MDE HIS 2008

For number 1-3, refer to clinical scenario below
28 y.o woman with heavy periods & fatigue comes to thr outpatient dept. These complaints occur since 3 months ago. Her conjunctivae are anemic. There is koilonychia without hepatosplenomegaly on physical examination. Lab findings : Hb 8.0 g/dl, WBC 5000/m3, thrombocyte 475.000/mm3
1. What is the most possible findings on the physical exam?
A. icteric sclerae
B. gum hypertrophy
C. atrophy of lingual papilae
D. lymphadenopathy on the neck
E. mass on the abdomen
Jawaban : C
Alasan : koilonychia  salah satu tanda iron deficiency anemia. A  tanda hemolytic anemia. B&D  tanda AML. E  tanda hepatosplenomegaly, tidak ada di kasus (Wintrobe ch 28)

2. Which of the following cells in erythropoiesis is dominant on her BM smear?
A. pronormoblast
B. basophilic normoblast
C. polychromatophilic normoblast
D. acidophilic normoblast
E. reticulocyte
Jawaban : E?
Alasan : sebenernya jawabannya “lack of stainable iron in reticuloendothelial cells”, tapi ga ada di pilihan.

3. What is the first to treat the patient?
A. blood transfusion
B. iron therapy
C. folate therapy
D. cobalamine therapy
E. eliminate the cause
Jawaban : B
Alasan : 1st choice treatment untuk IDA adalah mengembalikan kadar Fe. A indikasi Hb <7mg/dl. C&D  manifestasi klinis berbeda. (Wintrobe ch 28)

For number 4-5 refer to clinical scenario below
A 25 y.o woman admitted to hispital with complaints of fatigue & increased shortness of breath with exercise. The patient appeared pale and was tachycardia. Results of lab tests included HB 5.6 gr/dL, WBC 10.000/mm3, RBC 4.5x106, MCV 68.6 fL, MCH 16pg, MCHC 23%. Examination of perpheral blood smear revealed microcytic, hypochromic, and minimal anisopoikilocytosis.
4. Which of the folowing process is the most likely for the patient?
A. excess Hb synthesis
B. vit B12 deficiency
C. A quantitative defect in Hb synthesis
D. A qualitative defect in globin protein chains
E. folate deficiency
Jawaban : C
Alasan :peripheral blood smear menunjukkan IDA (Harmening hlm 103)

5. Which of the following test may useful in confirming the diagnosis?
A. measurement of serum Fe dan TIBC
B. Hb electrophoresis
C. vit B12 deficiency
D. chromosome analysis
E. flow cytometry
Jawaban : A
Alasan : kasus di atas adalah IDA, jadi pemeriksaan selanjutnya adalah pengukuran serum Fe dan TIBC (Harmening hlm 103-106)

6. A 12 month old boy presents to your office with a chief complaint of pallor. He has inadequate nutritional intake. On physical exam : pale conjunctivae, no liver & spleen enlargement. Lab : WBC 8100/m3, Hb 7.2 gr/dL, PLT 250.000/mm3. Peripheral blood smear : microcytosis, hypochromia.
What is the most likely etiology of this anemia?
A. vit B12 deficiency
B. folic acid deficiency
C. iron deficiency
D. beta globin deficiency
E. G6PD deficiency
Jawaban : C
Alasan: microcytosis, hypochromia  ciri IDA

7. What kind of peripheral blood smear appearances will be found?
A. Hypochromic, microcytic, anisopoikilocytosis with abundant of pencil cells
B. Hypochromic, microcytic, anisopoikilocytosis with abundant of target cells
C. Normochromic, normocytic, anisopoikilocytosis with abundant of target cells
D. Normochromic, normocytic, anisopoikilocytosis with abundant of pencil cells
E. Normochromic, macrocytic, anisopoikilocytosis with abundant of target cells
Jawaban : B
Alasan : ciri IDA (Harmening hlm 108 tabel 6-13)

8. What kind of lab exam will be found ?
A. Low serum Fe level, low TIBC, low transferrin saturation
B. Low serum Fe level, increased TIBC, low transferrin saturation
C. Low serum Fe level, low TIBC, increased transferrin saturation
D. Increased serum Fe level, increased TIBC, increased transferrin saturation
E. Increased serum Fe level, increased TIBC, increased ferritin saturation
Jawaban : C
Alasan : Harmening hlm 108 tabel 6-13

9. What is the most appropriate recommended treatment for this patient?
A. Multivitamin
B. Blood transfusion
C. Oral ferrous sulphate
D. An iron fortified cereal
E. Intramuscular iron dextran
Jawaban : C
Alasan : untuk memperbaiki status iron dalam serum

10. A 32 y.o. woman was referred to your hospital for evaluating her low level of Hb. She looks pale and on physical exam you found papillae atrophy of her tongue and dry skin. Which of the following is most likely epithelium damaged for her tongue?
A. Simple stratified keratinized
B. simple stratified nonkeratinized
C. simple squamous
D. simple cuboidal
E. simple ciliated columnar
Jawaban : B
Alasan : lidah termasuk simple stratified nonkeratinized

For number 11&12, refer to clinical scenario below
A 24 y.o woman presents to the hospital with multiple bruises on her arms. This symptoms occurs since 2 days ago. There is no recent illness or problems with bleeding or bruising in the past and she takes no medication. On exams, there are several purpuric lesion on each of her forearms. There is no adenopathy or organomegaly.
11. What is the 1st lab study would you order to investigate this?
A. Complete blood count (CBC)
B. bleeding time (BT)
C. Clotting time (CT)
D. Prothrombin time (PT)
E. activated partial thromboplastin time (aPTT)
Jawaban : A
Alasan : bruising  kelainan hemostasis. Oleh karena itu perlu dicek terlebih dahulu jumlah keseluruhan dari sel darah melalui CBC (Harmening hlm 517)

12. IF the PLT count is low which will be prolonged?
A. CT
B. BT
C. thrombin time (TT)
D. PT
E. aPTT
Jawaban : B
Alasan : BT  evaluasi PLT dan fungsi vaskular untuk membentuk PLT plug (Labman HIS)

13. A 4 m.o. boy was brought to the ER dept by his parents. The boy hsa bleeding from his arm after his hepatitis immunization. There was history of bleeding in the male family members. The ab shows normal CBC, BT 2 min(N:1-3min), aPTT 70sec (N:24-45), PT 12sec (N:10-14), TT 14 sec (N:11-15).
What is the other test will be suggested?
A. bone marrow smear
B. Cytokimia
C. Factor assay
D. Lupus anticoagulant
E. Hb electrophoresis
Jawaban : C
Alasan : bleeding  kelainan hemostasis, history of bleeding in male family member  penyakit genetik, BT & CBC normal  bukan kelainan PLT ata vaskular, PT normal  extrinsic dan common pathway normal, TT normal  common pathway normal, aPTT prolonged  kelainan pada intrinsic pathway  perlu factor assay (Wintrobe figure 51.8)

14. A 3 y.o. boy is referred to pediatric dept with fever as chief complaint which occur since 5 days ago. At the hospital, doctor performed Rumple leede test on him.
Which of the following ability is measured by this test?
A. the capillaries to resist pressure
B. the PLT to resist pressure
C. the capillaries to resist heat
D. the PLT to resist heat
E. the fibrinogen to resist heat
Jawaban : A
Alasan : a test in which the increased bleeding tendency characteristic of various disorders (as scarlet fever and thrombocytopenia) is indicated by the formation of multiple petechiae on the forearm following application of a tourniquet to the upper arm

For number 15-16 refer to this scenario below
A 50 y.o man present with pain in the right calf. He states that his mother had pulmonary emboli. Lab findings : aPTT 70 sec (N:24-25), PT 12 sec (N:10-14), ACA-IgG 80gpl. A Doppler ultrasound reveals a deep vein thrombosis.
15. What is the diagnosis of this case?
A. Factor V Leiden
B. antithrombin III deficiency
C. antiphospholipid syndrome
D. protein C deficiency
E. protein S deficiency
Jawaban : C
Alasan : DVT, pulmonary emboli (di kasus ada family member)  tanda APS (Harmening ch 27)

16. What is the additional test will be suggested?
A. Factor assay
B. Lupus anticoagulant assay
C. TPHA
D. ASTO
E. blood smear
Jawaban : B
Alasan : APS biasanya disebabkan oleh lupus anticoagulant atau anticardiolipin antibodies (Harmening ch 27)

For number 17-18 refer to the scenario below
A 3 y.o. boy is referred to the hematology dept with a chief complaint of bruising of his right thigh. He also noted that there were red dots on his extremities since 2 days ago. Lab results : Hb 12.8 gr/dL, Hct 38.5%, WBC 6000/mm,. Peripheral blood smear shows giant PLT and normal morphology of red and white blood cell lines.
17. What is the cause of the bleeding?
A. fibrinolysis disorder
B. vascular disorder
C. coagulation disorder
D. Quantitative PLT disorder
E. Qualitative PLT disorder
Jawaban : D
Alasan : giant PLT  menandakan kompensasi jumlah PLT yang kurang

18. What is most likely appearance of the bone marrow smear of this patient?
A. large promegakaryocyte
B. large megakaryoblast
C. small promegakaryocyte
D. megakaryocyte with PLT formation
E. megakaryocyte without PLT formation
Jawaban : D
Alasan : megakaryocyte with increased or normal number (Harmening hlm 474-475)

19. What is PLT receptor for von Willebrand factor?
A. glycoprotein Ia
B. glycoprotein Ib
C. glycoprotein IIa
D. glycoprotein Iib
E. glycoprotein III
Jawaban : B
Alasan : primary receptor for vWF is GpIb (Harmening ch 23)

20. A 12 y.o boy was brought to the emergency dept by his parents. The boy suffered from hemarthrosis. There was a history of bleeding in the male family members. The lab results shows normal CBC. What is the appearance of lab results on this patient?
A. PT prolonged, aPTT normal
B. CT normal, BT normal
C. BT prolonged, CT normal
D. PT normal, aPTT prolonged
E. PT normal, aPTT normal
Jawaban :
Alasan :
21.D. kasus kita kan ITP, untuk treatment dari penyakit autoimun, maka kita harus berikan obat imunosupressan.. di sini kortikosteroid. (wintrobe: ITP-Treatment)
22.B. keadaan ini kita curiga ke hemophilia, jadi untuk memastikan apakah ini hemophilia atau bukan, maka kita melakukan melakukan assay dari factor VIII
23. C. sudah terlihat dengan jelas dengan aptt yang prolonged. Bukan von willebrand, karena biasanya von willebrand yang turun sering diikuti dengan bleeding time yang naik .
24.D Hemophillia  jelas ya dari hasil pemeriksaan dan eksklusi dari option yang ada.
25. E. cryoprecipitate itu mengandung factor VIII ag dan c, Faktor XIII,dan fibrinogen, & dengan orang hemophilia tipe A, akan mendapatkan transfuse ini. Apabila dalam keadaan severe hemophilia, maka akan diberikan purified factor yang bersangkutan.
26. D. dalam hal ini dengan prolonged aptt dan pt dan normal fibrinogen, yang terjadi kemungkinan adalah vit k deficiency. DIC, biasanya diikuti dengan penurunan kadar fibrinogen.
27. D. Vit K
28. C. di Nelson ebook, untuk treatment vit-k deficiency ya diberikan vit-K karena vit-k sudah jadi specific antidote. Jadi kalo masih berdarah yang kita takutkan adalah keadaan hypovolemic . jadi mikirnya diberikan fresh frozen plasma.
29.E. Unperturbed EC possess procoagulant activities that promote coagulation after vascular injury or perturbation. However, in the absence of initiating stimuli, these activities remain latent and do not contribute to thrombosis. Major prothrombotic activities of resting EC include binding sites (receptors) for coagulation zymogens or proteases [factor XII, factor XI, factors X and Xa, factors IX and IXa , and thrombin] and cofactor proteins [high-molecular-weight kininogen , factor VIIIa , and factor Va] and synthesis and expression of factor V and von Willebrand factor. –wintrobe chapter 22 endothelium angiogenesis and regulation hemostasis.
30. A. kalo option E itu biasanya dengan gejala yang purpura, petechiae dll yang mencirikan masalah pada kapiler.
31.c. vWF bisa dilakukan assay untuk mendeteksi kadarnya secara terpisah dari FVIII-vWF complex.
32. B. DDAVP therapy of choice for vWD (type 1) dan hemophilia A minor. DDAVP mengakibatkan transient increase of VIIIc and VIIIag
33. C
34. E. sebenernya ga dapet dimana2, tapi dari buku wintrobe, Williams, dan Hoffman serta robin bilangnya bahwa CLL bisa mengarah transformasi ke prolymphocytic leukemia apabila di blood smearnya banyak prolymphocyte (sekitar >56%) dan mixed type (10-56%), ga ada keterangan dari bone marrow. Tapi kecurigaan saya itu adanya statement “B-cell dengan prolymphocytoid transformation), jadi kemungkinan jawabannya adalah E.
35.A. jelas primarynya jumlah trombosit yang dibawah 150rb
36.B
37.D, karena ga ada tanda2 lymphadenopathy
38. C
39.D. kecurigaannya adalah CLL  karena ada keterlibatan hematopoietic cells di bone marrow dan lymphadenopathy. Jadi untuk kofirmasi setelah peripheral blood smear, kita smear ke tempat yg dicurigai, yaitu bone marrow.
40.b.
41. Jawaban : E. Stage IV
Penjelasan :
Penyakit yang dimaksud adalah CLL (Chronic Lymphocytic Leukemia).
Staging menurut Rai System :
0 : lymphocytosis in peripheral blood & bone marrow
I : + lymphadenopathy
II : + splenomegaly
III : + anemia
IV : + thrombocytopenia
(Harmening, 310)

42. Jawaban : B/C/E(?) tapi akademik 2006 jawab A. hyperkalemia
Penjelasan :
Salah satu hasil lab CLL adalah hypogammaglobulinemia (Harmening, 302).
Dari beberapa sumber internet ada yang mengikutsertakan hyperkalemia (B), hyperuricemia (E), & hypernatremia (C).

