MDE HIS 2009

1. Lymph vessel in small intestines

a. Lacteal

b. Rugae

c. Pylorus

d. Corpus

e. Fundus

Jawab : A

Alasan : Specialized lymphatic vessels in the intestinal villi (tiny projections of the mucous membrane) that absorb fat are called lacteals (Moore hlm 265)

3. Largest lymphatic organ in body?

a. Gallbladder

b. Pancreas

c. Spleen

d. Tonsils

e. Liver

Jawab : C

Alasan : As the largest of the lymphatic organs, it (spleen) participates in the body's defense system as a site of lymphocyte (white blood cell) proliferation and of immune surveillance and response (Moore hlm 281)

9. 45 y.o., pallor, fatigue, pancytopenia, blood smear?

a. Erythrocyte normocytic normochromic

b. Erythrocyte microcytic normochromic

c. Leucocyte shift to the left

d. Myeloblast

e. Megakaryoblast

Jawab : A

Alasan : Kemungkinan diagnosis dengan SS di atas adalah aplastic anemia, dengan ciri RBC normocytic normochromic (Harmening hlm 133)

10. Pathogenesis megaloblastic anemia?

a. Abnormal nuclear & cytoplasm maturation

b. Defective DNA synthesis & nuclear maturation

c. Defective RNA synthesis & nuclear maturation

d. Defective RNA synthesis & cytoplasm maturation

e. Defective DNA synthesis & cytoplasm maturation

Jawab : B

Alasan : Megaloblastic anemia is a subgroup of macrocytic anaemia characterized by defective nuclear maturation caused by impaired DNA synthesis (Harmening hlm 112)

13. Hb, WBC, Ht, Platelet, RBC increase. Diagnosis?

Jawab : polycythemia vera

Alasan : Polycythemia vera (PV), also commonly called polycythemia rubra vera, is a chronic, clonal, myeloproliferative disorder characterized by a striking, absolute increase in the number of red blood corpuscles and in the total blood volume, and usually by leukocytosis, thrombocytosis, and splenomegaly. The bone marrow is typically hypercellular and exhibits hyperplasia of myeloid, erythroid, and megakaryocyte lineages. (Wintrobe hlm 1822)

15.A.untuk melihat dari et causa secara tepat dari penyebab lymphadenopathy, jika optionnya demikian maka pilihan kita adalah lymphnode biopsy. (Note: sebenarnya apabila dicurigai dari CA paru, maka dengan X-Ray juga bisa mendukung diagnose, lymphadenopathy sebagai akibat metastase s el CA)

18. E. dengan hasil pemeriksaan lab yang menunjukan low count of thrombocyte, maka sudah jelas bahwa ini gangguan dikarenakan jumlah platelet

a. fibrinolytic disorder related terhadap pembentukan thrombus

b, biasanya tidak berasosiasi dengan gannguan pada platelet secara kualitatif dan kuantitatif

c.jawaban tidak spesifik

d. ditandai dengan normal-slight low pada jumlah platelet, tapi terdapat gannguan dari fungsi platelet (biasanya dapat dibuktikan dengan pemeriksaan protein assay atau periksa lab untuk mengetahui underlying disease atau related-disease circulating agents )

21. D. cryoprecipitates. Ada di harmening hal 497

24. C. maksud dari soal sepertinya urutan organ yang terlibat dalam hematopoiesis

Yolk sac (1^st week – 8^th week of fetal life) – liver/spleen (2^nd months-9^th months) – bone marrow (shifting ketika 7^th month dan seterusnya jadi major site of hematopoiesis)

25. A. Yolk Sac. Lihat penjelasan di atas (Harmening hal 9)

26. WOTF characteristic of erythropoietin?

A. Cannot cross placental barrier

B. Of chromosome 11

C. Adult, secretion in liver most

D. Unborn, secretion in liver most

Jawaban : A.(?)

Pembahasan :

EPO adalah hormon yang dihasilkan di ginjal yang membantu proses erythropoiesis.

“Hybridization analysis of DNA from human chromosomes isolated by high resolution dual laser sorting provides evidence that the gene for human erythropoietin is located on human chromosome 7.” (internet)

“These results demonstrate that EPO does not cross the placenta into the fetus even under conditions of chronically elevated maternal EPO levels, and suggest that red cell production in the fetus is regulated by EPO produced from sites within the fetus.” (internet)

“There is no transport of erythropoietin across fetal membranes. This finding is particularly remarkable in view of results published recently indicating the placenta as a site of erythropoietin production. The lack of its transport across the human placenta is most likely due to its high molecular weight.” (internet)

27. What is normal maturation of cytoplasma in RBC?

A. Decrease in basophilic colour

B. Decrease in granules

C. Decrease in nucleoli

D. Increase in azurophilic granules

E. Increase in chromatin

Jawaban : A.

Pembahasan :

RBC yang normal warnanya semakin pink (decrease in basophilic colour), tidak mempunyai nucleus (juga nucleolus & chromatin di dalamnya), tidak mempunyai ganules. (Harmening, tabel 1-6, hlm13)

28. For reticulocyte count measurement, staining should be done?

A. Giemsa staining

B. Brilliant cresyl blue staining

C. Wright stain

D. Myeloperoxidase stain

E. Sudan black B stain

Jawaban : B. (?)

Pembahasan :

“When stained with new methylene blue, diffusely basophilic cell reveals ribosomes in granulofilamentous arrangement (or network of strands & ganules) and are classified as reticulocytes.” (Harmening, hlm 13)

“Cytoplasm of reticulocytes stains slightly basophilic with Wright's stain. However, when stained with a supravital-stain such as new methylene blue or brilliant cresyl blue, precipitated ribrosomal RNA (reticulum) can be demonstrated within the cell.” (internet)

30. Largest cell in bone marrow : 30-300 μm. Nucleus shape : lobular, cytoplasma : pale blue (white pink cast). Numerous azurophilic granules. What cell?

