MDE HIS

MDE HIS 2010

1. the special type of lymphatic capillaries in the small intestine are called?a. lactealsb. rugaec. pylorusd. funduse. corpus

2. tempat maturasi T-cell? thymus

4. thymus produces hormones that stimulate lymphocyte maturation.. what is the hormone?a. oxytocineb. thymocyinec. calcitonined. progesteronee. esterogen

5. jalur lymphatic vesselsa. afferent-sinus-efferent

9. Which of the following is the most presence in SLE ?A. hyperreactivity B cellB. hyperreactivity T cellC. hyperreactivity B and T cellD. hyperreactivity stem cellE. hyperreactivity thrombocyte

10. WOTF most likely cause of SLE?a. complement fixation factorb. anti DNA ab factorc. immune complex factord. autoantibody factore. coagulation factor

12.part of immunoglobulin molecule that bind to its antigen is called region (VH & VL) because it has a variability in its:a. molecular weightb. amino acid sequencec. …(ga jelas tulisannya)d. number of polymeratione. antigen recognition ability

for number 13-17

a. G6PDb. Methemoglobin reductasec. ALA synthased. Phosphoglycerate mutasee. NADH oxidase13. deficiency of this enzyme reduce NADPH level inside RBC causing hemolytic anemia A14. deficiency this enzyme will maintain heme FE in that reducing from fe2+ B15. product of their enzyme is important in regularly that binding of O2 to Hb 16. this enzyme is the key to regulating enzyme in controlling heme biosynthesis C17. this enzyme plays a key role in producing potent microbial agent inside active leukocyte

18. 5 years old boy ke RSHS karena bleeding from nostril. Doctor perform hemostasis test, most common anticoagulant yang digunakan dalam pemeriksaan lab kasus di atas?a. sodium citrateb. sodium oxalatec. sodium heparind. ….heparine. EDTA

21. the clinical laboratory staff performed PT & APTT on 8 years old boy come with prolonged bleeding after circumcisition, and the resul are: PT 12 sec (N:10-14), APTT: 67 sec (N:25-40). What is the additional test will be suggested?a. bleeding timeb. clotting timec. rumple leede testd. substitution teste. platelet aggregation test

22. A 5 y.o. boy,epistaxis,prolonged aPTT,yang lain normal. Ada history pada male family member. What is the diagnosis? HEMOFILI

23. tujuan torniquete test?a. ability of capillary to resist pressureb. ability of platelet to resist pressurec. ability of capillary to resist heatd. ability of platelet to resist heate. ability of platelet and capillary to resist pressure

24. because of the severe bleeding during delivery

of her baby, the doctor gave blood transfusion of a whole blood which was taken 5 days before. What is biochemical change during storage of the blood?a. plasma potassium naikb. plasma sodium naikc. plasma Hb turund. 2,3 DPG naike. pH naik

25. WBC = 15.000, apa itu?a. leukocytosisb. leucopenia

26. bagaimana rumus mencari MCV?

27. jika kadar Hb = 10, Ht = 31%, maka berapa nilai MCHC?

hypochromic microcytic Hb: low, MCV: 67 fL, possible morphology RBC 28. Mary’s CBC

29. a 5 year, fever, red dots on his extremities. Platelet count 50.000. term?a. thrombocytopeniab. thrombocytosisc. thromboastheniad. thrombopathiae. thrombosis

30. 21 y.o. woman, chronic fatigue, prolonged mens, conjunctivae anemic. Lab test: Hb: 8,3; RBC: 4,15x109; WBC: 4800, MCH:23, PCV: 26%, PLT: 374rb, MCV: 67 fL, MCHC: 29, reticulocyte: 0,5. Diagnosis…a. normocytic-normochromic anemiab. microcytic-normochromic anemiac.microcytic-hypochromic anemiad. normocytic-hypochromic anemiae. macrocytic-normochromic anemia

32. ,, RBC fever, mild sore throat, easy bruising, gingival bleeding. Hb , diff count: blast: 73%, promyelocyte: 10%, myelocyte: 10%,, WBCPLT lymphocyte: 7%. Diagnosis?a. AMLb. acute myelomonoblastic leukemiac. ALLd. CMLe. CLL

33. anak 7 thn, lymphadenopathy, spleenomegaly. Blast 78%, neutrofil 3%, limfosit 24%. Diagnosis?a. AMLb. ALLc. CLLd. CMLe. burkitt’s lymphoma

35. a 15 y.o. girl experiences flushing, pruritus, and urticaria, which began during a class trip to the local botanical garden. She is restless and uncomfortable and describes a sensation of burning in her skin. Which of the following is the best characterized her condition?a. superantigen activation of CD4+ T cellsb. CD8+ cell mediated cytolysis of keratinocyte in the skinc. CD4+ cell mediated delayed type hypersensitivity to poison ivyd. complement activation by antibody-antigen immune complex in the skine. activation of IgE coated mast cell induce release of histamine

37. increased HbA2 found in..a. IDAb. sideroblasticc. megaloblasticd. aplastice. thalasemia

39. in hemolytic anemia, there will be?