43. Jawaban : A. Increased sensitivity of hematopoietic stem cell to erythropoietin
Penjelasan :
Penyakit yang dimaksud adalah PV (Polycythemia Vera) ->soalnya ga lengkap.
“Erythroid progenitors are extremely sensitive to low levels of EPO supplied by serum that is inherently present in the basic culture medium.” (Harmening, 342)

44. Jawaban : A. Phlebotomy
Penjelasan :
Komplikasi utama dari PV adalah thrombosis akibat hiperviskositas darah & transisi PV menjadi MPD. Tujuan utama terapi adalah reduksi massa total RBC. Untuk itu dapat dilakukan terapi phlebotomy & cytotoxic myelosupressive agent. (Harmening, 346-347)

45. Jawaban : C.(?) tapi akademik 2006 jawab E. polycythemia, burned out, leukemic phase
Penjelasan :
“As previously mentioned, PV progress through several stages. In active erythrocytic phase, RBC can be maintained at satisfactory level. Many patients enter anemia period, and this spent phase (=burned out phase, from internet) ia associated with transformation to myelofibrosis. Presence of teardrop RBC on peripheral heralds transition PV to IMF.” (Harmening, 348)
Saya cenderung jawab C. erythrocte, burned out, myelofibrosis.

46. Jawaban : D. Lymphocytic lymphoma well-differentiated
Penjelasan :
“This pattern is diffuse & no lymphoid follicles are identified. The lymph node is replaced by an infiltrate of small (mature-appearing) neoplastic lymphocytes.” (Labman Pathology Anatomy)

47. Jawaban : A. Diffuse large B-cell lymphoma
Penjelasan :
“The malignant lymphocytes here are very large with moderately abundant cytoplasm, & the nuclei are round to ovoid with prominent nucleoli & occasional mitoses. Demonstration of CD-19 & CD-20 antigens would classify it as B-cell origin.” (Labman Pathology Anatomy)

48. ga ada soalnya…

49. ga ada soalnya…

50. Jawaban : C. Follicular lymphoma
Penjelasan :
“These lymphomas (-> follicular center lymphomas) are composed predominantly (more than 50%) of large cleaved cell (large cebtrocytes) & large non-cleaved (centroblast) cell. (Harmening, 405).

51. ga ada soalnya…

52. Jawaban : B. Epstein-Barr virus
Penjelasan :
Penyakit yang dimaksud adalah Burkitt’s lymphoma.
Ciri-cirinya : “Apoptosis is also very high & a starry-sky pattern of tingible-body macrophages is usually evident owing to phagocytosis of the apoptotic debris.” (Harmening, 413)
“The endemic & immunodeficiency-related cases are also assiciated with a high frequency of tumor cell incorporated EBV genomes.” (Harmening, 414)

53. ga ada soalnya…

54. ga ada soalnya…

55. Jawaban : A. Afferent lymphatics, medullary sinuses, hilus, efferent lymphatics
Penjelasan :
Struktur lymph node :
Lymphatic vessel : afferent vessel -> sub-capsular sinuses -> trabecular sinuses -> medullary sinuses -> hilum -> efferent vessel. (Labman Histology & Junquiera)

56. Jawaban : B/C(?) tapi akademik 2006 jawab D.HTLV-1
Penjelasan :
Penyakit yang dimaksud adalah Hodgkin’s lymphoma.
Karena ada non-painful lymph node swelling (Harmening, 402) dan gejalanya sesuai dengan klasifikasi Ann-Arbor (Harmening, 403).
Salah satu kemungkinan etiologinya adalah RNA-tumor-virus & EBV (Epstein-Barr virus). Kemungkinan lain adalah cytomegalovirus (B) & herpes virus 6 (C). (Harmening, 398-399).
HTLV-1 ditemukan pada non-Hodgkin’s lymphoma (Harmening, 416).

57. Jawaban : C. A nucleated Reed-Sternberg cell with large, inclusion nucleoli, & abundant cytoplasm is surrounded by mature lymphocytes
Penjelasan :
“The cytologic hallmark of Hodgkin’s lymphoma is the presence of unusual giant cell, the Reed-Sternberg cell. Features : large size, abundant acidophilic cytoplasm, multinucleated / polylobulated nucleus, & gigantic inclusion-like nucleoli.” (Harmening, 399)

58. Jawaban : D. Stage III B
Penjelasan :
Berdasarkan Ann-Arbor Staging :
I : involvement of single lymph node region / localized single extralymphatic site (IE)
II : involvement of 2/more lymph node regions at the same side of diaphragm / associated extralymphatic site (IIE)
III : involvement of lymph node regions on both side of diaphragm / associated extralymphatic site (IIIE)
IV : disseminated (multifocal) involvement of extralymphatic site & associated lymph nodes
Tambahan : A = asymptomatic, B = symptomatic (weight loss >10% in 6 months, fever >38°C, night sweat)
(Harmening, 403)
Pada kasus ini bilateral cervical & inguinal lymphadenopathy (=stage III) & ada symptom weight loss, fever, night sweat (=B).

59. Jawaban : B. Radiation
Penjelasan :
“Current modalities for the therapy of Hodgkin’s lymphoma are radiation, chemotherapy, or combination.” (Harmening, 403)

60. Jawaban : A G6PD-deficiency
Penjelasan :
Tabel 10-2 (Harmening, 159) chloramphenicol bisa menyebabkan G6PD deficiency.
Gejalanya anemia normochromic normocytic, back pain, hemoglobinuria & jaundice. (Harmening, 159)

61. E. Severe anemia (Hb < 7g/dl)
62. D. Karena : 8 mo, mild icterus, hepatosplenomegaly, decreased Hb, RDW increased, microcytosis, hypochromic
63. D jelas
64. D. WRBC = RBC, depleted of plasma, platelets, and leukocytes which can be deleterious to the recipient. Indication : for patients with antibodies to IgA or IgE immunoglobulins or thalassemic patients.
Packed red cell = RBC + small amounts of plasma with anticoagulant.

65. B. Semua sign n symptoms mengarah pada hemolytic anemia
66. A. Sign symptoms mengarah pada megaloblastic anemia ( terutama : malnourished). Di peripheral blood smear ditemukan : pancytopenia, macro-ovalocytes, hypersegmented neutrophils
67. B. Semua ciri2 pasien kita mengarah pada thalassemia. Peripheral blood smear : microcytic, hypochromic, >>> target cells (Harmening 196)
68. C (liat no 64)
69. B. Pasien kita terkena Megaloblastic anemia (increased MCV, weakness, fatigue,shortness of breath). Hb may be Normal to Low, absolute reticulocyte count is decreased. Pathogenesis : the defective nuclear maturation caused by a decrease in TTP synthesis from UMP. This deficiency interferes with nuclear maturation, DNA replication, and cell division.
70. C. Alasan diperkuat krn multiple Auer rod were seen.
71. D. Pasien kita anemia, leukocytosis,thrombocytopenia. Sepertinya dia kena leukemia.
72. B. Aplastic anemia : CBC shows pancytopenia, often with anemia being the most notable. The anemia is usually normochromic normocytic (Harmening 133)
73. B. Pasiennya mengalami pancytopenia (bukan leukemia), tapi aplastic.
74. C. Transfusion transmitted diseases : Hepatitis B, Hepatitis C, HIV, HTLV-1, CMV, HGV, Malaria, Babesiosis, Leishmaniasis, Lyme Disease, Chagas Disease - Chagas' Disease TTV, Creutzfeldt-Jakob CJD, KS and HHV-8, Toxoplasmosis, Cryoglobulinemia, Bacterial Contamination of Blood Products
75. C. Each unit of PRBCs is expected to raise circulating Hb by 1g/dl.
76. C. Disturbed cell = platelet (don’t have nuclear in mature cell, function : hemostasis, have OCS)
77. gtww..sorii
78. A.Adults = posterior superior iliac crest (most commonly), sternum (avoided in children), anterior superior iliac crest, spinal processes / vertebral bodies. Newborns and infant = upper end of the tibial bone. Jadi kalo diliat dr optionnya, maka jwbnnya A (Harmening 43)
79. D. Jelas,merupakan treatmenu utk IDA
80. B. Ferric iron is typically converted into ferrous state by the ACID of the stomach. (Harmening 101)
81. A.Folic Acid
That is important in synthesis of nucleid acid. It is interdependent with vit B12. Both of this are required for rapidly dividing cells. Deficiency of folic acid can cause megaliblastic anemia and also use for prevent neural tube defect (spine bifida)
82. E. Cyanocobalamine
It is the other name of vit B12. Necessary for synthesis of nuceid acid, maintenance of myelin production in nervous system and proper function od folic acid. Deficiency of vit B12 affect near all body tissue,particularly those cell containing rapidly dividing cell. So,deficiency of these vitamin also caue anemia,anemia megaloblastic. Loss of myelin cause decrease function of nervous system. The symptoms are paraesthesia,decrease of tendon reflex,and others.
83. A. Blood Transfusion
The diagnose of this patient is Iron Deficiency Anemia. So,the proper treatment (from the options) is blood transfusion. Blood transfusion is needed to do to treat the patient with Iron Deficiency Anemia if Hb decrease under 6 g/dl.
84. B. Urokinase
It is the enzyme endogenously produced by kidney present in blood and urine that is capable of breking up blood clots. It is activated plasminogen directly to plasmin,which dissolves blood clots.
85. the question is not complete
87. A. Decrese of basophilic color
The changes of RBC maturation,particularly in cytoplasma is from basophilic to red cytoplasma because of increase of HB.
88. C. Yolc sac - liver and spleen – red bone marrow
See harmening page 9
89. B. Briliant cresyl blue staining
See harmening page 80
90. C. Tissue hypoxia
See harmening page 15
91. B. Pelger-huetanomaly
Netrophil that has a bilobus nuclei or monolobed/round
93. B. ITP
More closed diagnose from the option is ITP
96.
98.
99. mechanism of action of allopurinol
Inhibitor to enzyme xanthin oxidase in uric acid production to treat of gout.

101)

102) ANS : D
EXP : tonsil incompletely encapsulated,each tonsil has 10-20 ep.invaginations that penetrate the tonsil deeply,forming crypts,whose lumen contain desquamated ep.cells,live & dead lymphocytes & bacteria (basic histology,junqueira,11th ed,pg 263-264)

103)

107)

108)

110) ANS : D
EXP : cytolytic T lymphocytes (CTLs) respond to antigen recognition by killing the antigen-bearing cell.these cells are usually CD8 & recognize antigen in the context of MHC class 1 molecules. (medical immunology,lange,10th ed,pg 141-142)

111) ANS : C
EXP : Thalidomide is very harmful to the fetus. Therefore, thalidomide should be avoided during pregnancy. Men and women who are taking thalidomide should use appropriate methods of birth control. Moreover, women of childbearing age should practice two forms of birth control concurrently. Men taking thalidomide should not donate sperm, and thalidomide users should not donate blood since the recipients of the sperm and blood may receive small amounts of thalidomide.
NURSING MOTHERS: It is not known whether thalidomide is excreted in breast milk.
SIDE EFFECTS: The most common side effects are drowsiness, dizziness, low blood pressure, weakness, rash and increased sensitivity to sunlight. Thalidomide also causes nerve damage and a decrease in white blood cells. Symptoms of nerve damage are tingling, numbness and pain in the feet or hands. (MedicineNet.com)


112)

113) ANS : E
EXP : corticosteroidadvantages :
• Promote normal intermediary metabolism
• Increase resistance to stress – high glucosegive high energyincrease resistance to stress(exp;trauma,fright,infection)
• Alter blood cell levels in plasma – cause decrease in eosinophils,basophils, monocytes & lymphocytes by redistributing them from the circulation to lymphoid tissue;increase blood levels of erythrocytes,hb,platelets PMN
• Anti-inflammatory action – exact mech.not fully understood.however,the lowering & inhition of peripheral lymphocytes & macrophages is known to play a role.interference in mast cell degranulation results in decreased histamine & capillary permeability.
• Affect other components of endocrine system
• Effects on other systems
(Lippincott,pharmacology,3rd ed,308-309)

114) ANS : C
EXP : dexamethasone=corticosteroids group;corticosteroid eye drops to control acute severe allergic conjunctivitis should be used very sparingly fro brief periods only,with careful monitoring by an ophtgalmologist (medical immunology,lange,10th ed,358)




115) ANS : C
EXP : side effects of glucocorticoidhyperglycemia may develop & lead to DM,other side-osteoporosis,increase risk of infection & classic Cushing-like syndrome (pharmacology,Lippincott,3rd ed,pg 312)

116)

117) ANS : A
EXP : pemphigus vulgaris – skin biopsy shows a suprabasal intraepidermal blister with loss of cohesion of keratinocytes(acantholysis);blisters that most commonly affect the scalp,chest,umbilicus,body folds;direct immunofluorescence reveals the deposition of IgG in virtually all patients & complement components (mostly C3) on epidermal cell surface forming a honeycomb pattern in 50% of all patients. (medical immunology,lange,10th ed,pg 504-505)

118) ANS : D
EXP : refer to explanation of the answer above

119) ANS : E
EXP : refer to explanation of the ans no. 117

120) ANS : B
EXP :