A. Normoblast

B. Myeloblast

C. Lymphoblast

D. Pronormoblast

E. Megakaryocyte

Jawaban : E.

Pembahasan :

Megakaryocyte berukuran besar (30-100 μm), nucleus berlobus, chromatin ber-granular, cytoplasm pale blue with pink cast, numerous fine azurophilic granules. (Harmening, tabel 1-13, hlm27)

35. Boy 12 y.o. dibawa ibunya ke ER, chief complaint hemarthrosis di lutut. Riwayat pendarahan di anggota keluarga laki-laki. What is the appearance in lab result?

A. CT normal, BT normal

B. PT normal, APTT normal

C. BT prolong, CT normal

D. PT prolong, APTT normal

E. PT normal, APTT prolong

Jawaban : A. (?)

Pembahasan :

“Spontaneous hemarthrosis and hematomas of deep structures are typical features of coagulation protein deficiency states and not platelet / vascular defects.” (Harmening, hlm 471).

BT à waktu yang dibutuhkan agar luka pada kulit berhenti berdarah, mengeveluasi jumlah / fungsi platelet.

CT à waktu yang dibutuhkan oleh darah untuk membentuk benang-benang fibrin.

APTT à screening test untuk mengevaluasi coagulation factor (intrinsic & common pathway)

PT à screening test untuk mengevaluasi coagulation factor (extrinsic & common pathway)

38. B. Pasien ini punya (+) family history of pulmonary emboli->thrombosis. PT normal (tidak ada masalah pada extrinsic pathway). ACA increased. Pasien ini terkena APS (1clinical criteria+1lab criteria)

39.C. hemarthrosis->gangguan pada coagulation factor.BT decreased (2.5-9.5 min). aPTT decreased.

40.A. karakteristik B&C adalah utk lymph node. Untuk tonsil karena ada crypt sehingga dia tidak totally encapsulated (seharusnya partially encapsulated) dan secara histology adalah simple stratified epithelium

41.E.Pasien kita ada sensasi gatal, runny nose, allergen : debu, IgE increased.

42.B.jelas.

43. cytokine? Histamine

*soalnya ga jelas

44. WOTF major substance is the most suitable H-1 antihistamine to treat this patient?

a. Cetrizine

b. Chlorpheniramine

c. Promethazone

d. Tripelonnamine

e. Diphenylamine

jawaban: A. Cetrize

Cetirizine adalah metabolit aktif dari hidroksizin dengan kerja kuat dan panjang.
Merupakan antihistamin selektif, antagonis reseptor H1 periferal dengan efek sedative yang rendah pada dosis aktif farmakologi dan mempunyai sifat tambahan sebagai anti alergi.
Cetirizine menghambat pelepasan histamin pada fase awal dan mengurangi migrasi sel inflamasi.

45. 70 y old with runny nose,since 10 y old,nasal blockage,sneezing,dll,what appropriate diagnostic tool?

a. Nasal endoscopy

b. Rhinoscopy

c. Nasal cyt

d. Total IgE

e. Skin prick test

jawaban: D

49. What aeroallergens highly involved in case above?

a. Latex

b. Pollen

c. Dust mite

d. animal dander

e. Human dander

jawaban: B.Pollen

50. 35 y old woman runny nose since 20 y ago,accompany with stiffy nose,nasal itchness,sneezing,after dust exposure. Symptomps felt for 5 days a week especially in the morning and before bedtime,difficult to concentrate,fatigue,sleeping disturbance. PE: bluish hue under the eyes,turbinate enlarge,pale bluish mucosal,IgE 1000. Long life therapy?

a. immunotherapy

b. frequent exercise

c. allergen avoidance

d. 6 month steroid nasal spray

e. 6 month antihistamine

jawaban: C. Allergen avoidance

pencegahan adalah treatment jangka panjang terbaik untuk therapy allergy

51)answer : A

Explanation : sign & symptoms semuanya mengarah pada allergic contact dermatitisàIgEàtype 1 hypersensitivity (more about allergic rhinitis??find it in Lange,10^th ed,pg 356)

52)answer : A

Explanation : histamineàrelease by mast cell,one of it action-smooth muscle contraction

(further reading in chapter 13,lange,ed 10^th ed,pg 194)

53)answer : characteristics of allergic rhinitis??

Explanation : lange,10^th ed,pg 356

*immunology,immunopathology & immunity,5^th ed,steward sell,pg 403 - exam : may reveal a transverse wrinkle across the middle of the nose caused by allergic salute.there is edema of submucosal tissue with an infiltration of eosinophils that is reversible.