40. in aplastic anemia you will find:a. pancytopeniab. polychromasiac. poikylocytosisd. anisocytosise. normoblastosis

41. an 11 year old male presented in ER with persistent epistaxis. Mother stated he was never sick before in his entire life. No history of recent viral infection, no family history of bleeding disorder and no organomegaly. Result blood test:Hb :13.2 g/dl (N:12-16)RBC : 4.52 million/mm3 (N :3.8-5.2 million/mm3)PCV : 38.2% (N:36-46)

Platelet : 10.000 (N: 150000-440000)WBC : 5300 (N:4000-11000)MCV 82.30 (N: 80-100)MCH : 29.7 pg/dl (N: 26-34)MCHC : 35.9% (N 31-37%)Diff count : PMN: 47%, lymphocyte : 39%, monocyte :14% Result of blood smear exam:RBC morphology : normocytic, normochromicWBC morphology : within normal limitPLT morphology : appear increased in sizeResult of coagulation testAPTT : 24.8 sec (N: 23-34)TT : 15.8 sec (N: 13-18)What is the most likely diagnosis?a. Secondary thrombocytopeniab. Thrombotic thrombocytopenic purpurac. Dengue hemorrhagic feverd. Immune thrombocytopenic purpurae. Drug induce thrombocytopenia42. which PE result is causing a blood donor rejection?a. weight of 55 kgb. pulse of 75 bpmc. temperature of 36.50 Cd. diastolic pressure of 110 mmHge. Hb of 13.5 g/dl

43. what would be result of group A blood given to a group O patient?a. non immune transfusion reactionb. immediate hemolytic transfusion reactionc. delayed hemolytic transfusion reactiond. immediate non immune transfusion reactione. delayed non immune transfusion reaction

44. a patient with present a platelet count of 350 x 10?./L and bleeding time of 12 minutes. These result most probably suggest:a. decreased platelet productionb. defective platelet functionc. increased platelet productiond. increased platelet destructivee. decreased platelet destructive

45. neutrophilic granulocyte development occurs in bone marrow. Which is the following stages development of that cell?a. promyelocyte, myeloblast, myelocyte,

metamyelocyte, band, and segmented neutrophilsb. myeloblast, promyelocyte, myelocyte, metamyelocyte, band, and segmented neutrophilsc. myeloblast, myelocyte, promyelocyte,metamyelocyte, band, and segmented neutrophilsd. myeloblast, promyelocyte, metamyelocyte,myelocyte, band, and segmented neutrophilse. segmented neutrophils, band, metamyelocyte, promyelocyte, myelocyte, and myeloblast,

46. A 40 year old man with an acute inflammation is reffered to Hasan Sadikin Hospital, which is the following laboratory test useful in this case?a. Hb, Leukocyte, plateletb. Hb, Leukocyte, Differential countingc. leukocyte, platelet, and differential countingd. leukocyte, erythrocyte, platelete. Hb, leukocyte, erythrocyte

47. a 20 year old man had been complaining of fatigue. She look pale and has come some unexplained large bruises. Hepatomegaly was present, but lymphadenopathy was absent. A routine CBC reveals: Hb 10g/dl, WBC: 110.000/ mm3, platelet: 35.000/ mm3, the differential count as follows : blast cell 53%, promyelocyte 12%, myelocyte 8%, metamyelocyte 6%, band 4%, segmented neutrophils 10%, lymphocyte 7%, auer rod was seen in many blast.What is the most possible diagnosis in this case?a. Acute lymphoblastic leukemiab. Chronic lymphoblastic leukemiac. Acute lymphocytic leukemiad. Acute myeloblastic leukemiae. Acute myelocytic leukemia

48. A 25 year old woman has suffered wheals in her arms, trunk, and chest two hours after she ate prawn. She feels severe itching and stinging. The clinical manifestation is more severe when she scratched the lesion. Which of the following substances is the most likely involved?a. IgAb. IgDc. IgEd. IgMe. IgG