121. Which of the following is the best place in-patient care ?
a. burn unit room
b. recovery room
c. high care unit room
d. standard in-patient room
e. intensive care unit room
Ans.
a/e
Since the age of 4, an 8 yo girl has been suffering sneezing, watery rhinorrhea, nasal blockage resulting in nasal voice, severe itch in her nose and throat, accompanied with red, watery, severe itching eyes without fever. It recurs everytime she is in the rice stock ham, rice, and ricefields, especially in harvest time. The eye’s topical glucocorticoid treatment, need monitoring of an ophthalmologist, due to defective cell mediated immunity.
122. Which of the following is the most unlikely sign of PE ?
a. allergic salute
b. Dennie-Morgan folds
c. facial twitching or grimacing
d. hyperemic nasal mucous
e. transverse nasal crease
Ans.
d
PE pada allergic rhinitis :
- facial twitching or grimacing
- allergic salute
- dennie-morgan folds
- transverse nasal crease
123. The eye’s topical glucocorticoid treatment, needs monitoring of an ophthalmologist, due to defective cell mediated immunity. Which one of the following needs to be detected early by ophthalmologist ?
a. cataract
b. corneal ulcer
c. glaucoma
d. herpes simplex virus infection
e. sight threatening side effect
Ans.
c
Topical glucocorticoid therapy frequently  intraocular pressure in normal eyes and exacerbates intraocular hypertension in patient with antecedent glaucoma. Intraocular pressure should be monitored when glucocorticoid are applied to the eye for more than 2 weeks.
A 4 months old baby girl comes to clinic with rash skin on her cheeks, which spare the perioral skin. It appears first as typical dryness (1 week ago) developing into red scaly plaques since 4 days ago. On the first day of life, she was given cow’s milk formula and was exclusively breastfed there after. Since 8 days ago cow’s milk formula containing porridge was added to her daily feeding. Her brother (5 yo) will wheeze and her mother sneeze after exposure to dust.
124. Which one of the following is the most likely diagnosis ?
a. contact dermatitis
b. irritant dermatitis
c. atopic dermatitis
d. Steven Johnson’s Syndrome
e. Streptococcal skin scalded syndrome
Ans.
c
Terjadi akibat konsumsi susu sapi.
125. Which one of the following is the most likely cause of this baby’s disease ?
a. house dust
b. house dust mite
c. wheat
d. cow’s milk
e. breast milk
Ans.
d
Telah diberikan selama 8 hari.
20 yo with runny nose as chief complaint. It occurs since he was 4 yo. There is also nasal blockage, itchy-nose, sneezing especially after dust inhalation. He wotks as bus driver. PE : facies adenoid and allergic shinners, enlargement inferior and middle turbinate with a boggy, pale, and bluish mucosa. Lab : IgE levels : 600 IU/ml
129. Runny nose. Major substance release ?
Ans.
IgE
130. for the above case, what is the most suitable H. I. Antihistamine for this patient ?
a. ceftrizine hydrochloride
b. chlorpheniramine maleat
c. promethazine hydrochloride
d. tripehennamite hydrochloride
e. diphenhydramine hydrochloride
Ans.
a
Sesuai dengan case. Efek samping pada CNS rendah.
132. A 32 yo mother who was 32 weeks pregnant (G1P0A0) came to allergic clinic with a runny nose and stuffy nose as a chief complaint. This nose problem was firstly notice in 2nd trimester. PE reveal allergic shinners, enlarged inferior turbinate and watery-clear mucus. Lab : IgE serum 340 IU/ml. Which of the following substance beside histamine might cause the nose problem to this patient ?
a. estrogen
b. bradykinin
c. prostaglandin
d. progesterone
e. leukotrienes
Ans.
e
Menampakkan late phase mediator yang memiliki efek sama dengan histamine namun lebih potent.
137. 5 yo boy comes to ENT clinic. Runny nose since 3 yo, also suffered nasal blockage, itchy, and sneezing especially when inhaled dust. Lab : IgE serum 600 IU/ml. Most frequent co-morbidity on pharynx in PE ?
a. pale mucosa
b. post nasal drip
c. pseudomembrane
d. hyperemic mucosa
e. cobblestone appearance
Ans.
b
terjadi akibat produksi mucus .
139. During christmast dinner, female is hospitalized because of tight throat and shortness of breath after eating shrimp. What is the diagnosis ?
a. choking
b. anaphylactic shock
c. shrimp in throat
d. laryngeal edema
e. asthma
Ans.
b
141. 5 yo went to Pangandaran. Swimming vigorously in sea water at high noon which spread multiple pruritic papules, develop immediately, small which 1-3 mm diameter surrounded with excessive ... What type of urticaria is she having ?
a. aquagenic urticaria
b. cholinergic urticaria
c. heat urticaria
d. psychogenic urticaria
e. solar urticaria
Ans.
b
Cholinergic urticaria is a disease of unknown cause in which small (1-3 mm) wheals with prominent surrounding flare appear after exercise, heat, or emotional stress.
161. From case 160. Permanent symptom in NLE
A. Cutaneous lesion
B. Congenital heart block
C. Pulmonary involvement
D. Neurologic involvement
E. Thrombocytosis
Jawab : B

162. Major cause of death to chronic corticosteroid administration ?
A. Infection
B. Nephritis
C. CNS disease
D. Pulmonary hemorrhage
E. Myocardial infarction
Jawab : A
Kenapa bukan E ? Karena kelainan jantung yang bisa disebabkan oleh corticosteroid adalah heart failure (terutama congestive heart failure), bukan myocardial infarction (= heart attack).

163. IV drug user, Anti-HIV (+), CD4 = 66, shortness of breath, bilateral infiltrate of lung. Which is true ?
A. Risk of multiple opportunistic infection
B. Risk of myocardial infarction
C. Risk of autoimmune disease
D. Risk of hematological disease
E. Risk of drug allergy
Jawab : A

164. 30 y.o. male had symptom of anemia, diagnosed as megaloblastic anemia. Drug avoided through …
A. Oral
B. Intravenous
C. Intravascular
D. Subcutaneous
E. Intracutaneous
Jawab : B
Penyebab megaloblastic anemia adalah defisiensi vitamin B12 atau asam folat. Untuk vitamin B12, bisa diberikan secara per oral atau intramuscular atau subcutaneous. Untuk asam folat, biasa diberikan secara oral.

165. Patient with malar rash, photosensitivity, atrophic lesion at periauricular, ANA (+), dsDNA (-), no protein in urine. Diagnosis ?
A. DLE
B. SLE
C. CLE
D. Acute SLE
E. Acute CLE
Jawab : E
Dari criteria SLE, yang terpenuhi hanya 3, yakni malar rash, photosensitivity, dan ANA (+), sehingga belum memenuhi diagnosis SLE (minimal 4 dari 11 kriteria). Jadi jelas termasuk CLE. Mengapa acute, bukan subacute atau chronic ? Bentuk lesi khas acute adalah malar rash, subacute lesi khasnya annular dan hyperkeratotic, chronic : discoid/DLE.

166. 45 y.o. female has rheumatoid arthritis for 6 years and has been treated with NSAIDs and, sometimes, corticosteroids for severe exacerbation. She feels the disease gets worsen. Due to acute exacerbation, she is treated with methotrexate. What is MoA of the last drug ?
Jawab :
Methotrexate adalah first choice untuk disease-modifying antirheumatic drugs (DMARDs). MoA-nya menginhibisi aminoimidazolecarboxamide ribonucleotide (AICAR) transformylase dan thymidylate synthetase dan efek sekunder (bukan utama) ke dyhidrofolate reductase dan penghambatan chemotaxis dari PMN. Penghambatan enzim-enzim ini menyebabkan berkurangnya sintesis thymidylate, purine nucleotide, dan serine dan methionine. Sehingga menyebabkan intervensi thd pembentukan DNA, RNA, dan protein sel.

167. –


168. Patient present with polyarthritis around small joint of hand and feet. According to Americal College of Rheumatology for rheumatoid arthritis ?
A. Systemic symptom
B. Swan neck appearance
C. Rheumatoid nodules
D. Oligoarthritis
E. Osteosclerosis
Jawab : maaf, saya kurang tahu maksud pertanyaannya >.<
Kriteria diagnosis untuk RA dari American College of Rheumatology (minimal 4 terpenuhi  diagnosis RA) :
1. Morning stiffness > 1 hour for at least 6 weeks
2. Arthritis and soft tissue swelling of >3 of 14 joints/joint groups, present for at least 6 weeks
3. Arthritis of hand joints, present for at least 6 weeks
4. Symmetric arthritis, present for at least 6 weeks
5. Subcutaneous nodules in specific places
6. Rheumatoid factor at level above 95th percentile
7. Radiological changes suggestive of joint erosions

169. –

170. Histopathology for above case :

171. Chief complaint : difficulty of breathing
3 weeks ago, had diarrhea and febrile.
General practitioner gave antibiotic and antidiarrhea, these drugs decrease the symptoms.
2 weeks ago, felt numbness and weakness in both extremities, which become worse.
PE : alert, RR 14/min, temperature 36.7
Neurological exam : symmetrical and bilateral tetraplegic, flaccid, gloves & stocking anesthetic.
Physiologic reflex absent
Oxygen saturation is decreased
CSF analysis : cytoalbuminic dissociation
Which of the following type of hypersensitivity is the most likely occur in this case ?
A. 1
B. 2
C. 3
D. 4
E. 1 – 4
Jawab : D
Dari chief complain “difficulty of breathing”, riwayat adanya infeksi gastrointestinal sebelumnya, hasil pemeriksaan neurologis yang menunjukkan adanya ascending paralysis, sepertinya ini adalah Guillain-Barre Syndrome, yang disebabkan reaksi hypersensitivity tipe 4.

172. –

173. HIV antibodies positive since 5 years
CD4 = 65
Difficulty in breathing.
Which one is true ?
A. High risk for infection
B. High risk for myocardial infection (infarction mgkn maksudnya)
C. High risk for hematologic disease
D. High risk for drug allergy
Jawab : A

174. Which of the following causes that can proceed to respiratory failure in this case ?
A. Ascending paralysis
B. Descending paralysis
C. Uncal herniation
D. Rostrocaudal herniation
E. Transtentorial herniation
Jawab : kalau ini kasus GBS, jawabnya A.

175. –

176. –

177. Appropriate tools to confirm diagnostic for baby’s HIV infection state ?
A. HIV DNA PCR
B. HIV RNA PCR
C. HIV culture
D. HIV p24 Ag ex
E. Anti-HIV-1
Jawab : B

178. Based on Indonesian Medical, what is appropriate drug for treatment for neonatal HIV infection ?
A. AZT + 3TC + NVP, 6 weeks
B. AZT + 3TC + ZDV, 6 weeks
C. AZT + ZDV
D. AZT + ZDV
E. Antimycotic
Jawab : A
untuk terapi AIDS, diperlukan gabungan 2 NRTI + 1 NNRTI atau 1 protease inhibitor. AZT dan 3TC termasuk NRTI, NVP termasuk NNRT, ZDV termasuk NRTI.

179. Which one of the following is mediator of early phase of mast cell degranulation ?
A. Prostaglandin
B. Leukotriene
C. PAF
D. Tryptase
E. IL-4
Jawab : D
Degranulasi mast cell menyebabkan pengeluaran histamine, heparin, dan tryptase pada fase awal (karena ketiga substansi itu ada di preformed granule). Di fase lambat, arachidonic acid, leukotriene, prostaglandin, cytokine, TNF, dan IL dilepaskan.

180. Which of the following molecule is opsonin that facilitates efficient phagocytosis of microbes by neutrophil and macrophage ?
A. IgA
B. IgG
C. IgE
D. CRP
E. IF
Jawab : B
Tabel 2-10 Lange Medical Immunology hal. 36 menyebutkan, opsonin dari macrophage salah satunya adalah immunoglobulin, especially IgG

181.8 months old boy, mild icterus, mycrocytosis, hypocromia, anisopoikilicytosis, polychromasia, basophilic stippling.Most appropiate condition

a. moderate anemia+splenomegali
b. moderate anemia+ hepatosplenomegali
c. severe anemia+ hepatomegali
d. severe anemia+ splenomegali
e. severe anemia+ hepatosplenomegali


182.which of following is present to facilitate efficient phagocytosis of microbe by neutrophil and macrophage
a.IgA d.CRP
b.IgG e.IF
c.IgE

Alasan: IgG protect against bacteria and virus by enhancing phagocytosis, neutralizing toxins, and triggering complement system.

183. a man diagnosed with AIDS 5 years ago.CD4+ count decreased.What is big risk
a.he is at risk getting oppurtunistic infection
b.he is at risk of getting trauma
c.he is at big risk of getting malformation
d.he is at risk of getting inflamation

Alasan: CD4+ cell ato helper T-cell berperan dalam proses imun system sehingga saat kadarnya rendah maka proses imun system juga akan menurun sehingga resiko terinfeksi tinggi.

184.63 year female has symetrical sweeling of proximal phalanges joints and small subcutaneus nodules over extensor surface on her arm. She report had pain and stiffness is most pronounced on arising in morning.which of following laboratory test result is typical in of patient disease?
a.positive IgM specific to streptococcal antigen
b.positive IgG specific to streptococcal
c.positive anti-double stranded DNA
d.positive rheumatoid factor
e.positive ASLO

Alasan:diagnosis kasus diatas ialah rheumatoid karena terdapat symetrical swelling in join kecil dan subcutaneus nodul uang disebut rheumatoid nodule dan pada RA rasa sakit terjadi saat bangun pagi dan improve throughtout of the day
Dimana ciri RA ialah: presence rheumatoid factorbin serum and synovial fluid, infiltartion lymphocyte and activated macrophage into involved synovium, dan local production TNF- alpha dan other proinflamatory cytokines in inflamed synovium.