54)answer :

56)answer : A

Explanation : milk contain more than 16 protein that might be allergenic,and skin reaction to a no.of these proteins occur in some sensitive children (immunology,immunopathology & immunity,5^th,pg 405)

In Spain,fish in the 3^rd most frequent allergen in children under 2 year of age after egg & cow`s milk (pediatric allergy & immunology,volume 19,Blackwell publishing)

*breastfeeding has been recognized for many years à result in a dramatic reduction in incidence of food allergy in children,particularly allergic eczema (immunology,immunopathology & immunity,5^th ed,steward sell,406)

58. C anaphylaxis

70. A/B

71. C

72. Zidovudine can improve cognitive function in short term

74. Corticosteroid or immunosupressant drugs

75. e. Burkitt lymphoma

- Follicular lymphoma: the most common form of NHL

Morphology: two principal cell types: (1) small cells with irregular or cleaved nuclear contours and scant cytoplasm (centrocytes-small cleaved cell), and (2) larger cell with open nuclear chromatin several nucleoli, and modest amount of cytoplasm (centroblast)

CF: tend to present with painless, generalized lympadenophaty, 30-50% occur histologic transformation, most commonly to diffuse large B-cell lymphoma

- Hodgkin’s lymphoma: characterized morphologically by the presence of distinctive neoplastic giant cell called Reed-Sternberg cell that induce the accumulation of reactive lymphocyte, histiocyte (macrophage), and granulocyte

Morphology: diagnostic Reed-Sternberg cell are large (15-45µm in diameter) and have either multiple nucleoli with multiple nuclear lobes, each with a large inclusion-like nucleolus about the size of small lymphocyte

Mononuclear variant contain only a single round or oblong nucleus with a large inclusion-like nucleolus

Lacunar cell seen predominantly in nodular sclerosis subtype

Reed-Sternberg present in an appropriate background of non-neoplastic inflammatory cells (lymphocytes, plasma cell, eosinophils)

- Diffuse Large B-cell Lymphoma (DLBCL)

Morphology: relatively large cell (usually 4-5 times diameter of small lymphocyte) and a diffuse pattern growth

CF: rapidly enlarging, often symptomatic, mass at single nodal or extranodal site

- Burkitt lymphoma

Morphology: high mitotic index is typical, as apoptotic tumor cell death, accounting for the presence of numerous tissue macrophages with ingested nuclear debris

Benign macrophage are diffusely distributed among the tumor cell and have abundant clear cytoplasm, creating characteristic “starry sky” pattern

77. b. Hodgkin

- Clinical difference between Hodgkin and NHL

Hodgkin	NHL
More often localized to a single axial group of nodes (cervical, mediastinal, para-aortic)	More frequent involvement of multiple peripheral nodes
Orderly spread by contiguity	Noncontiguous spread
Mesenteric nodes and Waldeyer ring rarely involved	Mesenteric nodes and Waldeyer ring commonly involved
Extranodal involvement uncommon	Extranodal involvement common

- Chronic Lymphocytic Leukimia (CLL)/Small Lymphocytic Lymphoma (SLL)

Morphology: prolymphocyte gather together focally to form loose aggregates referred to proliferation center, because they contain large number of mitotically active cells

Lymphocyte are round, fragile and frequently disrupted in the process of making smear, called smuged cell

CF: asymptomatic, disrupt normal immune function through uncertain mechanism

78. a. EBV

- Hodgkin

Etiology: one important clue is the frequent present of EBV episomes in the Reed-Sternberg cell of many cases of mixed cellularity HL

79. a. I A

- Clinical staging of Hodgkin and NHL (Ann Arbor Classification)

Stage	Distribution of Disease
I	Involvement of single lymph node region (I) or involvement of a single extralymphatic organ or site (IE)
II	Involvement of two or more lymph node region on the same side of diaphragm alone (II) or with involvement of limited contiguous extralymphatic organ or tissue (IIE)
III	Involvement of lymph node region on both side of diaphragm (III), which may include spleen (IIIS) and/or limited contiguous extralymphatic organ or site (IIIE, IIIES)
IV	Multiple or disseminated foci of involvement of one or more extralymphatic organ or tissue with or without lymphatic involvement

80. ???

- Acute Lymphoblastic Leukemia/Lymphoma: group of neoplasm composed of immature, precursor B or T lymphocyte referred to lymphoblast

Majority (85%) of ALL are precursor B-cell tumor that typically manifest as childhood acute leukemia

Less common precursor T-cell ALL tend to present in adolescent male as lymphomas often with thymic involvement

Morphology: ALL with lymphomatous presentation are mostly of pre-T cell type

The nuclear chromatin is delicate and finely stippled, and nucleoli are either absent or inconspicuous

CF: abrupt stormy onset, symptoms related to depression of normal marrow function, bone pain and tenderness, generalized lymphadenopathy, splenomegaly, and hepatomegaly caused by neoplastic infiltration, CNS manifestation, headache, vomiting

Source from Robin 7^thed, page 673-691

80. 39-year-old male has been infected by HIV since 8 years ago. From the PE, doctor found lymph node enlargement in right cervical region. Diagnosis ?

A. Diffuse large B cell lymphoma

B. Small lymphocytic lymphoma

C. Non-Hodgkin lymphoma

D. Lymphoblastic lymphoma

E. Follicular lymphoma

Jawab : A

Pembahasan :

Robbins edisi 7 hal. 667 pada

ETIOLOGICAL AND PATHOGENETIC FACTORS IN WHITE CELL NEOPLASIA : OVERVIEW

Environmental Agents

menyebutkan :

“Sustained B-cell stimulation due to immune dysregulation may increase the risk of oncogenic events. An important example is HIV infection, which leads to polyclonal B-cell activation and marked hyperplasia of germinal center B cells. HIV-infected individuals are at high risk for B-cell lymphomas derived from germinal center B cells and most such tumors have oncogenic chromosomal translocations involving immunoglobulin loci.”

Dari situ, dapat dilihat bahwa HIV adalah faktor risiko untuk lymphoma yang melibatkan B cell.

Dari option, yang merupakan tumor yang melibatkan B cell adalah option A, B, C, D, E.

Namun, option C dan D tidak ditujukan spesifik untuk lymphoma B-cell (bisa T-cell juga). Karena itu bisa dicoret.

Lalu kita selidiki option A, B, dan E.