49. an 11 year old boy come to dermatology outpatient with chief complaint itchy skin rashes on both elbows. He also complained about dry skin on limbs. His mother has a history of allergy to seafood and cat dander. The dermatological status reveal erythematous papules, scales, and lichenification on both elbows. Which of the following is the most common predilection of this case?a. face, especially cheeksb. scalpc. diaper aread. extensor area of the extremitiese. flexural fold of the extremities

50. a 45 year old man has had recurrent blister on his body since 1 year ago. No itchy. Nickolsky sign positive. No history drug allergy. His skin lesion improved with corticosteroid. Which of the following is the most likely finding on histopatological of his skin?a. intra epidermal blisterb. sub epidermal blisterc. infrabasal blisterd. infradermal blistere. intradermal blister

51. a nurse that works at operation room comes to dermatovenerologist with chief complaint rash and papules at her hands that felt itchy and stinging. The complaint occurs after she used a new brand gloves. She has history of sneezing and running nose in the morning. The dermatological status reveal erythematous macules and papules on her both hands. Which of the following is the most mechanism that plays role in the pathogenesis in this case?a. type I hypersensitivityb. type II hypersensitivityc. type III hypersensitivityd. type IV hypersensitivitye. autoimmunity

52. A 15 year old boy has occasional fever, malar rash, athralgia. He looks pale and weakness. The malar rash is not itchy which became more severe on sun exposure. Which of the following laboratory findings is the most likely to be

abnormal?a. urinalisis: bilirubin (+)b. Hb : 16 gr/dlc. SGOT/SGPT 50/60d. leukosit 2000/mm3e. urinalysis: urobilinogen (+)

54. 54 y.o.male, chief complaint: burning stinging dusky red macule on lip and genitalia. Appear after taking ibuproven 6 months ago. Dermatological status: rounded erythematosus, hyperpigmentia macule on lip and genitalia. Diagnose?a. exenthematous eruptionb. pustular eruptionc. fixed drug eruptiond. bulous eruptione. drug induced lichenoid

57. most important cell in hypersensitivity type IV?

TEN58. 24 y.o. man complain : crust, hyperemic nasal mucus.. total body surface affected 35%. What is the diagnose?

59. 25 y.o. female comes to hospital with chief complaint of redness, itchy oatches and some blister on her neck. For a week she has redness itchy patches and small blister on her neck, color area which spread rapidly involving upper chest. 2 weeks ago, using imitation neckless. 6 months ago suffered redness itchy patches on wrist after using new bracelet. PE dan lab normal. Patch test positive 3 to nickel. Diagnosis?a. contact urticariab. irritant contact dermatitisc. atopic dermatitisd. allergic contact dermatitise. seborrheic dermatitis

61. a y.o boy come to the hospital with chief complaint redness, itchy patches on both knees and elbows. He also has rhinitis and a history of redness itchy patches on cheeks when he was 2 years old. PE within normal limit. Lab result: IgE total 500. What is the most likely diagnosis?a. sebrrhoic dermatitisb. nummular dermatitisc. acrodermatitisd. atopic dermatitis

e. stasis dermatitis

63. a histosection show an organ with large amount of lymph tissue including nodules with germinal centers and deeply in vaginated mucosal surface formed by stratified but poorly defined epitel?a. liverb. spleenc. palatine tonsild. thymus glande. payer patche

64. a developing erythrocyte + neutrophil in RBM may be differentiated from one another by presence of:a. golgi apparatusb. granulec. mitochondriad. peroxisomee. RER

66. antigen specific binding that occurs in graft rejection as result from..a. T-Cellb. plasma cellc. monocyted…..e. …

67. a 25 y.o.man is being evaluated for his anemia. On PE the doctor finds his sclera are subicteric and his spleen is enlarged (Schuffner II). What is the most possible of this patient?a.iron deficiency anemiab. hemolytic anemiac. aplastic anemiad. pernicious anemiae. sideroblastic anemia

68. a 60 y.o. woman presented to the physician with easy satiety and fullnesss in her abdomen. Her spleen was enlarged (scuffner II). Lab test showed Hb: 17.5 g/dl, Ht 54%, WBC 30.000/ mm3, PLT 600.000/ mm3. Which of the following is the most possible diagnosis of her problem?a. myelofibrosis with myeloid metaplasiab. chronic granulocytic leukemiac. lymphocytic chronic leukemia

d. polycytemia vera rubrae. multiple myeloma

69. a 35 y.o woman comes to your clinic with a chief complaint of physical weakness since 2 months ago. She looks pale and on physical examination you find papilla atrophy of her tongue and spoon nail. What is the most important factor in managing this patient?a. elimination the causeb. avoid certain dietc. while blood transfusiond. vitamin supplementatione. hematinic agent therapy