185.SLE is the diseasse of autoimmune origin.Which of following act as antigen from the production of antibodies in the case
a.snRNP (small nuclear ribonucleoprotein)
b.Mrna
c.rRNA (ribosomal ribonucleic acid)
d.cDNA (circular deoxyribonucleic acid)
e.dsDNA (double stranded DNA)

alasan: high titer of anti-ds-DNA antibodies are characterized of SLE.in contrast, anti ss-DNA are not specific and can be found in other autoimune disease ( RA, cronic active hepatitis dsb)\

186.lihat soalny di buku kumpulan soal
a.hair fall d.difficult concentration
b.skin rash e.symetrical polyarticular inflamation
c.systemic symptom

alasan: main problem / chief complain ialah keluhan yang mebuat seseorang datang beribat ke dokter.

187.one morning, as a medical student, you are observing in rheumatology clinic of hasan sadikin general hospital, a 20 years old woman presented with symetrical painful and swollen joints including proximal interphalanges (PIPs).metacarpophalanges (MCPs), wrist,knee and ankles. The other symptom were fever and subcutaneus nodules.Which of the following is thhe most likely diagnosis in this case
a.SLE d.artritis reactive
b.Rheumatoid artritis e.osteomyelitis
c.spondyloartritis alasan : lihat pembahasan no 184

188.patient with symetric polyartritis particularly off small joints of the hands and feet should be checked for rheumatoid factor.which of the following symptom were included in the american college of rheumatology duagnostic criteria for rheumatoid artritis
a.systemic symptom d.oligoartritis
b.swan neck deformities e.osteoslerosis
c.rheumatoid nodule

Alasan: most characteristic feature of hand in RA are
- ulnar deviation (boutonniere) deformity = flexion of proximal interphalanges joint and hyperextention of distal interphalanges joint resulting from volar slippage of lateral band of superficial extensor tendons.
- swan neck deformities (hyperextention of proximal interphalange joint and
- flexion of distal interphalange joints resulting from contarcture of intinsic muscle of the hand)
189.a young man, 24 years old had a history back pain and stiffness especially in the morning, over the past 3 months and relieved by increased avtivity or anti-inflamatory medication.he did not have constitutional complaints of fever or weight loss.in addition for the last months he has sweeling and stiffness in his knees and unable to walk.rheumatology finding: legs,knees,and ankles were inflamed and swollen, spine: schober test (+).what is the differential diagnosis in this patient
A.gouty artritis and osteoartritis
b.rheumatoid artritis and spondyloartritis
c.septic artritis and rheumatoid artritis
d.osteoartritis and rheumatoid artritis
e.SLE and spondyloartritis

Alasan: diagnosis kasus diatas ialah RA karna ada stiffness saat pagi hari dan spondyloartritis karna ada schober test (+) yang umumnya pada sacroiliac joint, spine and large periperal joints.yang ditanya adalah differential diagnosis

190.48 year old business man had history of mild hypertention.usually he had no symptoms and for the hypertension he has had hydochlorothiazole theraphy for 3 days.he wake up in the night with painful and warm in hiss feet.one hour later his symptom become worst, warm and redness.he called the doctor and received analgesic.what kind of drugs can induce the acute attack of gouty artritis
a.low dose aspirin d.paracetamol
b.allupurinol e.prednisone
c.hydrochlorothiazide

alasan: drugs (including diuretics ex hydrochlothiazide and cyclosporine A), and chronic ethanol (especially beer and hard liquor) can induce GA.asprin juga bisa mengakibatkan GA tapi tidak saat low dose.

192.an 18 year old in room full of people who are coughing and sneezing.the influenza viral particle that she inhales attach to respiratory epithalium and viral transformation reduce the class I MHC molecules on these epithelial cells.which of the following cell that respond to destroy the infected cells.
a.neutrophile d.NK cells
b.monocyte e.dendritic cell
c.CD4 cells

alasan: infected target cell by viral> fragment dipecah dan diikat ke permukaan sel oleh MHC> cytotoxic CD4 > melekat ke MHC> CD4 release cytotoxic substance cause death infected cell by release perforin dan granzyme.

193.in rsponse with mucobacterium tuberculosis, agranuloma forms in the lung. Within the granulooma ae cell expressing class II MHC antigens.these cell liberate cytokines that promote fibroblastic production in colagen within granulomma.WOTF blood leucocyte are in the mechanism
a.neutrophle d.NK cells
b.monocyte e.basophile
c.B cell

Alasan: MHC II diekspresi oleh APC (dendritic cell, macrophage, dan B cell)

194.a 43 year old male presents several flaccid lesion with crusts on his back.patology anatomy diagnosis from the biopsy which obtained from the lesion was pemphigius folaceus.Which of the most appropiate histopatologic appereance for the case above
a.spongiosis within epidermis
b.superficial perivascular lymphocytic infiltrate
c.intraepidermal blister with acantholitic
d.dermal and epidermal edema and mast cell degranulation
e.subcorneal blister with acantholitic cells.

Alasan: microscopic pada pemphigius folaceus ialh subcorneal clister is apparent with acantholysis.

196.Gouty artritis that is caused by overproduction of uric acid.which of the following is a precursor of uric acid
a.pyrimidine d.thymine
b.purine e.uracil
c.cytosine

alasan: uric acid produced by xanthine oxidase from xanthine and hypoxanthine, which in true produced from purine.

197.allupurinol is compound used to trear gout.which of the follwing is the mechanism of action of the dug above
a.inhibit degradation of guanosine to guanine
b.inhibits degradation of guanine to xanthine
c.increase excretion of hypoxanthine
d.activates degradation of uric acid to allantoin
e.inhibit degradation of hypoxanthine to xanthine

alasan: allopurinol inhibit synthesis xanthine oxidase and prevent synthesis of urate from hypoxanthine and xanthine (xanthine oxidase: ubah degradasi xypoxanthine menjadi xanthine)

198.according to the origin and physiologic process of ejaculation, antigenicity of the semen is divided into antigens derived from testes, epididymis and spermatozoa and antigen derived from the secretions of reproductive accesory glands.WOTF is most likely the sperm coating antigen originated from seminal plasma:
a.trasferrin d.albumin
b.acid phosphatase e.globulin
c.scaferrin

199.breakdown of normal protective mechanism, ex the blood testis barier, appear to be the major factor cause of antigen leakage causing antisperm antibody (ASA) formation.ASA may cause fertility by which of the following ways
a.interfering with spermmatozoa production
b.interfering with spermatozoa capacitation
c.reducing the amount of spermatozoa
d.reducing the mobility of spermatozoa
e.agglutinating and immobilizing the spermatozoa

200.WBC have been found found to carry numerous different antigen in HLA system.the presence of a particular region on leucocyte means that a corrsponding alleles is the present in genotype making up that person.which of the followinh is most likely explanation pf HLA symptom

a. objective of transplantation
b. antigens in the HLA system are controlled by cromosome 8
c. alleles of the genotype maybe homoxygous and heteroxygous
d. alleles of the genotype are always homozygous
e. alleles of the genotype are always heterozygous

alasan: the succes of organ or tissue tranplantation depends on histocompability –that is, the tissue histocompability between donor and the recipient.tissue typing (histocompability testing) is done before any organ transplant.antigen of HLA system are controlled by cromosome 6.

MDE HIS 2007-2

1. Jawaban : C
Alasan : soal kurang lengkap, klo hanya segini harusnya bisa semua. Tapi klo ada hemarthrosis (bleeding in joint) biasanya karena masalah koagulasi.

2. Jawaban : A
Alasan : ada thrombocytopenia sedangkan blood count lain normal, ada sejarah bleeding (Harmening hlm 474)

3. Jawaban : C
Alasan : Hb nomal  12-16 (women), WBC  4800-10800, PLT  150000-350000 (tabel Harmening)

4. Jawaban : A
Alasan : gejala paling sering pada ITP adalah bleeding, dan yang paling berbahaya bila terjadi di intrakranial

5. Jawaban : C/D
Alasan : sebenernya di bukunya “most of the case will respond to corticosteroid” jadi masukin yang D juga. Treatment awal diberikan corticosteroid atau IV Ig (wintrobe)

6. Jawaban : C
Alasan : BM smear  peningkatan jumlah megakaryocyte (harmening hlm 444)

7. Jawaban : A
Alasan : Harmening hlm 444

8. Jawaban : C
Alasan : dari SS mungkin yang bterjadi adalah Hodgkin’s lymphoma

9. Jawaban : A
Alasan : diagnosis untuk keganasan pada lymph (node) dilakukan melalui biopsy

10. Jawaban : D
Alasan : Robbins hlm 688

11. Jawaban : B
Alasan : kebanyakan pasien ditreatment dengan chemotherapy (cytostatic)

12. Jawaban : E
Alasan : adverse prognostic factors identified in the international study are: Age >= 45 years, Stage IV disease, Hemoglobin < 10.5 g/dl, Lymphocyte count < 600/µl or < 8%, Male, Albumin < 4.0 g/dl, White blood count >= 15,000/µl

13. Jawaban : IDA
Alasan : sign & symptom cocok dgn IDA

14. Jawaban : Acidophilic normoblast
Alasan : sebenernya jawabannya “lack of stainable iron in reticuloendothelial cells”, tapi ga ada di pilihan.

15. Jawaban : Hemorrhagic disease of newborn
Alasan : prolonged PT dan aPTT  kelainan pada intrinsic dan extrinsic pathway  multiple coagulation factor disorder

16. Jawaban : A/B
Alasan : PLT count normal  kemungkinana kelainan di faktor koagulasi (Harmening hlm 465-466)

17. Jawaban : E
Alasan : nampak soalnya salah, harusnya PLT count berkurang, jadi diagnosisnya ITP

18. Jawaban : B
Alasan : ada faktor genetis (pada male family member) dan peningkatan aPTT  kelainan proses koagulasi (secondary hemostasis)

19. Jawaban : C
Alasan : prolnged aPTT, hemarthrosis, history of bleeding in male family member (Harmening hlm 501)

20. Jawaban : D
Alasan : hemophilia A  kelainan faktor VIII

21. E. jelas ya, liat penjelasan no 24 tahun 2007-1
22. E. pasien kita ini kemungkinan dikarenakan DIC (salah satu etiologynya adalah sepsis)  terjadi peningkatan konsumsi dari faktor2 koagulasi sehingga terjadi depleted dari ketersediaan factor koagulasi; dan peningkatan degradasinya. Terbukti dengan adanya gejala hemorrhagic aktif (purpura dan petechiae yang diffuse dan pendarahan di tmpt injeksi) serta peningkatan APTT n PT dan penurunanthrombocyte dan fibrinogen dengan elevated degradation product D-Dimer. Coba lihat harmening hal 528 tabel 26.4
Note: DIC itu mempunyai manifestasi yang unik, tergantung dari manifestasi mana yang dominan, bisa manifestasi pendarahan atau manifestasi thrombotic.
23. E. PT dan APTT yang meningkat (masalah multiple coagulation factors), dan pasien kita masih berumur 3 hari, kemungkinan besar, hemorhagic disease pada masa breastfed ialah akibat dari deficiency vit K; yang di mana vit K mempengaruhi factor II,VII,IX,X..
24.B. karena abnormal response dari mast cell dari compensatory cholinergic in thermoregulation.
25.?
26.?
27?
28?
29. E. jelas ada tanda2 hemolytic anemia  pale yang disertai icterus, splenomegaly (SII)
30. agak ga jelas. Untuk H.spherocyte  splenectomy; untuk Thalasemia dan Sickle Cell disease  transfusion PRC, hydroxyurea atau bone marrow transplantation. Untuk hemolytic anemia karena autoimmune  dikasih glucocorticoid, tapi… di sini soalnya ga gitu jelas.
31. jika optionnya seperti ini, diagnosis pastinya melalui Hb electrophoresis.
33.??
38. D.kalo granulocyte hyperpigmentation itu ga ada.adanya adalah hypersegmentation yang muncul pada megaloblastic anemia.
39. D. robbins hal 676
40.?? Ini kan pasien uda kita curigai ada hemophilia, test yang dilakukan selanjutnya ialah factor VIII assay untuk memastikan betul bahwa memang ada deficiency di situ.. tapi kalo dibilang substitutional test, ga ketemu itu apa…
41. Jawaban : E. cryoprecipitate
Pembahasan :
Penyakitnya adalah hemophilia, karena ada riwayat bleeding pada keluarga laki-laki & APTT turun.
“Cryoprecipitate = a concentrated source of coagulation fator VIII.” (Harmening, glossary 699)
“Although cryoprecipitate is a rich source of FVIII, it is not the product of choice beause of the high incidence of parenteral transmitted HIV.” (Harmening, 502)
“Fresh Frozen Plasma = a frozen plasma product contains all clotting factors. It is useful for clotting factors deficiency other than hemophilia A, vWB disease, hypofibrinogenemia.” (Harmening, glossary 701)
Yawda kasih cryo- aja, daripada yang laen lebih ga nyambung, ya ngga??