Untuk option A : diffuse large B cell lymphoma, pada Robbins edisi 7 hal. 677,

disebutkan bahwa penyakit ini memiliki 2 subtype khusus yang sering ditemui pada pasien terinfeksi HIV

manifestasi klinisnya yang sering ditemukan adalah “rapidly enlarging, often symptomatic mass at a single nodal or extranodal site”.

Kedua keadaan di atas cocok dengan pasien.

Untuk option B : small lymphocytic lymphoma, pada Robbins edisi 7 hal. 674, manifestasi klinisnya adalah “often asymptomatic. When symptoms appear, they are nonspecific and include easy fatigability, weigt loss, and anorexia. Generalized lymphadenopathy and hepatosplenomegaly are present in 50-60% of all cases”

Untuk option E : follicular lymphoma, pada Robbins edisi 7 hal. 675, disebutkan manifestasi klinisnya adalah “painless, generalized lymphadenopathy”.

Pada pasien kita, lymphadenopathy hanya ditemukan di satu tempat, yaitu right cervical region. Sehingga, bisa disimpulkan option A benar.

81. Acute enteritis, lalu diberi obat. Timbul “target lesion” 2-5 cm, distributed symmetrically on upper arm and chest. Obat apa yang diberikan tadi ?

A. Prednisolone

B. Hydrocortisone

C. Chlorpheniramine maleate

D. Trimethoprim-sulfomethoxazole

Jawab : D

Pembahasan :

Target lesion adalah ciri khas dari keadaan erythema multiforme, dan bisa disebabkan oleh administrasi beberapa obat : sulfonamide, penicillin, barbiturate, salicylate, hydantoin, antimalarial (Robbins edisi 7 p. 1255). Erythema multiforme, pada patogenesisnya, disebabkan oleh reaksi imunologi yang melibatkan cytotoxic T-cell dengan akibat apoptosis maupun perusakan sel epithelial (Robbins edisi 7 p. 1256).

Jawaban D, karena :

trimethoprim-sulfomethoxazole termasuk pada golongan sulfonamide, yang memang dapat menyebabkan erythema multiforme. Sulfonamide banyak digunakan bersama dengan trimethoprim.

Prednisolone & hydrocortisone adalah golongan glucocorticoids, yang justru digunakan untuk supresi reaksi imunologi, sehingga tidak mungkin menyebabkan kondisi di atas (berdasarkan patogenesisnya).

Chlorpheniramine adalah golongan anti-histamine yang toxicity-nya tidak termasuk pembentukan target lesion (toxicity anti-histamine : sedation, convulsion, excitation, anti-muscarinic action, Katzung p. …)

82. 26-year-old man, with target cell.

A. erythema multiforme

B. bullous pemphigoid

C. pemphigus

Jawab : A

Pembahasan :

Mungkin yang dimaksud disini adalah target lesion, yang merupakan ciri dari erythema multiforme

83. Which of the following is the most likely diagnosis of subepidermal bullae ?

A. Bullous pemphigus

B. Pemphigus vulgaris

C. Erythema multiforme

D. Pemphigus folliaceus

E. Subcorneal pustular dermatosis

Jawab : A

Pembahasan :

Bullous pemphigoid : morfologinya adalah terdapat subepidermal, non-acantholytic blister (Robbins edisi 7 p. 1261)

Pemphigus vulgaris : morfologi khasnya adalah terdapat suprabasal acantholytic blister (Robbins edisi 7 p. 1260)

Erythema multiforme : morfologi khasnya adalah terdapat target lesion pada ekstremitas yang terdistribusi secara simetris. Pada lesi itu ditemukan nekrosis sentral dikelilingi inflamasi perivenular (Robbins edisi 7. p. 1256)

Pemphigus folliaceus : -

Subcorneal pustular dermatosis : -

84. What substances are contained predominantly in subepidermal bullae ?

A. Inflammatory cell

B. Acantholysis cell

C. Spongiosis cell

D. Neutrophil cell

E. Fibrin

Jawab : A

Pembahasan :

Subepidermal bullae berarti mengarah ke penyakit bullous pemphigoid (lihat penjelasan no. 83). Morfologi dari bullous pemphigoid :

“Early lesions show a dsuperficial and sometimes deep perivascular infiltrate of lymphocytes and variable numbers of eosinophils, occasional neutrophils, superficial dermal edema, and associated basal cell layer vacuolization. Eosinophils showing degranulation are typically detected directly beneath the epidermal basal cell layer. The vacuolated basal cell layer eventually gives rise to a fluid-filled blister.”

(Robbins edisi 7 p. 1261)

Limfosit, eosinophil, neutrophil, semuanya adalah sel inflammatory. Di penjelasan no. 83, juga disebutkan bahwa blister-nya non-acantholytic (tidak ada lysis epidermis), karena itu option B salah. Option C salah karena tidak disebutkan ada edema intercellular pada epidermis (yang ada adalah edema pada dermis). Option E salah karena tidak ada hal yg melibatkan fibrin.

85. If platelet count is low, which of the following will be prolonged ?

A. clotting time

B. bleeding time

C. thrombin time

D. prothrombin time

E. activated partial thromboplastin time

Jawab : B

Pembahasan :

Untuk mengetahui fungsi platelet, dilakukan bleeding time. Jika ada kelainan kuantitatif maupun kualitatif dari platelet, maka bleeding time akan meningkat (abnormal). (Tabel 23-26 Harmening edisi 4 p. 467 )

Prothrombin time dan activated partial thromboplastin time adalah untuk mengetahui fungsi sistem koagulasi jalur ekstrinsik dan intrinsik. Thrombin time digunakan untuk menilai proses pembentukan fibrin. Clotting time ? tidak ditemukan istilah tsb. di Harmening, tapi berdasarkan kata-kata “clotting”, mungkin ini lebih mengarah ke penilaian hemostasis sekunder, yang lebih banyak melibatkan faktor koagulasi daripada platelet.