70. a 20 y.o. male present with a chief complaint of unilateral painless masses in the right neck region of 3 months duration. He has weight loss from 40 kg to 35 kg over a 3 month-interval. He has no fever and no diameter, rubbery, non tender and mobile. He has no splenomegaly. What is the most appropriate examination to diagnose this patient?a. chest X-rayb. lymph node biopsyc. abdominal CT scand. neck ultrasonographye. peripheral blood smear

71. a 40 y.o male is referred to an internist by a surgeon for an evaluation of anemia. The patient will undergo operation for his internal hemorrhoid and the laboratory screening before operation shows that his Hb level is 8 g/dl. The internist finds that the patient’s conjunctivae are pale and there is papilla atrophy of his tongue and spoon nail. What is another most possible findings on physical examination of this patient?a. moist handb. brittle hairc. clubbing fingerd. hepatomegalye. splenomegaly

72. a 20 y.o woman comes to your private practice with swelling and stiffness as chief complaint. Over the past month she has been extremely tired and unable to keep up with her coursework. She falls asleep in classes and has found some difficulty with concentration. Recently, she has felt feverish,

but has not bothered to take her temperature. She comments that her hair seems to be falling out after brushing or washing her hair. PE revealed a raised, warm rash on her cheeks and small ulceration on the hard palate. Mild tender synovitis are found in both wrist as well as in the second and third metacarpointerphalangeal joints of both hands. A small effusion is present in the left knee. Test principal diagnostic result specific for this condition is a high titer of an autoantibodies against. Which of the following the most appropriate serologic test for this patient?a. VDRLb. anti nuclear antibodyc. Rheumatoid factord. Anti ds-DNAe. Anti ss-DNA

73. a 14 year old male complains of spontaneous joint bleeding on his left leg. There was history of bleeding after circumcision when he was 7 year old. PE reveals hemarthrosis, no other obvious bleeding. Lab findings show Hb 14 g/dl, WBC 8000/ml, PLT 225.000/ml. which of the following is the most likely explanation of his problem?a. quantitative platelet disorderb. qualitative platelet disorderc. coagulation disorderd. thrombosis disordere. vascular disorder

74. a 50 y.o male presents with a chief complaint of bilateral painless masses in the neck region of 6 months duration. He also has fever, night sweat and weight loss from 60 to 50 kg over a 6 month interval. On PE, the patient found to have bilateral supraclavicular and cervical lymphadenopathy, diameter 2-3 cm, rubbery, non tender and mobile. He has no splenomegaly. What is the most possible factor to determine the prognosis in this case?a. liver enzyme levelb. creatinine levelc. LDH leveld. uric acid levele. Hb level

75. 72. a 20 y.o woman comes to your private practice with swelling and stiffness as chief

complaint. Over the past month she has been extremely tired and unable to keep up with her coursework. She falls asleep in classes and has found some difficulty with concentration. Recently, she has felt feverish, but has not bothered to take her temperature. She comments that her hair seems to be falling out after brushing or washing her hair. PE revealed a raised, warm rash on her cheeks and small ulceration on the hard palate. Mild tender synovitis are found in both wrist as well as in the second and third metacarpointerphalangeal joints of both hands. A small effusion is present in the left knee. Which of the following appearance should be expected on histopatological examination if biopsy was taken from the skin lesion?a. pathology findings like with IgA dermatitisb. microscopically: there is basal cell vacuolization but without lymphocyte infiltrationc. immunofluoresence studies no granular band of immunoglobulin and complementsd. microscopically there are epidermis atrophy with hydrophic generatione. hyperkeratosis and parakeratosis usually can fined in the microscopic findings

for question 76 to 77, refer to scenario below:a 24 year old man comes to the physician because of spontaneous gum bleeding since 2 days before. He has also been complaining fatigue and dizziness since a month ago and has been feeling a little feverish in the evening for two weeks. He looks pale, gingival bleeding is noted. There are no lymphadenopathies nor liver and spleen enlargement. Kab result show: Hb: 7 g/dl, Ht: 18 %, WBC: 2500/mm3, PLT 35.000/mm376. if his bone marrow smear shows cellular hypoplasia, which of the following is the most likely to predict the prognosis of his disease?a. Hbb. Htc. RBC countd. WBC counte. PLT count