42. Jawaban : C. scafferin
Pembahasan :
“At least six sperm-coating antigens have since been identified in human seminal plasma. Only two of these antigens, lactoferrin, also known as scafferin, and the seminal plasma No. 7 antigen (ferrisplan) have been shown to originate in the human seminal vesicles.” (internet)

43. Jawaban : B. BCB staining
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 (BCB), precipitated ribrosomal RNA (reticulum) can be demonstrated within the cell.” (internet)

44. Jawaban : (?) akademik 2006 jawab A. increase potassium
Pembahasan :

45. Jawaban : (?) akademik 2006 jawab A. whole blood
Pembahasan :

46. Jawaban : pronormoblast / rubriblast
Pembahasan :
Youngest RBC -> pronormoblast / rubriblast (Harmening, 10, tabel 1-6, 13)

47. Jawaban : myeloblast – promyelocyte – N.myelocyte – N.metamyelocyte – N.band – N.segmented
Pembahasan :
Stage of neutrophil development (Harmening, tabel 1-7, 17)

48. Jawaban : B. leukocyte, Hb, diff.count
Pembahasan :
Inflamasi berkaitan dengan naiknya jumlah sel-sel leukosit, untuk tahu lebih jelas penyebabnya kita lakukan diff.count. Platelet & reticulocyte kurang berkaitan dengan proses inflamasi. Jadi yang paling mungkin B.

49. Jawaban : A. microcytic, hypochromic anemia
Pembahasan :
(Harmening, tabel4-3, 77)
MCV (80-100 fL) -> turun, microcytic
MCH (22-31 pg)
MCHC (32-36%) -> turun, hypochromic
Pada kasus, ketiganya turun, maka microcytic hypochromic anemia.

50. Jawaban : B. iron deficiency anemia
Pembahasan :
MCV, MCH, MCHC turun -> microcytic hypochromic anemia.
A. megaloblastic anemia -> macrocytic normochromic
B. IDA -> microcytic hypochromic (V)
C. hemolytic anemia -> normocytic normochromic
D. aplastic anemia -> normocytic normochromic
E. pernicious anemia = megaloblastic
(Harmening, tabel 4-3, 77)

51. Jawaban : B. normoblast with marked nucleus
Pembahasan :
“IDA –> the bone marrow revealed a mild to moderate increase in erythroid progenitors (normoblasts).” (Robbins, 646)

52 – 53. ga ada soalnya...

54. Jawaban : E. bullous pemphigoid
Pembahasan :
“Bullous pemphigoid –> a bullous autoimmune disease usually in eldery.
Lesion = pruritic papular / urticarial lesion with large tense bullae, subepidermal blister with eosinophils.
Mechanism = interaction of antibody with bullous pemphigoid antigen (BPAG12) at hemidesmosome of basal keratinocyte.” (Fitzpatrick pocket, 112)

55. ga ada soalnya...

56. Jawaban : A. abnormal synthesis of globin chain
Pembahasan :
“In thalassemia, a defect in the rate of production of one of the globin chains causes a decrease in the ammount of normal physiologic Hb produced, resulting in microcytic hypochromic anemia.” (Harmening, 188)

57. Jawaban : C packed red cell
Pembahasan :
Karena terdapat defek pada pembentukan rantai globin dari Hb, dari RBC. Maka transfusi yang sesuai adalah packed red cell.

58. Jawaban : E. aplastic anemia
Pembahasan :
“Aplastic anemia is a disorder characterized by cellular depletion & fatty replacement of bone marrow. Decrease in hematopoietic progenitors laed to diminished production of erythocyte, leukocyte, & platelet and development of peripheral blood cytopenia.” (Harmening, 129)

59. Jawaban : (?)
Pembahasan :
Penyakitnya adalah IDA, karena serum iron & ferritin turun.Terapi dengan iron replacement.
“Iron toxicity (acute) = necrotizing gastroenteritis, vomit, abdominal pain, bloody diarhea, may be followed by shock, lethargy, dyspnea, and in severe cases metabolic acidosis & death. (Katzung, 531)

60. ga ada soalnya...

61. D
62. C. Tanda2 dari pasien ini mengarah ke IDA. Lab result dari pasien yg mengidap IDA adalah decreased serum ferritin, increased TIBC
63. E. seperti case IDA kita (no hepatosplenomegaly)
64. D
65. C
66. A.
67. D. Dari tanda2nya pasien kita terkena leukemia. Kalo brittle hair=anemia; koilonychias=anemia; dry skin=anemia. Nah gum hypertrophy bias terjadi karena infiltrasi dari leukemic clone.
68. C. Pasien kita terkena leukemic tipe AML (dewasa), khususnya AML M3
69. B.
70. ga nyambung soalnya
71. A
73. E
74.C
75. C
78. A
79. D
80. ga jelas soalnya
100) A
101) C
102) A
103) D
104) D
105)
106) A
107) E
108) C
109) A
110) D
111) C
112) D
124. which of the following is the characteristic of rhinorrhea ?
Ans.
-
125. a 24 years old women with runny nose, sneezing in the morning. No cough, headache, fever, anterior rhinoscopy with swelling of mucous which appeared pale or bluish in color, clear discharge, no septum deviation, no polyp and decrease air passage. Which of gland activity should be abnormal ?
Ans.
B. Exocrine
126. a 6 years old girl came to outpatient department of RSHS with chief complaint red, itchy, circumscribed patches on her body. She ate shrimp an hour ago. She’s allergic to cold but has no history of food allergy. Which of the following skin layer is abnormal ?
Ans.
A. Pars papillaris
128. a 24 years old male, IV drug user, lab result shows HIV (+). Which of the following cell killed by the virus ?
Ans.
C. CD4+ T lymphocyte
132. which of the following cells is mediated in transmitting this virus to CD4+ and T lymphocytes ?
Ans.
?
133. which of the following target cell will be killed by cytotoxic T cell induced by viral infection ?
Ans.
B. Infected by virus and identical at class I MHC loci at cytotoxic T cell
134. after binding to its specific antigen, a B lymphocyte may switch which of the following component ?
Ans.
B. Immunoglobulin heavy chain class
135. which of the following must be exposed on the surface of APC that activate T helper ?
Ans.
D. Class II antigen
136. which of the following class immunoglobulin is present in highest concentration in the blood of human newborn ?
Ans.
A. IgG
137. which of the following statement is the most likely is the macrophage during an antibody response ?
Ans.
D. Processing antigen and presenting it
139. MoA of allopurinol ?
Ans.
Allopurinol inhibits xanthineoxidase and prevents the synthesis of urate from hypoxanthine and xanthine.
20 years old woman, swelling and stiffness as chief complain. Over past month, extremely tired and unable to keep up with coursework, fall asleep in classes and difficult to concentrate. Recently felt feverish, but not take her temperature. Hair seems to be falling out after brushing or washing hair. PE : raised and warm rash on cheeks, small ulceration on hard palate and mild tender synovitis at both wrist, 2nd and 3rd interphalangeal joints at both hands. There is small effusion in left knee.
140. which of the following is the most likely diagnosis ?
Ans.
D. SLE

190.A.Prevent rather than reversing histamin action on target tissue

193.E.Agglutinating and immobilizing the spermatozoa

196.B.Competitive inhibitor of histamine, by reversible binding of H1 receptor.

197.D.Topical Antihistamin

198.B.NSAID

199.C.IgA

200.D.Polyclonal antibody generate by injection of human thymocyte in animal

Pembahasan bisa dilihat di MDE 2007-1

MDE HIS 2007-1

1. Male, 14 y.o : joint bleeding. Ada history bleeding. Hemarthrosis. Hb 14gr/dL. WBC 8000. PLT 225.000. How can you explain this problem?
A. quantitative PLT disorder
B. qualitative PLT disorder
C. coagulation disorder
D. thrombotic disorder
E. vascular disorder
Jawaban : C
Alasan : karakteristik coagulation disorder : hemarthrosis dan hematoma. A, B, E  primary hemostasis disorder  PLT ↓qualitative & ↑quantitative, vasculat defect. (Harmening hlm 471-472)

2. Lab test apa untuk konfirmasi diagnosis?

3. Diagnosis?
A. ITP
B. henoch S purpura
C. von Willebrand disease
D. DIC
E. Acute leukemia
Jawaban : C
Alasan : kelainan koagulasi dengan SS di atas paling mungkin vWF disease

4. Character of cell in IDA?
Jawaban : hypochromic, microcytic RBC

5. Abnormalities PLT di atas disebabkan oleh?
Jawaban : ITP

6. Most appropriate statement of the case?
A. mostly will have spontaneous remission
B. mostly will need splenectomy
C. mostly will need IV Ig
D. about half respond to corticosteroid
E. about half will change to leukemia
Jawaban : D
Alasan : Patients with ITP are initially treated with corticosteroid to rapidly increase PLT and improve hemostasis (Harmening hlm 475)

7. Cells that will increase in bone marrw smear as a compensation in this case?
A. thrombocyte
B. reticulocyte
C. magakaryocyte
D. myeloblast
E. normoblast
Jawaban : C
Alasan : jumlah PLT ↓  dikompensasi dengan bentuk dan ukuran yang besar dikarenakan pembentukan yang belum sempurna

8. In primary hemostasis, what mediates the PLT adhesion to expose collagen within the endothelium of the vessel wall?
A. GpIb
B. fibrinogen
C. plasmin
D. PDGF
E. kinin
Jawaban : A
Alasan : Harmening bab introduction to hemostasis

50 y.o. male, bilateral painless mass in the neck, fever, night sweat, weight loss (60-50). PE : bilateral subclavicular and cervical lymphadenopathy diameter 1-3, rubbery, non-tender, hepatosplenomegaly (-)
9. Which is the cause of lymphadenopathy?
A. Inflammation
B. Infection
C. Metastasis malignancy
D. Lymph node
E. Autoimmune
Jawaban : C
Alasan : ada mass, fever, night sweat, weight loss  kemungkinan besar ada keganasan

10. The most appropriate exam :
A. lymph node biopsy
B. Abdomen USG
C. LDH
D. Bone marrow aspiration
E. PBS
Jawaban : A
Alasan : untuk memeriksa jenis jaringan lymph yang terkena diperlukan biopsy

11. Clinical stage :
A. IA
B. IB
C. IIA
D. IIB
E. IIIA
Jawaban : D
Alasan : dengan ciri2 di atas kemungkinan kasus yang terjadi adalah hodgkin lymphoma. Klasifikasi :
• Stage I is involvement of a single lymph node region (I) or single extralymphatic site (Ie);
• Stage II is involvement of two or more lymph node regions on the same side of the diaphragm (II) or of one lymph node region and a contiguous extralymphatic site (IIe);
• Stage III is involvement of lymph node regions on both sides of the diaphragm, which may include the spleen (IIIs) and/or limited contiguous extralymphatic organ or site (IIIe, IIIes);
• Stage IV is disseminated involvement of one or more extralymphatic organs
The absence of systemic symptoms is signified by adding 'A' to the stage; the presence of systemic symptoms is signified by adding 'B' to the stage. For localized extranodal extension from mass of nodes that does not advance the stage, subscript 'E' is added.

12. Which is the most appropriate source of the most cause of lymph adenopathy?
A. Head
B. Oral cavity
C. Thorax
D. Inguinal
E. Inferior extremity
Jawaban : A
Alasan : Cervical adenopathy is a common feature of many viral/bacterial infections

13. What is the positive factor to determine prognosis?
A. Liver enzyme level
B. Creatine level
C. LDH level
D. Uric acid level
E. Hb level
Jawaban :
Alasan : The adverse prognostic factors identified in the international study are:
• Age >= 45 years
• Stage IV disease
• Hemoglobin < 10.5 g/dl
• Lymphocyte count < 600/µl or < 8%
• Male
• Albumin < 4.0 g/dl
• White blood count >= 15,000/µl

Female, 33 y.o. fatigue, shortness of breath with exercise, heavy menstrual bleeding for several years, increase TIBC, decrease ferritin and transferrin
14. Diagnosis?
A. Thalassemia
B. Acquired hemolytic anemia
C. Pernicious anemia
D. Aplastic anemia
E. Iron deficinecy anemia
Jawaban : E
Alasan : karena ada increase TIBC, decrease ferritin and transferrin

15. What cell that will be difficult to found in bone marrow smear?
A. Basophilic normoblast
B. Polychromatophilic normoblast
C. Acidophilic normoblast
D. Reticulocyte
E. Pronormoblast
Jawaban : E?
Alasan : sebenernya jawabannya “lack of stainable iron in reticuloendothelial cells”, tapi ga ada di pilihan.

16. A 18 y.o. female acute onset of bruising & rash for 3 days, had...approx. 2 weeks ago, no fever, no history bleeding, no hepatomegaly. Diffuse petechial rash on trunk & extremities. Lab : Hb 11.5, Hct 36, WBC 6000, PLT 15.000/mm3, PT/PTT normal. Diagnosis?
A. Hemophilia
B. von Willebrand disease
C. ITP
D. Hemorrhagic disease for newborn
E. DIC
Jawaban : C
Alasan : PLT <30.000, ada petechiae (Harmening hlm 474)

17. A 5 y.o. male, RS akibat pneumococcal sepsis selama 3 hari, diffuse petechiae purpura, venipuncture bleeding, hypotension, adn shock. PLT and fibrinogen decrease. Characteristic :
A. ↑ PLT
B. ↑ plasma fibrinogen
C. ↑ factor VIII
D. ↑ tPA
E. ↑ D-dimer
Jawaban : E
Alasan : penurunan fibrinogen  menandakan banyak pemecahan fibrinogen  akan menghasilkan D-dimer (Harmening hlm 463)

18. a previous healthy baby  unconscious for the 3rd day of life. CT scan : intrasranial bleeding. Lab : HB 11, WBC 6000, PLT 117.500, PT dan aPTT ↑, BP normal.
A. ↓ PLT
B. ↓ fibrinogen
C. ↓ AHF
D. ↓ factor II, VII, IX, X
E. ↓ nature inhibitor of coagulation
Jawaban : D
Alasan : peningkatan PT  gangguan extrinsic/common pathway. Peningkatan aPTT  gangguan intrinsic/common pathway. Kemungkinan mengalami gangguan multifactor.