94. Which is the most important in delivering O₂ from maternal blood to fetal blood?
a. ATP

b. NADP

c. NADPH

d. Glukosa

e. 2,3 DPG
Jawaban : E

Alasan : faktor penting untuk mengontrol afinitas Hb terhadap O₂ adalah 2,3 DPG (Harmening)

95. Compound yang bertanggung jawab agar membrane RBC tidak mengalami denaturasi akibat oxidant injury adalah

a. ATP

b. NADP

c. NADPH

d. Glucose

e. 2,3 DPG

Jawaban : A

Alasan : loss of ATP à decrease in the phosphorylation of spectrin (Harmening hlm 61)

96. RBC maintains Fe state?

a. ATP

b. NADH

c. NADPH

d. Glucose

e. 2,3 DPG

Jawaban : B

Alasan : pada gbr metabolisme RBC terdapat NADH-metHb reductase yang berfungsi mengubah metHb menjadi Hb à menjaga agar tetap dalam bentuk Fe²⁺

97. Iron deficiency anemia à Fe supplement tidak efektif. Mengapa?

Jawaban : antacid

Alasan : Goodman & Gillman hlm 1448

98. Patient 33 y.o. woman complains fatigue and increase dyspnea with exercise. History reveals heavy menstrual bleeding. Lab result : increase TIBC, decrease serum transferase and ferritin. Diagnosis?

a. Thallasemia

b. Acquired hemolytic anemia

c. Pernicious anemia

d. Aplastic anemia

e. Iron deficiency anemia

Jawaban : E

Alasan : Harmening hlm 105 table 6-7

99. E. Pronormoblast. Ciri khasnya round/oval moderate to large cell with large nuclei. Its nuclei is very little different to myeloid. à Harmening. Pronormoblast agak sulit dibedakan dengan promyeloblast dengan giemsa staining karena butuh pewarnaan yang lebih spesifik. à catatan lab act.

Note: biasanya sel darah yang belum terdifferensiasi dengan sempurna, maka ciri-ciri spesifiknya juga belum jelas terlihat.

Normoblast acidophil = sel erythrocyte immature dengan cytoplasm yang lebih pinkish karena sudah terproduksi HB

Normoblast polikromatrofil = ketika distaining, sel tersebut memiliki campuran warna biru dengan adanya warna pink

Normoblast= ?

Retikulosit = nucleinya sudah terextrude dengan gambaran staining new metilen blue masih ada sedikit granule-network ribosom

104. ?

106. B. Thalasemia, karena adanya tanda2 dari hemolytic anemia ( increased bilirubin, icteric, hepato-splenomegaly, dengan decreased RBC, MCH,MCHC dan increased reticulocyte count) yang terjadi pada first year of life. Tanda2 lain for the next years berupa hypertrophied of maxilla causing forward protrusion of the upper teeth and overbite, dan gambaran mongoloid face

107.Aplastic anemia. Dicirikan gambaran bone marrow berupa hypocellular = karena failure blood cell production oleh bone marrow yang melibatkan RBC, WBC, dan platelet (penurunan jumlah RBC,WBC, dan platelet melalui blood smear)

Manifestasi klinis : anemia = progressive fatigue, dyspnea, palpitasi

Thrombocytopenia: petechiae,purpura, ecchymoses, mucosal bleeding

Leukopenia : sign of infection (late manifest)

112. D.Ferrosulfate. toksisitass akut dapat menyebabkan gastroenteritis nokrotikans dengan vomit,nausea, abdominal pain, dan bloody diare. EPO,Cyanocobalamin, dan folic acid tidak ditemukan adanya side effect..

113. Most likely structure of thymus :

1. Medulla appear darker than cortex
2. Large number of T-cell in cortex
3. Has mesenchymal reticular cells
4. Has lymph vessels
5. The cortex has Hassal’s corpusle

Jawaban : B.

Pembahasan :

A à seharusnya lighter

C à seharusnya epithelial reticular cells

D à thymus tidak memiliki afferent lymph vessel & hanya punya sedikit efferent lymph vessel

E à seharusnya medulla

B à benar, karena pada cortex terdapat banyak sel limfosit-T kecil yang nantinya akan berproliferasi & bermaturasi ke arah medulla

(Junquiera, 266-267)

115. WOTF susbstane is the 1^st line deense against this disease?

1. Antibody
2. Complement
3. Interleukin-1
4. Class 1 interferon
5. Class 2 interferon

Jawaban : ?

Pembahasan : ? (soalnya ga ada…)

117. HIV, yang benar?

1. RNA, SS, envelope (-)
2. RNA, SS, envelope (+)
3. DNA, SS, envelope (-)
4. DNA, DS, envelope (+)
5. DNA, DS, envelope (-)

Jawaban : B.