77. if his bone marrow smear shows cellular hypoplasia and he needs blood transfusion, what kind of transfusion would you give to this patient?a. fresh whole blood

b. packed red cellc. washed red celld. platelet concentratee. fresh frozen plasma

for question number 78-79, refer to scenario below:a 40 y.o. man is admitted to the ward with anemia. He has history of fever for a month, and gum bleeding occasionally. Lab result: Hb : 6 g/dl, wbc: 60.000/mm3, PLT: 57.000/mm378. if his bone marrow shows poorly differentiated blast more than 30% of the cells, with auer rod in the cytoplasm, what is the diagnose of the patient?a. acute myeloblastic leukemia- M0b. acute myeloblastic leukemia- M1c. acute myeloblastic leukemia- M2d. acute myeloblastic leukemia- M3e. acute myeloblastic leukemia- M4

79. what is the next appropriate step in making diagnosis?a. cytochemistryb. cytogeneticc. immunophenotypingd. absolute valuese. peripheral smear

80. a 20 y.o. man presents with chief complaint of unilateral painless masses in the right neck region of 3 months duration. He has weight loss from 44 to 35 kg over a 3 month interval. He has no fever and no night sweat. On PE, the patient has three right cervical lymphadenopathies, 3-4 cm in diameter, rubbery, non-tender, and mobile. He has no splenomegaly. Which of the following viral is the most likely cause of the lymphadenopathy?a. Hepatitis C virusb. Hepatitis B virusc. Ebstein Barr virusd. Human papiloma viruse. HTLV-1

81. a 20 y.o. female complains of easy bruising of the arm and legs for several months. She also has recurrent bleeding from the nose and heavy menstrual bleeding since 2 weeks. Physical examination reveals echymoses and petechiae on

the thighs and forearm, no other obvious bleeding. Laboratory findings show Hb 13 g/dl, WBC 4000/ mm3, PLT 25.000/ mm3. what is the most life threatening complication in this case?a. intracranial bleedingb. DICc. Gastrointestinal bleedingd. menomethorrhargie. joint bleeding

82. a a 20 y.o.woman is screened to asses her complaint of weakness. The vital signs are normal. She looks pale and her sclera are slight jaundice. There are also mild hepatosplenomegaly. Her liver enzyme are normal, with total bilirubin 3.2 mg/dl and direct bilirubin 1.1 mg/dl.if direct and indirect coombs’ test are positive, what is the best treatment for this patient?a. blood transfusionb. splenectomyc. corticosteroidd. immunoglobuline. radiotherapy

83. a 50. Y.o female presents with painless neck swelling. She notes fevers, night sweats for the last 6 months. No history of bleeding. On PE you note a 4 cm left anterior cervical lymph node, multiple right anterior right cervical lymph nodes, no palpable axillary lymph node, 2-3 cm and a 3 cm right inguinal lymph node. They are non tender and mobile. The oropharynx is clear. She has hepatosplenomegaly. What is the most appropriate treatment of this patient?a. antibioticb. cytostaticc. tuberculostaticd. operatione. radiation

84. a 14 y.o. male complains of pain and swelling on his right knee. There is a history of the same symptom with his younger brother. PE reveals hemarthrosis on his right knee, no anemia. Lab findings show Hb 14 g/dl, WBC 8000/ mm3, PLT 225.000/ mm3 BT 1 minute (N: 1-3), prothrombin time in normal limit, APTT 70 sec (N: control 35 sec). which of the following is the most likely explanation of his problem?

a. vascular disorderb. thrombosis disorderc. coagulation disorderd. qualitative platelet disordere. quantitative platelet disorder

85. a 50 y.o. man has had progressive weakness and dyspnea with exertion for 3 months. He appears malnourished and the conjunctivae are pale, and there are scattered petechiae. Lab studies shows: Hb: 6 g/dl, WBC: 3500/ mm3 with hypersegmented neutrophils, PLT 60.000/ mm3, MCV 115 fL, Reticulocyte count: 0.5%. the bone marrow smear of this patient shows:a. Erythropoietic hypoplasiab. granulopoietic hypoplasiac. thrombopoietic hypoplasiad. giant stab celle. giant platelet

86. a 55 y.o woman is hospitalized with anemia. She has enlarged cervical lymph nodes and splenomegaly (Schuffner III). Lab result: 6 gr/dl, WBC 60.000/ mm3, PLT 57.000/ mm3. the peripheral blood lymphocyte count is 40.000/ mm3. the most likely diagnosis of this patient:a. chronic myelocytic leukemiab. chronic lymphocytic leukemiac. multiple myelomad. myelofibrosise. leukemoid reaction