19. Diagnosis :
A. Hemophilia
B. DIC
C. Hemorrhagic disease in newborn
D. congenital hypofibrinogenemia
E. von Willebrand disease
Jawaban : C
Alasan : gangguan koagulasi akibat kurangnya vit K untuk pembentukan faktor koagulasi (Wintrobe ch )60

20. Vitamin yang dibutuhkan?
A. Vit A
B. Vit B
C. Vit K
Jawaban : C
Alasan : vit K merupakan vit yang dibutuhkan untuk pembentukan faktor koagulasi.
21.C. dibuktikan dengan adanya low Hb, HCT, MCV,MCH, dan retikulosit tanpa adanya tanda2 hemolitik anemia (hepatosplenomegaly, jaundice, increasing bilirubin). Pada anak kecil, salah satu penyebab dari Fe deficiency adalah malnutrisi atau infeksi parasit yang dibuktikan dengan adanya underweight..
22. Penampakan yang muncul apabila seseorang terkena IDA yaitu
Peripheral blood smear : microcytic,hypochrome, aniso-poikilocytosis, terdapat pencil shape, juga terdapat target cell
Bone marrow smear : mild-moderate erythrocytosis, decrease-depleted dari sideroblastic cells appearance, bahkan bisa sampai nuclear distortion, nuclear budding, karyohexis, dan nuclear fragmentation of normoblastic cells
23. ans: aplastic: dengan adanya tanda2 pancytopenia di bone marrow dan peripheral : anemia (fatigue, pallor, RBC count rendah), leukocytopenia (rentan terjadi infeksi => fever), thrombocytopenia (petechiae, ecchymoses, gum bleeding).
24. ans: E. hemophilia A karena depleted dari factor VIIc, oleh karena itu, treatment yang tepat ialah cryoprecipitate (mengandung factor VIIIc, VIIIag, fibrinogen, dan XIII) atau purified factor VIII.
25.?? Ga ngerti.. sorii
26. A. pendarahan  hypovolemic condition.. berdasarkan wintrobe pada bab transfusion medicine, keadaan hypovolemic ditangani dengan transfuse whole blood.
27. A. yang menjadi key wordnya adalah deep blue scanty dengan no granule yang merupakan cirri dari normoblastic cell.. jika dilihat dari option yang berwarna biru itu pronormoblast dan normoblast basophilic.. tapi warna dari pronormoblast adalah dark/royal blue, sedangkan warna normoblast basophil adalah basophil, lebih terang dari pronormoblast.
28.?
29. selama acute inflammation : CBC, CRP / ESR.
30.A. gambarannya ialah MCV rendah = microcytic, MCHC rendah = hypochrome.
31.B. gambarannya mengarah Fe deficiency.
-Megalloblastic = MCV biasanya naik
-Hemolytic anemia = MCV,MCH turun, MCHC turun(hereditary spherocytocyte naik) tapi ada peningkatan dari RBC dan reticulocyte count serta ada tanda2 seperti jaundice,splenomegaly
-Aplastic = jumlah WBC dan platelet juga turun
-Pernicious anemia = gambaran megalloblastic.
32. B. liat penjelasan no 22
33. C. adanya peningkatan yang besar dari blast cell golongan myeloid. Jadi jelas merupakan AML.
34. seharusnya sih tipe FAB M3, karena ditandai dengan adanya abundant auer rod di leukemic cells (faggot cells) dan adanya tanda hemorrhagic manifestation dari DIC.
35.A. adanya tanda2 anemia : pale dan hb turun, increasing destruction dari RBC berupa splenomegaly, dan adanya kompensasi anemia, yaitu peningkatan retikulosit  kecurigaan hemolytic anemia (kalo deficient B12, tanda2nya bisa kaya di atas tapi retikulositnya turun). Lalu gambaran anisopoikylocytosis, polychromasia, large target cell merupakan gambaran yang bisa terjadi pada sickle cell anemia dan thlasemia (sickle cell trait punya gambaran yang normal di apus darah tepi). Lalu pasien kita ini sudah berumur 5 tahun, padahal thalasemia itu termanifest pada 1st year of life. Jadi jawaban adalah A.
36. soalnya seperti tadi. ANS: A. untuk mendiagnosis dari sickle cell, lab exam selanjutnya ialah electrophoresis. Hasil yang diharapkan adalah adanya peningkatan dari HbS sehingga hasil electrophoresisnya terhadap HbS men jadi lebih nyata.
37. A. jelas ya..
38.A. pilihan treatment untuk sickle cell anemia ialah chronic transfusion, hydroxyurea, dan bone marrow transplantation. Yang ditransfusi untuk kasus sickle cell anemia adalah normal red cell. Jadi pilihan ke arah packed red cell (PRC)
39.C.
40. ??
41. Jawaban : D. decrease serum ferritin
Pembahasan :
Merupakan ciri-ciri Iron Deficiency Anemia (IDA).
Hasil lab : decrease serum ferritin level, derease serum iron level, increase TIBC (Harmening, 104)

42. Jawaban : C. vitamin C
Pembahasan :
Menurut internet, vitamin C memang membantu absorbsi non-heme iron.

43. Jawaban : A. vitamin B12
Pembahasan :
Clinical manifestation of vit.B deficiency:
-peripheral nerve : paresthesia, areflexia, symmetric tingling.
-posterior spinal columns : clumsiness, incoordinate gait.
-lateral spinal columns : weakness & stiffness of limbs, memory impairment, depression.
(Harmening, 119)

44. Jawaban : (?) akademik 2006 jawab D. gum hypertrophy
Pembahasan :
“Classic symptoms of vit B12 deficiency include weakness, glossitis, paresthesia.” (Harmening, 118)

45. Jawaban : B hemolytic
Pembahasan :
Subiteric sclera -> banyak bilirubin di darah -> banyak pemecahan RBC (hemolytic) -> splenomegaly (kerja berat, tempat pemecahan RBC)

46. Jawaban : E. glossitis
Pembahasan :
Merupakan penyakit anemia megaloblastik, karena ada ciri-ciri weakness, numbness, hypersegmented neutrophil (Harmening115,119). Maka PE-nya kemungkinan terdapat glossitis (Harmening, 118)

47. Jawaban : E. hyperativity of macrophage cell
Pembahasan :
Penyakitnya anemia hemolitik, karena yellow skin.
“Each day 1% of old RBC in circulation are taken out by a system of fixed macrophages in the body known as the reticuloendothelial system (RES). Although RES cells are located in various organs and throughout te body, those of spleen, called littoral cells, are the most sensitive detectors of RBC abnormalities.” (Harmening, 70)

48. Jawaban : C. gaster
Pembahasan :
Penyakitnya anemia megaloblastik, karena ada giant stab/band cell (Harmening, tabel 7-1,115).
Kemungkinan penyebabnya berasal dari gaster. “Pernicious anemia = vit B12 deficiency anemia. Caused by deficiency of IF. IF is secreted by gastic parietal cell, and in this case there is parietal cell atrophy.” (Harmening, 117)

49. Jawaban : (?) akademik 2006 jawab A. Hodgkin lymphoma
Pembahasan :
Penyakit yang histopatologinya ada “rossete-like formation” = ?

50. Jawaban : B. chronic lymphocytic leukemia
Pembahasan :
WBC sangat meningkat -> keganasan.
Periphreal blood, mature lymphocyte meningkat -> chronic lymphocytic leukemia /CLL (Harmening, tabel 16-2, 275)

51. Jawaban : C. observe
Pembahasan :
Klasifikasi Rai-Binet untuk CLL (Harmening, tabel17-5, 310).
Pada kasus ada splenomegali, jadi masuk stage II. Treatmentnya observation, karena pada kasus ini asymptomatic (Harmening, tabel17-6, 311)

52. Jawaban : (?) akademik 2006 jawab A. B-prolymphoid transf well diff.
Pembahasan :
“CLL is most frequent neoplasm of B lymphocyte.” (Harmening, 302)
“Photomicrogaph of bone marrow aspirate smear from CLL patient. Note monotonous appearance of mature-appearing lymphocytes with condensed nuclear chromatin.” (Harmening, fig 17-2, 303)
A. pro- vs mature = ?

53-60. ga ada soalnya...


83.
84.
85. B. G6PD
Sulfamethoxazole has side effect that cause deficiency of glucose 6 phosphate. Deficiency of this enzyme can cause breakdown of RBC (hemolisys)
86. C. Normochromic normocytic
Hemolityc blood smear
87.
88. B. Type B child
89. D. Father Rr
90. C. Palatine tonsil
The lymphoid tissue in palatine tonsils forms a band that contains free lymphocytes and lymphoid nodules, generally with germinal centers . Deeply invaginated mucosal surface is the characteristic of these tonsil. Each tonsil has 10–20 epithelial invaginations that penetrate the tonsil deeply, forming crypts, whose lumens contain desquamated epithelial cells, live and dead lymphocytes, and bacteria. (jonquera,bab palatine tonsil)
95. E. 0,3 in 1:1000
Ephinephrine is injected intramuscularly or subcutaneously in dose 0,2-0,5 ml/kg BW for adults and 0,1 ml/kg BW for children to treatment treat anaphylaxis reaction.It is in aqueous 1:1000 solution.
96. B. irreversible shock
The most frequent cause of death in the case of anaphylaxis
97. D. IgG
IgG is the autoantibody of SLE so it can cross placenta
98. D. between 12-16 week of gestation
99. A. congenital heart block
100. A. infection
One of effext of steroid administration is immunosuppressant. It is increase the r isk of infection.

100) D
103) A
104) B
105) A
106)
107) A
108) hypersensitivity type 1
109) A
110) B
111)
112)
113)Ig E (+) = atopy
114) B
115) A
116)
117)
118) D (I think)
119) C
120) A
126. a girl 6 year old wheal with certain blanching after eating shrimp. Have allergy cold, no food allergy before. What skin layer appears abnormal ?
Ans.
D. Pars papillaris
127. a 25 years old man came to hospital with a sign of inflammation in his left leg. Which of the following vessels is most likely abnormal ?
Ans.
C. Capillary
128. a 20 years old IV drugs user came into the internal medicine department for general check up. Lab finding shows that he has HIV. Which is most likely cell killed by above virus ?
Ans.
C. CD4+ T lymphocyte
129. most likely characteristic above virus ?
Ans.
C. Have single stranded RNA
130. what gene is likely needed for replication for above virus ?
Ans.
B. Tat
133. following target cell will be killed by cytotoxic T cell induced by viral infection ?
Ans.
B. Infected by virus and identical at class I MHC loci of the cytotoxic T cell
134. after binding to its specific antigen, B lymphocytes may switch t which of the following component ?
Ans.
C. Variable region of the Ig heavy chain
135. which one of the following must be expressed on the surface of APC that activate T helper cells ?
Ans.
D. Class II MHC antigen
136. which of the following class of immunoglobulin is present in highest concentration in the blood of a newborn ?
Ans.
A. IgG
137. which of the following statement is the response of macrophage for antibody reaction ?
Ans.
A. Lysing virus infected cell
138. male 47 years old, chief complaint right toe swelling. In middle night : pricking, stiffness on his right toe. One hour later more painful. Few hours later swelling red and painful. He has tight hypertension, easy socializing with his friends. He is also overweight. Diagnosis ?
Ans.
A. Gouty arthritis
141. which of the following criteria include the ACR diagnostic criteria for her disease ?
Ans.
B. Increase ANA titer and positive anti dsDNA

For questions number 161 – 163, see the case below :
25-year-old woman, red, itchy, circumscribed patches with central blanching on her body, swollen lips, and itchy tongue after consumption of methampirone. BP 80/60. RR 24/min. Temperature 37.5°C. PR 130/min

161. Which of the following mediator most likely inhibiting the process causing the above condition ?
A. PGI2
B. PGE2
C. PGD2
D. PGF2
E. TXA2
Jawab : E
Hipersensitivitas tipe I. Gejala-gejalanya disebabkan oleh mediator-mediator yang menyebabkan vasodilatasi dan peningkatan permeabilitas vascular. Thromboxane (vasokonstriktor) dapat menyebabkan penghambatan.

162. What is the enzyme responsible ?
A. Adenylate cyclase
B. Guanylate cyclase
C. Thymidine cyclase
D. Uridine cyclase
E. Cystosine cyclase
?

163. Which mediator is inhibited on this phase ?
A. Histamine
B. Leukotriene
C. Prostaglandin
D. Prostacyclin
E. Thromboxane
Jawab : E

164. Chief complain : runny nose. He started sneezing after he cleaned books. Family history : sibling has urticaria. Father has rhinitis. What is the antibody responsible ?
A. IgG
B. IgA
C. IgE
D. IgM
E. IgD
Jawab : C
Allergic rhinitis  IgE-mediated 

165. Malar rash especially on photosensitivity area, caused by immune complex. What type of hypersensitivity responsible ?
A. I
B. II
C. III
D. IV
E. All above
Jawab : C
Kata kuncinya adalah “immune complex”, apalagi sign and symptom merujuk ke lupus. Jadi, hypersensitivity type III.

166. A 7-year-old girl suffered from multiple rashes on her face and symmetrical macule rashes on her feet and trunk. She also complained itchy redness and patches on her elbow and knee fold. Both parents have intermittent asthma, and her sister has unexplained urticaria. Which immunology abnormality that most commonly occurs ?
A. Decrease IgE
B. Decrease basophilic histamine release
C. Decrease IL-13 by TH1
D. Increase IFN gamma by TH-2
E. Increase soluble IL-2 receptor
Jawab : C
Diagnosisnya adalah psoriasis. Psoriasis adalah penyakit autoimmune yang dimediasi oleh T-cell. Di Robbins (hal. 1257) disebutkan, pada psoriasis, terdapat cytokine “soup” yang didominasi oleh TH1 cytokines seperti IL-12, IFN-γ, dan TNF-α. (catatan : TH2 cytokine : IL-4 dan IL-13). Seperti kita tahu, TH1 dan TH2 cytokine (maupun selnya) cenderung timpang dalam keadaan tertentu, misalnya jika keadaan hypersensitivity type I (e.g. allergic rhinitis), maka yg dominan adalah TH2 dengan konsekuensi supresi oleh TH1.
Maka karena pada psoriasis yang dominan adalah TH1, terjadi supresi TH2 cytokine (yakni IL-13).