Pembahasan :

HIV adalah retrovirus, yang memiliki envelope yang mengandung 2 copy (diploid) single-stranded RNA. (Immunology Mosby,316)

118. MOA treatment HIV?

Jawaban :

Pembahasan :

Pengobatan HIV adalah dengan antiretroviral therapy (ART), dengan metode Highly Active ART (HAART) yang berupa kombinasi 3-4 antiretroviral agent untuk memaksimalkan efektivitas & mengurangi risiko resistensi. Ada 4 kelas obat :

1. Nucleoside & Nucleotide Reverse Transcriptase Inhibitor (NRTI) à inhibitor kompetitif HIV-1 reverse transcriptase, dengan bantuan aktivasi intrasitoplasmik lewat fosforilasi oleh enzim seluler menjadi bentuk triphosphate. MoA lain memasuki rantai DNA virus, lalu melakukan terminasi.
2. Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) à menempel langsung ke HIV-1 reverse transcriptase (tanpa perlu aktivasi lebih dahulu), sehingga memblok RNA- & DNA-dependent DNA polymerase.
3. Protease Inhibitor (PI) à mencegah cleavage Gag-Pol polyprotein, sehingga yang diproduksi adalah partikel virus yang imatur & non-infeksi.
4. Fusion Inhibitor à menegah perubahan bentuk (konformasi) dari virus, yang dibutuhkan untuk fusi virus dengan membran sel, sehingga mencegah masuknya virus ke dalam sel.

(Katzung, 798-811)

119. 20 tahun, diagnosis fever, 3 hari yang lalu tertusuk paku di plantar pedis, T=39°C, lymph node enlargement di right groin, apa yang berperan?

1. NK cell
2. Mastocyte
3. Marophage
4. T-lymphocyte
5. Complement

Jawaban : C. (?)

Pembahasan : Karena terdapat pembesaran lymph node yang merupakan hyperplasia dari lymphoid follicles & hyperplasia sel fagositik di sepanjang sinus lymph node, yaitu macrophage yang memfagosit partikel asing yang masuk untuk mencegah penyebaran ke seluruh tubuh. (Robbins,84 & Guyton, 432-433)

120.B.

121. sori ga jelas (T cell yang mana? Cytotoxic? T h2/ Th1?)

122. sori ga ngerti maksudnya.

123. A. Pada pasien kita mengalami allergy (increased of histamine->bronchoconstriction, increased of mucus production). Oleh karena itu di-therapy dengan antihistamine.

126. C (lange 103)

129. angioedema terjadi karena apa?

Mastocyte

130. pada type I hypersensitivity yang bertanggungjawab untuk perkembangan mast cell,B cell,eosinophil?

a. CD4 T Lymphocyte

b. CD8

c. macrophage

d. monocyte

jawaban: CD4 T lymphocyte

133. 21 y.o woman malar rash,photo distribution,derm exam: atrophic lesion on periauricular region,ANA (+),Anti DsDNA(-),No urine protein. Treatment?

a. vit C

b. steroid

c. retinoid

d. sunblock

e. antibiotic

137. Most life threatening complication (ITP)?

a. intracranial bleeding

b. DIC

c. GI bleeding

d. Menomethrorhagi

e. joint bleeding

137. WOTF can cause death?

a. Intracranial hemorrhage

b. DIC

c. GI bleeding

d. Menomethrorhagi

e. joint bleeding

138) ANS: A

EXP: primary hemostasis is defined by platelet membrane glycoprotein Ib(GPIb) and von Willebrand`s factor(vWF)

REFERENCE : HARMENING,4^TH ED,INTRODUCTION TO HEMOSTASIS,PG 442.

141) ANS : A

EXP : table 17-5,staging system for chronic lymphocytic leukemia,from Rai system,stage 1 is characterized by lymphocytosis and enlarged lymph node,whereas for Binet system,stage a is characterized by 2/<>10 + no anemia / thrombocytopenia (Hgb≥10g/dL,platelet > 100 x 10^9/L)

REFERENCE : HARMENING,4^TH ED,CHRONIC LEUKEMIA & RELATED LYMPHOPROLIFERATIVE DISORDERS(TABLE 17-5,STAGING SYSTEM FOR CHRONIC LYMPHOCYTIC LEUKEMIA),PG 310

144) ANS : B

EXP : afibrinogenemia – it can cause profuse bleeding after slight trauma & delay in wound healing.initial symptoms include bleeding from the umbilical cord stump.other symptoms:intracranial bleeding, epistaxis,gastrointestinal bleeding & menorrhagia.

Lab result : prolongation of PT,APTT,RT,TT,and absence of measurable fibrinogen

REFERENCE : HARMENING,4^TH ED,DISORDERS OF PLASMA CLOTTING FACTORS,PG 497.

145) QUESTION NOT COMPLETE..

146) ANS : A

EXP : characterized by decrease in Hb concentration,hematocrit,MCV.

REFERENCE : HARMENING,4^TH ED,PG 104 (sorry friends,but please,do explore more)

149. Anak 5 thn bleeding setelah immunization hepatitis B. Platelet N, WBC N. RBC/Hb ↓, PT dan APTT ↑. Diagnosis ?

a. Factor deficiency

b. Factor …

c. Vit. K deficiency

Ans.

a. Factor deficiency

PT & APTT prolonged = defisiensi factor intrinsik dan ekstrinsik

151. 3 y.o pale, underweight, lab :

Hb 7,2 Ht 23 % Platelet % Leukocyte N. eosinophilia, leucocyte diff. count : MCV ↓, MCH, Reticulocyte, diagnosis ?

a. Β thalassemia

b. Β thalassemia major

c. Iron deficiency

d. Sideroblastic anemia

e. Lead fusion

Ans.

Wah bingung sayah

153. a 5 y.o boy admitted to hospital for pallor dan easy bruising. PE : pallor, widespread ptechiae, ecchymosis, bleeding gums, fever. No lymphadenopathy, no hepatosplenomegaly. CBC, reticulocyte ↓. MCV, MCH, MCHC N. BM smear hypocellular (25 % cellularity). Most likely diagnosis ?

a. IDA

b. ALL

c. Myelodysplastic syndrome

d. Aplastic anemia

e. Megaloblastic anemia

Ans.

d. Aplastic anemia

Merupakan kegagalan bone marrow dalam menghasilkan komponen darah yang ditandai dengan hypocellular (penurunan aktivitas cellular, N = >30%) sehingga semua komponen darah berkurang.

