kepala anterior.

164.C.Le-fort II fracture
Pembahasan: Le-fort fracture = pyramidal fracture (dari posterolateral part maksilari sinus > superomedially melalui infraorbital foramin,lacrimal dan ethmoid to bridge of nose > central part of face including hard palate dan alveolar process.

165.C.ESR 60/90
Pembahasan: terjadi peningkatan ESR pada kasus TB tulang dimana ESR normal =0-20mm/hour.

Pembahasan: pada keadaan exfoliative dermatitis ialah eosinophilia, high level Ig A, Hypoalbuminemia, negative nitrogen balance dan anemia.

167.E.The most sensitive tumor marker to detect and monitor the course of colorectal carcinoma.
Pembahasan: CEA memiliki tingkat sensitivitas 60-90% pada colorectal carcinoma, 50-80@ pada pankreas tumor, dan 25-50 % pada digastric dan breast carcinoma

168.E.Serum Uric Acid
Pembahasan: Diagnosis kasus ialah Gout dimana tejadi peningkatan uric acid pada darah.

169.B.Aspiration of the joint fluid for culture and sensitivity.

170.B.Give an antibiotik and analgesic then refer to dentist.

171.E.Angina van ludwig

172.A.Proper method of tooth bruishing

173.A.Rheumatoid artritis
Morfologi RA=
1.Infiltrasi synovial stroma by dense perivascular inflamatory cells
2.Increase vascularitas owing to vasodilatasi dan angigenesis
3.Increase fibrin > rice bodies
4.Accumulasi neutrofil in synovial fluid
5.Osteoclast activity in underlying bone
6.Pannus formation

Pembahasan: Cukup jelas di robbin bab tulang

Pembahasan: diagnosis Gout dimana terjad acumulasi cristal uric acid.

176.D.Soft tissue sweeling

177.C.Glioblastoma multiforme
Pembahasan: pada glioblastoma multiforme morfoliginya sama dengan anaplasia astrocytoma + necrosism vascular,dan endothelial cell proliferation.

178.A.Non- ossifying fibromal

179..C.Compound nevus
Melanocyt nevus : differensiasi melanocyt yang sel-sel yang highly dendritis yang terinterspersi di basal keratinovyt to round cell aggregate di dermoepidermal juncion,terdiri dari beberapa jenis>
a.Junctional nevy: early developmenatal stage
b.Compound nevy: di bawah underlying dermis
c.Intradermas nevus : epidermal nest may be lost

Pembahasan: diagnosis tumor adiposa tissue (lipoma dan liposarcoma)
-Lipoma: terdapat mature adipocyte, well encapsulated, intramuscular, dan pooly circumscribed
-liposarcoma : well differentiated,myoid,round cell,pleomorphic variant,cell lipocyte, lipoblast,mimic fat cells and contain rounnd cell cytoplasmic vacuola
Tapi lebih berat ke A karena terdapat lypocyte (adiposcyte yang mature ) (osteocyte=mature osteoblast)

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