See the case below :
9-year-old boy came to ophthalmology department whith a chief complain of itching, blepharospasm, photophobia, and copious mucoid discharge. Visual acuity is within normal limit. The slit examination revealed cobblestone in superior tarsal conjunctivae.

167. The most likely diagnosis is :
A. Vernal conjunctivitis
B. Atopic conjunctivitis
C. Acute conjunctivitis
D. Flictenuralis conjunctivitis
E. Follicle conjunctivitis
Jawab : A
Kata “cobblestone in superior tarsal conjunctivae” menunjukkan vernal conjunctivitis (Lange Immunology hal. 527).

168. Which type of hypersensitivity can cause this reaction :
A. Type I and II
B. Type I and III
C. Type I and IV
D. Type II and III
E. Type II and IV
Jawab : A
Di Lange (hal. 527) disebutkan vernal conjunctivitis adalah atopic disease, jadi termasuk tipe I. Selain itu, dia dikategorikan juga di bawah “antibody-mediated disease”, jadi masuk tipe II juga. Memang immunologic pathogenesisnya belum terlalu jelas.

169. A 40-year-old lady complained decrease of her vision since 3 days ago. She was also diagnosed as TB patient. On clinical exam, there is ciliary injection, anterior chamber …, keratic precipitate. What is the most likely diagnosis ?
A. Acute uveitis
B. Vitritis
C. Choroiditis
D. Endophthalmitis
E. Pars planitis
Jawab : A
Uveitis dikarakteristikkan dengan adanya keratotic precipitate (berupa WBC) pada endothelium. Selain itu, ada ciliary injection (tapi tidak spesifik untuk uveitis).

170. The drug for acute uveitis ?
Cycloplegics (block nerve impulse to ciliary muscles, therefore easing pain) dan topical steroid.

171. 50-year-old man, red, and painful eyes with excessive tears. Examination results : peripheral corneal ulcer, negative fluorescence. What is the most likely diagnosis ?
A. Bacterial ulcer
B. Herpetic ulcer
C. Geographian ulcer
D. Fungal ulcer
E. Maroon ulcer
?

See the case below :
A 20-year-old man. Weakness  worst and numbness. 10 days ago, he had fever, diarrhea, and was healed by treatment. PE : dyspnea. Neurologic exam : tetraparesis, glove-stocking hypesthesia and decreased physiological reflex.

172. What is the finding in blood ?
A. Increase glucose with normal protein
B. Increase glucose with normal cell
C. Increase glucose with normal glucose
?

173. What microbe can cause this case ?
A. H. influenza
B. Campylobacter jejuni
C. Cytomegalovirus
D. S. typhii
E. Herpes zoster
Jawab : B
Guillain-Barre Syndrome bisa disebabkan Campylobacter jejuni, HIV, EBV, cytomegalovirus. Tapi karena didahului gastrointestinal infection (diare yang disembuhkan dengan treatment), maka B lebih tepat.

174. What is the possible cause of dyspnea ?
A. Ascending paralysis
B. Metabolic acidosis
C. Pulmonary distress
D. Laryngeal spasm
E. Metabolic alkalosis
Jawab : A
Guillain-Barre Syndrome dikarakteristikkan dengan adanya ascending paralysis dari ekstremitas bagian distal. Salah satu komplikasinya adalah respiratory failure.

175. Neurophysiological examination as an additional for this case :
A. EEG
B. EMG
C. NCS
D. Evoked potential
E. TCD
Jawab : NCS atau EMG
Di fase awal, NCS (nerve conduction studies) akan menunjukkan adanya prolonged distal motor latencies dan prolonged/absent F waves. Setelah 4-6 minggu, EMG menunjukkan adanya denervasi otot.

176. Drugs of choice for this case :
A. Corticosteroid
B. Immunoglobulin
C. Plasmapharesis
D. Neurotrophic
E. Neuroprotected
Jawab : B
Treatmentnya berupa plasmapharesis dan immunoglobulin IV. Karena pertanyaannya “drugs” of choice, jadi jawabnya B.

177. –
178. –
179. –
180. –

182.D.Intraepidermal blister with acantholitic cell

Alasan: Microscopic pada pemphigus vulgaris ialah: an intraepidermal blister is present containing acantholytic cells.There is marked intracellular edema and eosinophilic spongiosis.

189.C.Decrease cAMP dependent protein kinase

Alasan: dengan penurunan cAMP dependent protein kinase akan mengakibatkan peningkatan cAMP yang akan menghambat degranulasi.

190.A.preventing rather than reversing histamin’s action on target tissue

Alasan: MOA of anti-histamin in prevent effect H1 receptor activation through reversible, competitive inhibition of histamine by binding to H1-receptor.As a result,antihistamin work best in preventing rather than reversing the action of histamine.

192.C.Scofferin

193.E.Agglutination and immobilizing spermatozoa

Alasan: ASA (Anti Spermatozoa Antibody) akan attract to sperm yang mengkibatkan reducing mortality dan make clump together so difficult form sperm to fertilize an egg.

194.A.Object of transplatation

Alasan: The succes of an organ or tissue transplant depends on histocompability-that is, the tissue compability between the donor and the recipient.

195.E.Loratadine

Alasan: dari keseluruh obsi hanya loratadine yang termasuk second generation (yang lain termasuk first generation) dimana second genertaion lebih baik daripada first generation karena tidak mengakibatkan CNS side effect.

197.B.NSAID

Alasan: pada treatment RA, NSAID merupakan first line treatment sedangkan cytotoxic agent seperti MTX dan cyclophosphamide dan corticosteroid merupakan second line.

198.C.Topical Antihistamin

Alasan: Pada pasein ini mengalami hypersensitivity type I sehingga treatment paling cocok ialah permberian anti-histamin

199.B.IgA

Alasan: IgA merupakan antibody yang banyak dijumpai di cairan tubuh (secret) seperti air liur, keringat, air mata, vaginal secret dsb

200.D.Polyclonal antibody generated by repeated rejection of human tymocyte into animals

MDE HIS 2006

1. Jawaban : C

Alasan : Hb, Hct ↓ à anemia, MCV ↓ à microcytic, MCHC ↓ à hypochromic

2. Jawaban : B

Alasan : diagnosis à IDA (harmening hlm 104)

3. Jawaban : A

Alasan : promyelocyte&myelocyte à myeloblastic, immature cells à acute leukimia (AML)

4. Jawaban : D

Alasan : blast ↑, PMN ↓, lymphocyte N. ALL lebih sering pada anak-anak.

5. Jawaban : E

Alasan : hasil lab merujuk pada CML

6. Jawaban : C

Alasan : kemungkinan yang btrjadi adalah contact dermatitis (hypersensistivity tipe 4)

7. Jawaban : B

Alasan : ELISA menggunakan enzim dan substrat dari enxim tsb yang akan memberi warna pada antigen

8. Jawaban : D

Alasan : salah satu tes untuk SLE adalah tes anti dsDNA

9. Jawaban : A

Alasan : poison ivy à contact dermatitis à hypersensitivity tipe 4 àT cell berperan

10. Jawaban : E

Alasan : 15 minutes à acute phase reaction à A, B, C, D benar. E à late phase reaction

11. Jawaban : C

Alasan : kemungkinan diagnosis adalah Hodgkin’s lymphoma

12. Jawaban : A

Alasan : diagnosis untuk keganasan pada lymph (node) dilakukan melalui biopsy

13. Jawaban : C

Alasan : Robbins hlm 688

14. Jawaban : B

Alasan : kebanyakan pasien ditreatment dengan chemotherapy (cytostatic)

15. Jawaban : E

Alasan : adverse prognostic factors identified in the international study are: Age >= 45 years, Stage IV disease, Hemoglobin <>, Lymphocyte count <>, Male, Albumin <>, White blood count >= 15,000/µl

16. Jawaban : A

Alasan : petechiae, ecchymosis, PLT ↓ (Harmening hlm 474)

17. Jawaban : B

Alasan : Harmening hlm 475

18. Jawaban : B

Alasan : Harmening hlm 475

19. Jawaban : B

Alasan : Harmening hlm 475

20. Jawaban : D

Alasan : Harmening hlm 475

21.C. jelas ya, setelah kita tahu kadar Hb, kita tahu keadaan RBCnya secara blood chemistry dan komponen2 yang terlibat yang diindikasikan (serum iron, TIBC, dll), lalu kita liat morfologinya RBC dengan smear

22. B. IDA juga bisa bermanifest ke lapisan kulit (spoon nail, atrophy tongue, brittle hair)

23. C. Wintrobe bilangnya 3-6 months, tapi Harisson bilangnya 6-12 bulan karena di harisson itu prinsip treatment adalah hilangkan anemia dan increase and relieve iron storage 0,5-1 mg.

24.D. kalo liat dari wintrobe dan harisson, respon therapy itu diliat dari

- symptom yang relieve

- increase back of reticulocyte ke jumlah normal

- Hb naik ke arah normal

- kadar EPO yang turun

- Fe absorption turun

Tapi kalo diliat dari prinsip treatmentnya harisson yang melihat sampai adanya iron storage, maka melihat keberhasilannya ya kita lihat storagenya berupa feritin.

25. A. EPO masih punya efek untuk “menghiperplasiakan” sel erythroid precussor pronormoblast yang CFU-E, yang masih sensitive terhadap EPO.(compare: Sedangkan yang BFU-E itu sensitive terhadap Interleukin)

26. B.

27. D. jelas ya, AML-M3 itu dicirikan dengan promyelocyte dominant, adanya faggot cell dengan adanya manifestasi DIC , bisa berupa thrombosisnya atau hemorhagicnya. Di sini kebetulan manifestasinya berupa hemorrhagic.

28. D. di sini kecurigaan kea rah deficiency dari vit b12. Etionya berupa:

- dietary : kurang banyak vit b12-nya

- needednya meningkat è pada wanita hamil

- absorption : infeksi, kelainan congenital pada GI tract, adanya autoimun (cthnya yang ganggu parietal cell bwt release IF), hereditary deficiency release dari IF,neoplasia, gangguan release IF gasterektomy, dll. Ngeliat dari kasus, achlohydria ini merupakan salah satu etiologi dari absentnya release substance dari sel2 parietal yang juga release IF.

29.D. anemia apalstik treatmentnya berupa supportive dan transplantion of bone marrow.

30.C. pada spherocyte, ditandai dengan adanya kenaikan MCHC dan osmotic fragility test yang meningkat karena ketidakmampuan cytoskeleton RBC untuk mempertahankan bentuk dan resistensi tekanan osmosis

31. A. karena makin banyak tersintesisnya Hb, warna cytoplasmanya jadi makin jadi merah.

32. normal maturasi RBC:

- perubahan warna kea rah acidophil karena increasing dari kadar Hb

- chromatin condensed, loss nucleoili, loss nucleus

- decrease of mitochondria

33. B. azurophillic granule itu ada di tahap progranulocyte, kalo uda mature, granulocyte itu akan mengandung specific granule. Di lecture note, maturasi abnormal pada WBC bisahypersegmen nuclei dan persisten azurophillic granule di cytoplasm.

34. D.

35. C. ngeliat optionnya, ini mengarah ke WBC maturation. Jadi yang jelas adalah C.

36. E. karena adanya defect di rantai beta, maka akan adanya mekanisme kompensasi berupa switching rantai beta ke rantai gamma dan delta, sehingga membentuk rantai Hb 2 alfa + 2 gamma atau 2 delta. Sehingga yang meningkat masing2 adalah HbF (dengan gamma) dan HbA₂ (dengan delta)

37. B. jelas ya..

38. C. karena adanya penurunan jumlah RBC maka mekanisme yang terjadi adalah reaksi kompensasi berupa peningkatan retikulosit.

39. A. aplastic anemia berupa pancytopenia (penurunan sel2 hematopoietic) di perifer dan hypoccellular pada bone marrow.

40. D. ada di harmening

41. Jawaban : B. eosinophils

Pembahasan :

Jelas ya... eosinophil naik saat keadaan alergi & infeksi parasit.

42. Jawaban : D. basophils

Pembahasan :

“Mast cell granules, in addition to all other substances that are present in the granules of basophils, contain serotonin & proteolytic enzymes.” (Harmening, 42)

43. Jawaban : A. sternum

Pembahasan :

“The sites for bone marrow studies in adults are most commonly the posterior superior iliac crest, occasionally the sternum, and very rarely anterior superior iliac crest & spinal process of vertebral bodies.” (Harmening, 43)

44. Jawaban : A. T-lymphocyte

Pembahasan :

“The incidence of acute GVHD (graft-versus-host disease) can be reduced by depleting the donor marrow of the cell responsible for the GVHD reaction, namely T-lymphocyte.” (Harmening, 324)

45. Jawaban : B. mast cell

Pembahasan :

Anaphylactic shock terjadi karena pelepasan histamin secara masif & sistemik dari mast cell yang mengalami degranulasi akibat menempelnya antigen spesifik dengan antibodi yang menempel pada permukaan mast cell.

46. Jawaban : C. causing the histamine ...

Pembahasan :

Penjelasan sama dengan nomor 45...

47. Jawaban : D. hemophilia

Pembahasan :

Terdapat hematoma. Hasil lab, BT normal, PT normal, APTT prolong.