154. Etiology ?

a. Infiltrative malignant

b. Bone marrow failure

c. Coagulation disorder

d. Overwhelmed infection

e. Platelet disorder

Ans.

b. Bone marrow failure

Lihat pembahasan di atas

156. Youngest cell erythrocyte, cell size 14-18 µm. N:C = 8:1. Scanty bluish cytoplasm.

a. Pronormoblast

b. Normoblast acidophilic

c. Normoblast polichromatophilic

d. Normoblast basophilic

e. Reticulocyte

Ans.

a. Pronormoblast

Ukuran 14-19 µm, tapi N:C harusnya 4:1, ga ada fase erythroid yang N:Cnya sampai 8:1.

?? (3) 60 tahun male left abdominal discomfort & dizziness. PE : BP 160/95 RR 24 Pulse 96. Liver just palpable. Spleen schuffner 3. Lab Hb 18,2 Hct 56 % WBC 20.000 Platelet 550.000. Complication of this disease ?

a. Bleeding

b. Thrombosis

c. Infection

d. Anemia

e. Hemolysis

Ans.

d. Anemia

Ini adalah ciri2 policythemia vera, Hct, WBC, Platelet, Hb ↑.

Komplikasi policythemia vera adalah anemia.

?? (4) 7 years old boy, yellowish since 3 days ago, no fever, he dranks sulfomethoxazole 3 weeks ago, further has the same history but neither of his sister…

Ans.

Sayah bingung. Tapi yellowish seperti ini mungkin hemolytic anemia.

157. Neutrophil granulocytic development

Myeloblast: round nucleus, reddish-blue, nucleoli, N:C=4:1, 10-20µm

Promyelocyte: primary granule, reddish-blue, N:C=3:1, 20µm

N. myelocyte: secondary granule, eccentrally round nucleus, pinkish, N:C=2:1

N. metamyelocyte: nucleus slightly indented, pinkish granule, N:C=1:1, 10-18µm

Band netrophil: nuclear indentation greater than half, pink granule, smaller

Segmented netrophil: nucleus divide into 2-5 lobes connected by thin filament

159. FAB Classification of Acute Myelogenous Leukemias (AML)

M0, Minimally differentiated AML

Blasts lack cytologic and myeloperoxidase negative but express myeloid antigens and resemble myeloblasts

M1, AML without differentiation

Very immature, >3% of blasts are peroxidase positive; few granules and little maturation at myeloblast stage.

M2, AML with maturation

Full myeloid maturation through granulocytes; Auer rods present in most cases

M3, Acute promyelocytic leukemia

Most cells are hypergranular promyelocytes, often with many Auer rods per cell; patients are 35 to 40 years age

M4, Acute myelomonocytic leukemia

Myelocytic and monocytic differentiation; myeloid elements show maturation; monoblasts are positive for nonspecific esterases

M5, Acute monocytic leukemia

- M5a subtype, monoblasts (peroxidase-negative, nonspecific esterase-positive) and promonocytes predominate in marrow and blood;

- M5b subtype, mature monocytes predominate in the peripheral blood;

- M5a and M5b occur in older patients; characterized by incidence of organomegaly, lymphadenopathy, and tissue infiltration.

M6, Acute erythroleukemia

Dysplastic erythroid precursors (megaloblastoid, with giant or multiple nuclei), and within the non-erythroid cells, >30% are myeloblasts; seen in advanced age.

M7, Acute megakaryocytic leukemia

Blasts of megakaryocytic predominate; blasts react with platelet-specific antibodies directed against GPIIb/IIIa or vWF; myelofibrosis or increased marrow reticulin seen in most cases.

165. ?

- If diagnosis is Chronic Lymphocytic Leukimia, yg increase pada BM smear:

B-cell with prolymphocytic transformation to diffuse large B-cell lymphoma

Worse prognosis, mungkin well differentiated lymphocyte

167. ?

- Chronic Lymphocytic Leukimia (CLL) / Small Lymphocytic Lymphoma (SLL)

Merupakan peripheral B-cell Neoplasm

Morphology: prolymphocyte gather together focally to form loose aggregates referred to proliferation center, because they contain large number of mitotically active cells

Lymphocyte are round, fragile and frequently disrupted in the process of making smear, called smuged cell

CF: asymptomatic, disrupt normal immune function through uncertain mechanism

- Chronic Myelogenous Leukimia (CML)

Between 25-60 years of age

Patfis: merupakan chronic MPDs with presence of distinctive molecular abnormality, yaitu ABL gene on chromosome 9 and BCR gene on chromosome 22

Morphology: CML marrow usually 100% cellular with mostly maturing granulocytic precursor; megakaryocyte increase; erythroid progenitor normal or decrease; pheripheral blood reveal leukocytosis; ada splenomegaly; hepatomegaly and mild lymphadenophaty

CF: insidious, mild to moderate anemia, abdomen sensation caused by extreme splenomegaly

169. Hasil lab: normal RBC, find in smear?

c. normochrom normocytic

- hypochromic: pale RBC, kekurangan Fe

- anisocytosis: banyak RBC yg bervariasi ukurannya

- normocytic: RBC of normal size

176.Atrophy Lingual?

Gak tahu pertanyaanya apa tapi atropi lingual terjadi pada keadaan iron deficiency anemia (IDA).