87. a 15 y.o boy is brought to the physician by his mother due to masses on his right neck. He has also been fatigue since a month. The physician notes that his conjunctivae are anemic and there are lymph nodes palpated on his right neck, 1-3 cm in diameter, rubbery and not painful. There are also hepatosplenomegaly and bruising on his leg. Lab result shows : Hb 8gr/dl, WBC 3000/ mm3 PLT 60.000 /mm3, the peripheral smears shows pancytopenia and smudge cells. If his bone marrow shows blast more than 30% of the cells, within 1-2 nucleoli, what is the prognosis of his disease?a. curable with radiotherapyb. curable with chemotherapyc. curable with chemoradiationd. curable with immunotherapy

e. curable with antibiotics

88. a 55 y.o woman has had progressive weakness and numbness on her extremities. Lab studies shows: Hb 8gr/dl, WBC: 4500/ mm3 with hypersegmented neutrophils, PLT: 150.000/ mm3, MCV: 125 fL, reticulocyte count: 1 %. Which is the most possible abnormality found on the PE?a. conjunctivitisb. gingivitisc. arthrititisd. stomatitise. glossitis

89. which statement is true for arterial thrombosis?a. long term use if oral contraceptive pillb. stasis in blood vesselc. begin with endothelial injuryd. deficiency of natural inhibitor is the basic processe. deficiency of plasminogen activator inhibitor I (PAI-1)

90. 50 y.o female, chief complaint of bilateral painless masses in the neck region of 6 months duration. He also has fever, night sweat and weight 50kg) over 6 months interval. PE : bilateral supraclavicularloss (60kg and cervical lymphadenopathy. Diameter 2-3 cm, rubbery, non tender and mobile, no hepatospleenomegaly. Which of the following is the most likely cause of the lymphadenopathy?a. inflammationb. infectionc. metastases malignancyd. lymphnode malignancye. autoimmune

93. if biopsy of the lymph node reveals no reed Stenberg cells and abdominal ultrasound shows paraaortic lymph node enlargement, which of the following is the most likely diagnosis?a. non hodgkin’s malignant lymphoma stadium IIb. non hodgkin’s malignant lymphoma stadium IIIc. hodgkin’s lymphoma stadium, stadium IIId. hodgkin’s lymphoma stadium IIe. non hodgkin’s malignant lymphoma stadium IV

96.gen untuk replikasi HIV? …a. gp120b. tatc. gp41d. p11

104. the highest concentration of immunoglobulin that secreted by gut…a. IgGb. IgAc. IgMd. IgDe. IgE

106. 35 y.o woman: allergic rhinitis, sneezing, nasal obstruction, and impaired QOL. Which of the following test is the safest and sensitive for her?a. intradermal testb. patch testc. prick testd. radioallergosorbent teste. skin end point titration test

108. 33 years old man came to ENT clinic with bilateral nasal obstruction followed by on and off runny nose for 6 months. The symptom is worst in the morning and cold temperature. No fever, headache, no nasal itching. PE : boggy edematous in lateral wall nose, septum, and especially in turbinates. Lab test are normal. Which of the following is most appropriate diagnose of this case?a. fungal rhinitisb. allergic rhinitisc. vasomotor rhinitisd. occupational rhinitise. medicamentosa rhinitis

111.which Ig that has a role in allergic rhinitis?a. IgGb. IgAc. IgDd. IgEe. IgM

112. seorang wanita 24 tahun, hamil 32 minggu datang ke klinik alergi chief runny nose dan nasal stiffing. PE: enlarge inferiorcomplaint turbinate, watery mucous, ada latar belakang keluarga alergi

dan asma. Which of the following substance beside histamine that make nasal problem?a. bradikininb. esterogenc. leukotriend. prostaglandine. progesterone

113. 90% of ATP needed by RBC is generated by :A. Hexose monophospate shuntB. Kreb’s cycleC. Leukering-rappaport pathwayD. Embden-meyerhof glycolytic pathwayE. MetHb reductase pathway

115. the clinical manifestation that distinguish pernicious anemia from folic acid anemia with the presence of..a. neurologic abnormalitiesb. fatiguec. weaknessd. shortness of bresthe. slight jaundice

117. following hospital admission with loss of consciousness and hypotension after an antibiotic injection of primary health center. A 6 y.o. girl, atopic with 18 kg BW was given aqueous epinephrine subcutaneous. Dosisnya?a. 0,18 ml 1:1000b. 0,36 ml 1:1000c. 3,6 ml 1:1000d. 0,18 ml 1:1000e. 0,36 ml 1:1000