Penyakitnya hemophilia A. (Harmening, tabel 25-1, 496)

48. Jawaban : D. deficiency of factor VIII

Pembahasan :

Hemophilia A terjadi akibat defisiensi faktor VIII. (Harmening, tabel 25-1, 496)

49. Jawaban : D. defect of secondary hemostasis

Pembahasan :

“Secondary hemostasis involves the enzymatic activation of coagulation proteins to produce fibrin from fibrinogen, thereby stabilizing the fragile clot.” (Harmening, 442).

Hemophilia A terjadi akibat defisiensi faktor koagulasi VIII -> defek pada secondary hemostasis.

50. Jawaban : D. deficiency of factor VIII

Pembahasan :

Penjelasan sama dengan nomor 48,

51. Jawaban : D. defect of secondary hemostasis

Pembahasan :

Penjelasan sama dengan nomor 49,

52. Jawaban : A. cryoprecipitate

Pembahasan :

Penyakitnya adalah hemophilia.

“Cryoprecipitate = a concentrated source of coagulation fator VIII.” (Harmening, glossary 699)

“Although cryoprecipitate is a rich source of FVIII, it is not the product of choice beause of the high incidence of parenteral transmitted HIV.” (Harmening, 502)

“Fresh Frozen Plasma = a frozen plasma product contains all clotting factors. It is useful for clotting factors deficiency other than hemophilia A, vWB disease, hypofibrinogenemia.” (Harmening, glossary 701)

Yawda kasih cryoprecipitate aja, daripada yang laen lebih ga nyambung, ya ngga??

53. Jawaban : E. hemarthroses

Pembahasan :

“Hemarthrosis is a primary symptom of hemophilia involving knees, elbows, ankles, shoulders, hips, wrists.” (Harmening, 501)

54. Jawaban : B. defect of platelet production

Pembahasan :

D & E salah karena PT & APTT normal,berarti tidak ada kelainan pada fungsi faktor koagulasi (intrinsik & ekstrinsik). Petechiae adalah karakteristik abnormality of vessel or the platelets, and are exceedingly rare in coagulation disorders. Dan dari kasus, jelas jumlah plateletnya sangat turun. Maka defek produksi platelet yang mungkin.

55. Jawaban : B. immune thrombocytic purpura

Pembahasan :

“Platelets undergo premature destruction as a result of autoantibody. Antiplatelet antibody can also bind to precursor bone marrow megakaryocyte. Tha bone marrow is characterized by increased or normal number of megakaryocyte.” (Harmening, 474)

56. Jawaban : D. defect in factor coagulation

Pembahasan :

Prolong PT -> defect in factor coagulation (common pathway & extrinsic)

Prolong APTT -> defect in factor coagulation (common pathway & intrinsic)

57. Jawaban : C. vitamin K deficiency

Pembahasan :

“Acquired deficiencies of the vitamin K-dependent coagulation factors are relatively common because the body does not contain appreciable stores of vitamin K.” (Harmening, 655)

58. Jawaban : C. fresh frozen plasma

Pembahasan :

“Fresh Frozen Plasma = a frozen plasma product contains all clotting factors. It is useful for clotting factors deficiency other than hemophilia A, vWB disease, hypofibrinogenemia.” (Harmening, glossary 701)

59. Jawaban : B. polycythemia vera rubra

Pembahasan :

Coffee ground vomit = muntahan yang mengandung darah yang berubah gelap bercampur dengan isi lambung akibat pengumpulan darah dalam lambung. (Dorland)

“Elevation of the RBC count, Hb, and Ht are the most important findings in PV.” (Harmening, 343)

“GI disorders associated with PV include peptic ulcer, and possibly, massive hemorrhages from varices in the esophagus, stomach, or bowel.” (Harmening, 342)

60. Jawaban : C.normal O2 saturation, erythrocyte mass over 36 ml/kg, high serum vit.B12

Pembahasan :

“The arterial O2 saturation is normal in most patients with PV.” (Harmening, 344)

“Absolute erythocytosis is present in men with values at least 36 mL/kg, and in women with at least 32 mL/kg.” (Harmening, 343)

“Increased serum vitamin B12 or vitamin B12-binding proteins.” (Harmening, tabel 18-8, 345)

A. salah low B12 / B. salah low O2 / D. salah pada kasus male / E. salah high O2.

61. sori gtw

62. A

63. D

64. D

65. A (mungkin yg dimaksud diagnosis of CML depends on…)

66. sorii gtw

67. sori gtw

68. E

69. B

70. C

71. E

72. B

73. C

74. A

75. B

76. C

77. B

78. D

79. B

80. C

100) B

101) A

102) A

103) C

104)

105) D

106) C

107) C

108) A

111) A

112) E

113) C

114) E

115) C

116) A

117) E

118) A

119) D

120) D

121. how is the mechanism of action of antihistamine ?

Ans.

-

122. which of the following is the characteristic for the first generation of antihistamine ?

Ans.

B. Cross blood brain barrier

123. how does the antihistamine works best in allergic disease ?

Ans.

B. Reversing rather than preventing histamine’s actions on target tissue

124. which of the following can be given simulaneously with antihistamine, metabolized through hepatic cytochrome P450 pathway ?

Ans.

?

125. when might corticosteroids be NOT beneficial at all in the management of anaphylaxis ?

Ans.

?

126. where exactly is the site of action of glucocorticoids in allergic inflammation ?

Ans.

?

127. cytokines that release by macrophage and have role in maturation of T helper cell is ?

Ans.

B. IL-12

128. the highest concentration of immunoglobulin that can be found in gut secretion is ?

Ans.

B. igA

129. antigen that come from human body substance and has ability to induce immune response to human body self is called ?

Ans.

C. Autologous antigen

130. the role of class I MHC in immune response is presenting antigen from ?

Ans.

A. Infected cell to Tc cell

131. viral receptor of HIV on human cell is ?

Ans.

D. CD4

132. the most important defense body mechanism in infection of HIV is ?

Ans.

D. Cell mediated immunity

133. one of the following statement of HIV characteristics is not true ?

Ans.

E. Grouped in unenveloped virus

134. antigen binding site of immunoglobulin are build by ?

Ans.

E. N-terminal of H&L chains

135. if the amount of IgM can be detected from sera of neonatus, it indicates ?

Ans.

C. Intrauterine infectious disease

136. which of the following human body cells does NOT have class I MHC on its surface ?

Ans.

?

137. one of the following is TRUE regarding Discoid Lupus Erythematous (DLE) ?

Ans.

A. Patient’s with systemic lupus erythematous (SLE) can develop DLE-like skin patches

138. the lupus band test has correlation with ?

Ans.

B. Discoid Lupus Erythematous

139. microscopic studies on biopsy of DLE show ?

Ans.

C. Epidermal atrophy

140. one of the following pathologic finding is most likely associated with systemic lupus erythematous (SLE) ?

Ans.

A. Glomerular deposition of immune complex

181.The presence of iron deficiency anemia to iron therapy is influenced by?

A.The type of iron compound

B.Sex

C.Dose interval

D.Ability of patient to absorb medicinal iron

E.Age

Alasan:

Failure of iron therapy dapat diakibatkan oleh: incorrect diagnosis, complicating illness, failure of patient to take prescribed medication, inadequate prescription (dose form), and malabsorbtion of iron.

182.The drug that has effect of myelinization process in peripheral nerve

A.Iron

B.Cobalt

C.Folic Acid

D.Cyanocobalamin

E.Riboflavin

Alasan: Pada keadaan Megaloblastic anemia (deficiency B12) biasanya disertai gangguan neuropsyciatric dimana B12 berperan dalam mencegah degenerasi peripheral nerve, posterior colum dan lateral colum.

183.The majority of iron in the body is found in

A.Myeloglobin

B.Enzyme

C.Hemoglobin

D.Storage iron

E.Hemosiderine

Alasan: 2/3 iron berupa hemoglobin iron sedangkan 1/3 berupa tissue iron dan proporsi kecil berupa plasma dan transport iron.

184.The most common cause of nutritional anemia in human being is

A.Iron deficiency

B.Riboflavin deficiency

C.Pyridoxine deficiency

D.Vit- B12 deficiency

E.Folic acid deficiency

Alasan: pada wanita sering terjadi IDA khususnya saat menstruasi begitu juga pada pria , kasus IDA juga sering dijumpai.

185.Substance know to facilitate absorption of non-heme iron

A.Vit A

B.Vit E

C.Vit C

D.Vit D

E.Vit K

Alasan: Absorbis acid (Vit C) dan succinate acid increase absorbtion of ferrous iron.

186.The drug which has effect such as paresthesia of hand and feet, dimunation of vibration, and resultant unsteadiness.

A.Vit B12

B.Iron

C.Cupprum

D.Pyridoxin

E.Cobalt

Alasan: lihat pembahasan no 183.

187.Soalny lihat di buku soal ya (panjang banget)

What is the most likely diagnosis:

1. Secondary trombocytopenia
2. Thrombotic trombocytopenia purpura
3. Dengue hemorhagic fever
4. Immune trombocytopenic purpura
5. Drug induced trombocytopenia.

188.Which pysical examination result can cause a blood donor rejected

A.Weight 55 kg

B.Pulse 75 bpm

C.Temperature 36.5 c

D.Diastolic 110 mg

E.Hb 13.5 g/dl

189.what transmitted disease test shold be performed on blood that will transfused to donor.

A.Malaria,HBSag, VDRL, and ebstein barr virus

B.Ebstein barr virus, VDRL,HBSag, and cytomegalovirus

C.HIV, HBSag, HCV, and malaria

D.HLV,HCV,HBSag and VDRL

Alasan: seluruh type penyakit tersebut sering diperiksa saat akan transfusi darah sedangkan VDRL tidak dilakukan karena VDRL tidak ditransmisi melalui darah melainkan STI

190.What blood type is possible for an offspring of AO dan BO person

a.AB,A or B

b.A or B

c.AB,A.B or O

d.AB or o

e.O

Alasan: I^AI^O + I^BI^O > I^AI^B (AB), I^AI^O (A), I^OI^B (B), I^OI^O (O)

191.What would be the result of group A blood given to group O pasien

A.non immune transfusion reaction

b.immediate hemolytic transfusion reaction

c.delayed hemolytic transfusion reaction

d.immediate non immune transfusio reaction

e.delayed non immune trasfusion reaction

Alasan: apabila darah A diberi ke darah O akan terjadi agglutinasi dimana proses ini melibatkan proses immune cytotoxic (hemolytic) transfusion reaction. Kejadian ini termasuk type hypersensitivity type 2

192.A patien with hypofibrinogenemia.What component is the best choice for transfusion

a.granulocyte

b.cryoprecipitate

c.FFP

d.platelet concentrate

e.PRC (Packed Red Cell)

Alasan: Cryoprecipitate kaya akan FC VIII dan fibrinogen

193.a male cancer patient with hemoglobin of 6 g/dl was admitted to the hospital with acute abdominal pain.Small bowel resection was indicated,the attending physician wanted to raise the patien’s Hb to 12 g/dl before surgery.How many units of RBCs would most likely to be required to accomplish this?

a.eight

b.seven

c.six

d.five

e.four

Alasan: 1 PRC dapat meningkatkan 1 g/dl Hb dan 3-4 Ht

194.What is characteristic finding seen in the peripheral smear patien with multiple myeloma

a.microcytic hypocromic cells

b.intracellular inclusion bodies

c.rouleux

d.hypersegmented neutropil

e.teardrop cell

Alasan: Pada multiple myeloma terdapat high level serum M protein yang mengakibatkan red cell in smear of peripheral blood to stick to one another in linear array yang disebut roulex formation

195.What are the lab finding in polycytemic vera

b. peningkatan Ht,RBC, granulocyte and platelet

Alasan: polycytemic vera ialah hematopoietic stem cell disorder characterized by accelerated erytropoiesis ,proliferasi myeloid dan megakaryocytic element of bone marrow.

196.a patient present with platelet count of 1500/L and bleeding time of 12 minutes.these result probably suggest

a.penurunan platelet production

b.penurunan platelet function

c.peningkatan platelet production

d.peningkatan platelet destruction

e.penurunan platelet destruction

Alasan: pada kasus tersebut pasien mengalami prolonge bleeding time (N=30 Second- 2 minute) dimana akibat produksi platelet yang rendah (N=150.000-450.000)

197.Which coagulation disorder decreased activity of factor VIIIC,vf:Ag,VWF and cause prolong bleeding time test?

a.hypoprothrombinemia

b.von willebrand disease

c.hemophilia A

d.hemophilia B

e.parahemophila

198.The factor that efect that has normal APTT and a prolonged PT is

a.hypoprothrombinemia

b.Von willebrand’s disease

c.hemophilia A

d.hemophilia B

e.decreased platelet destruction

Alasan : b,c,d slah karena yang terjadi adalah normal PT dan prolonged APTT sedangkan e salah karena PT dan APTT nya normal

Karena PT untuk melihat kadar factor I,II,V,VII, dan X sedangkan APTT untuk melihat kadar factor I,II,V,VIII,IX,X,XI,XII

199.whIch of the following process in involved in alternative pathway of the complement

a.induced by binding IgGI and CI

b.induced by antigen-antigen IgG2 complex

c.induced by activation of C4

d.induced by microbial cell suface

e.induced by activation by C2

200.whuch of the following cytokines play important role in synovitis?

a.INF Gamma

b.IL-12

c.TNF-alpha

d.IL-2

E.IL-4

Alasan: pada synovitis melibatkan 3 cytokines major yakni TNF-alpha,IL-12 dan IFN-gamma namun proporsinya TNF-alpha > IL-12 > IFN-gamma