Dimana pemeriksaan Lab IDA:

- Serum Iron : Tinggi

- TIBC : Tinggi

- Ferritin : Rendah

178.6 Year old girl oupatient RSHS redt itchy circumscribed patched with central blanching on body.Ate shrimp an hour ago she also allergic to cold weather skin layer..?

Dari cerita diatas bahwa pasien mengalami hypersensitivitas yang ditandai oleh adanya urticaria.

Ciri-ciri urticaria:

- Lesion: papule/wheal,circumscibed lightly erythematous with central blanching/blanched with pressure.

- Location: Upper cornum of the dermis

- Sensation: Pruritis

Patfis:

Vascular permeability is the most important factor in the pathofisiology of urticarial lession.Histopatologi exam pada urticarial lesion menunjukan dilation engorgement of minute cutaneus blood vessel,dilated lympatic, and a minimal perivascular infiltrat that may predominantly contain eosinophile.

For 180-182

A 24 Year old man,IDU, Came to dept.internal medicine for general check up.Lab

result HIV (+)

180.WOTF cell killed by above virus?

C.CD4 T-cell

HIV infects primarily vital cells in the human immune system such as T-helper cell(to

be specific, CD4 T cells), macrophage and dendritic cell.

HIV infection leads to low levels of CD4⁺ T cell through three main mechanisms: First, direct viral killing of infected cells; second, increased rates of apoptosis in infected cells; and third, killing of infected CD4⁺ T cells by CD8 cytotoxic lymphocytes that recognize infected cells. When CD4⁺ T cell numbers decline below a critical level, cell-mediated immunity is lost, and the body becomes progressively more susceptible to opportunistic infections.

181.WOTF gene is most likely need for replication of above cell?

B.Tat

1. Gp 120: p120 is essential for virus entry into cells as it plays a vital role in seeking out specific cell surface receptors for entry.
2. Tat: Tat vastly increases the level of transcription of the HIV DNA.
3. Pol: it means polymerase
4. Gp41: is a glycoprotein non-covalently-bound to gp120, and provides the second step by which HIV enters the cell. It is originally buried within the viral envelope, but, when gp120 binds to a CD4 receptor, gp120 changes its conformation, causing gp41 to become exposed, where it can assist in fusion with the host cell.
5. P11: Sorry.I haven’t find it.

182.WOTF is the component above virus that enhances penetration of virus into host cell?

A.Gp120

Penjelasan lihat no 181

183. Which of the following cell that presenting the antigen to CD4 T-cell?

A. NK cell

B. Dendritic cell

Jawaban : B

Alasan : dendritic cell mengekspresikan protein MHC II (Lange)

184. After binding to its specific antigen, B lymphocyte may switch to what of the following component?

A. Ig light chain

B. Ig heavy chain

C. Variable region of IgG heavy chain

D. Variable region of IgG light chain

E. Hinge region of the heavy chain

Jawaban : C

Alasan : agak ga ngerti maksudnya apa, mungkin yang dimaksud adalah binding site dari Ig terhadap antigen, yaitu di variable heavy chain

185.B. sudah jelas ya bahwa APC seperti dendritic cell dan macrophage, setelah mereka memprocessed antigen melalui proses endosomal, processing antigen tersebut akan diekspresikan bersama MHC class II di membrane sel untuk derecognize oleh THelper dalam proses adaptive immunity

187. C.macrophage memiliki kemampuan sebagai phagocyte dan sebagai APC. Hubungannya dengan antibody ialah macrophage memiliki Fc receptor dan receptor untuk opsonin dan complement component receptor untuk memfagosit opsonized imunnogen. Kemudian melalui FcR (dan yang lainnya via Toll-like Receptor) activate oxidative killing. Atau selain dibunuh, processed fragmented immunogen tersebut kemudian dipresentasikan di sel membrane

b. lysing virus merupakan respon tugas dari cytotoxic T-Cell

c.activating cytotoxic cell dilakukan oleh TH cell melalui IL-2

e. activating plasma cell dilakukan oleh TH cell melalui Il-4 dan IL-13 atau contact dengan CD40-CD40L (B-lymphocyte) atau langsung contact immunogen dengan membrane bound antibody

11y.o. boy with itchy skin rashes on both elbows, also complaints dry skin on limbs. His mother has history of allergy to seafood and cat dander. Dermato status : erythematous papules, scales, lichenefication on both elbows.

188. Diagnosis?

1. Nummular dermatitis
2. Xerosis cutis
3. Atopic dermatitis
4. Food allergy

Jawaban : C.

Pembahasan :

Nummular dermatitisà lesi kulit berbentuk koin / diskoid

Xerosis cutis à keadaan kekeringan pada kulit, ditandai dengan : eritema, deskuamasi kering, retak halus, gatal; terutama selama musim dingin saat kelembaban udara rendah sehingga terjadi kehilangan air berlebih dari stratum korneum (Dorland)

Food allegy à tidak disebutkan setelah makan apa

Atopic dermatitis à kecenderungan seseorang (secara herediter) untuk memproduksi IgE dalam jumlah banyak terhadap paparan allergen dosis endah & memunculkan manifestasi pada kulit (eczema)

189. WOTF is predilection of this case?

1. Face, especially cheeks
2. Scalp
3. Diaper area
4. Extensor
5. Flexural fold of the extremities

Jawaban : E.

Pembahasan :

Pada bayi à terutama pipi & menyebar ke sekitarnya

Pada anak2 & dewasa à terutama permukaan fleksor (antecubital & popliteal fossa)

(Fitzpatrick pocket, 36)