118. 7 y.o. boy come to the clinic after taking acetylsalycilat acid. He come with symmetric blistering around arms and legs, painful ulcer, hemorrhage in lip and mucous and conjunctiva ulcer involving in cornea. Total skin lesion less than 10% BSA. What is thee best treatment for this disease?a. glucocorticoidb. NSAIDc. Cyclosporind. immunoglobuline. cyclosulphate

angioedema dan gatal2. Obat yang cocok?119.

anak kecil, habis makan shrimp antihistamine121. following administration with loss of consciousness and hypotension, a 7 y.o. girl, body weight 22 kg was given injection aqueous epinephrine. Which of the following was the hypersensitivity cause?a. type Ib. type IIc. type IIId. type IVe. type I-IV

122. kinds of urticaria that immediately appear after vigorous swimming at seawater in the beach, at high noon on hot summer day, except:a. heat urticariab. solar urticariac. cholinergic urticariad. psychogenic urticariae. aquagenic urticaria

123. lymphoid organ yang perkembangannya tidak dipengaruhi antigen…a. spleenb. thymusc. bone marrowd. bursa equivalente. yolk sac

124. in which hypersensitivity determination plasma/serum tryptase is helpful?a. DD IgE mediated and non IgE mediated type Ib. diagnose type I hypersensitivityc. diagnose type II hypersensitivityd. diagnose type III hypersensitivitye. diagnose type IV hypersensitivity

125. which of the following antibody, involve in atopic disease? ans: IgE

126. 12 y.o. boy follow skin prick test. The purpose of the test is to identified….a. IgE mediated type I hypersensitivityb. non IgE mediated type I hypersensitivityc. IgE & non IgE type I hypersensitivityd. type II hypersensitivitye. type III hypersensitivity

128. diagnosis thalasemia trait is frequently misdiagnosed with…a. IDAb. aplsatic anemiac. megaloblastic anemiad. autoimmune hemolytic anemiae. sideroblastic anemia

129. what is the right indicating to do ceasarian section operation in HIV pregnant mother?e. transversal transmission preventing

130. bayi lahir normal, 3 kg dari ibu yang menderita HIV. Dilahirkan secara cesar pada minggu 38 kehamilan. Pendekatan diagnosis untuk konfirmasi bayi itu sudah terinfeksi HIV atau belum..a. anti HIV-1b. HIV p-24c. HIV RNAd. HIV DNAe. culture

132. antibody yang dapat ditransfer dari ibu ke janin melalui transplacental?a. IgEb. IgAc. IgGd. IgDe. IgM

133. characteristic of cutaneous lesion of NLE:a. facialb. acralc. extensord. diffusee. photo distribution

138. which of the following clinical manifestation is permanent in NLE?a. congenital heart blockb. cutaneous lesionc. pulmonary involvementd. neurology involvemente. thrombocytopenia

142. appropriate treatment for IDAa. blood transfusion

b. multivitamin intakec. oral ferrous sulfated. intramuscular iron dextrante. an iron fortified cereal

146. WOTF agent would be the most likely to dampen the immune response in organ transplantation and autoimmune disease…a. levimasoleb. thalidomidec. serolimusd. IFNe. IL-2

154. WOTF is the site of action of corticosteroid in allergic reaction?a.b. inhibiting IgE class switching on plasma cellsc. inhibiting interaction on mast celld. inhibiting phospolipase-A2 liberated arachidonic acide. inhibiting leukotriene binding its receptor on eosinophils

156. drugs that need intrinsic factor for its absorption?a. pyridoxineb. folic acidc. cyanocobalamined. riboflavine. Iron

158. moleku yang membantu absorbs non heme Fe..a. vit Cb. vit B12c. Vit B6d. Vit De. Vit A

159. which of the following drug yang punya efek ke numbness and weakness?a. vit b12b….c. pyridoxined….e…..

163. which of the following statement is correct

about phenothiazine?a. produce marked sedationb. produce marked adverse GI bleedingc. may cause increase appetite weight gaind. also act as antitussivee. only marketed as sleeping aid

164. which of the following statement is regarding the effect of H1 receptor antagonist is true?a. poor absorbed after oral administrationb. have limited use in allergic bronchospasmc. all have muscarinic-cholinergic antagonis activityd. not induce microsomal enzymese. cause increase in appetite

165. Mengenai alegy dan hypersensitivitya. delayed reaction occurs in asthmab. histamine play role in bronchospasmc. hay fever, other than histamine lead to nose irritationd. red flare and hives in urticaria karena mixture toxic leukotriente. anaphylaxis : localized reaction in vascular system

166. girl 5 y.o., chief complaint rash di trunk dan extremities, easy brushing, no fever, no history bleeding, PE no splenomegaly. Lab : normal, platelet 15.000. treatment for this patient?Hb,Hct, WBC a.b.c. suspension for thrombocyted.e.

