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.