168. 4 y.o boy, chief complaint: bruishing on his right knee and joint pain, there are palpable bruises on the right thigh and hemarthrosis on the right knee. Lab: Hb: 12.8, HCT: 38.5%, WBC: 9000, platelet: 220.000, BT 3 min, PT: 11 sec, APTT: 98 sec. his brother has same history. WOTF lab result is supposed to be abnormal in this patient..a. factor I deficiencyb. factor V deficiencyc. factor VII deficiencyd. factor VIII deficiencye. factor XIII deficiency

170. ……. Neurological examination show tetraparesis, stocking glove paresethesia and decreased physiologic reflex. Lumbar puncture is done. What is the result?a. increased glucose with normal cellb. increased glucose with increased proteinc. decreased protein with normal celld. decreased protein with decreased glucosee. decreased protein with increased glucose

171. which is the most possible cause of this case…a. H.influenzab. campylobacter jejunic. CMVd. salmonella thypiie. Herpes zoster

174. which of the following has been the mainstay treatment for this patient (SJS)a. glucocorticoidb. NSAIDc. cyclosporined. immunoglobuline. cyclophospamide

177. red eye, pain, easy tearing. Peripheral corneal ulcer. Treatment..a. oral antibioticb. anti fungalc. topical corticosteroidd.antihistamine. topical antibiotic

179. male, 50 y.o. chief complain red eye,pain, excessive tearing, objective exam : peripheral corneal ulcer. Main treatment?A. oral antibioticB. antifungalC. topical corticosteroidD. antihistamineE. topical antibiotic

184. immunoglobulin paling terpengaruh untuk melindungi tubuh seperti contohnya toxic infection : dipteri?A .IgGb. IgMc. IgAd. IgD

e. IgE

189. 54 y.o. woman terkena rhinitis. Dia menggunakan nasal spray. Obat tersebut dapat menyebabkan apa?a.b. rebound phenomenonc. mulberry rhinitisd.e.

199. bleeding time which of the following option is markedly prolonged?a. VIII deficiencyb. Taking high dose of aspirinc. malabsorption of vit.kd. abnormal liver functione. ….

MDE HIS 2009

1. Lymph vessel in small intestines

a. Lacteal

b. Rugae

c. Pylorus

d. Corpus

e. Fundus

Jawab : A

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

3. Largest lymphatic organ in body?

a. Gallbladder

b. Pancreas

c. Spleen

d. Tonsils

e. Liver

Jawab : C

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

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

a. Erythrocyte normocytic normochromic

b. Erythrocyte microcytic normochromic

c. Leucocyte shift to the left

d. Myeloblast

e. Megakaryoblast

Jawab : A

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

10. Pathogenesis megaloblastic anemia?

a. Abnormal nuclear & cytoplasm maturation

b. Defective DNA synthesis & nuclear maturation

c. Defective RNA synthesis & nuclear maturation

d. Defective RNA synthesis & cytoplasm maturation

e. Defective DNA synthesis & cytoplasm maturation

Jawab : B

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

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

Jawab : polycythemia vera

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

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

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

a. fibrinolytic disorder related terhadap pembentukan thrombus

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

c.jawaban tidak spesifik

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

21. D. cryoprecipitates. Ada di harmening hal 497

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

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

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

26. WOTF characteristic of erythropoietin?A. Cannot cross placental barrierB. Of chromosome 11C. Adult, secretion in liver mostD. Unborn, secretion in liver most

Jawaban : A.(?)

Pembahasan :

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

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

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

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

27. What is normal maturation of cytoplasma in RBC?

A. Decrease in basophilic colour

B. Decrease in granules

C. Decrease in nucleoli

D. Increase in azurophilic granules

E. Increase in chromatin

Jawaban : A.

Pembahasan :

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

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

A. Giemsa staining

B. Brilliant cresyl blue staining

C. Wright stain

D. Myeloperoxidase stain

E. Sudan black B stain

Jawaban : B. (?)

Pembahasan :

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

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

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

A. Normoblast

B. Myeloblast

C. Lymphoblast

D. Pronormoblast

E. Megakaryocyte

Jawaban : E.

Pembahasan :

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

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

A. CT normal, BT normal

B. PT normal, APTT normal

C. BT prolong, CT normal

D. PT prolong, APTT normal

E. PT normal, APTT prolong

Jawaban : A. (?)

Pembahasan :

“Spontaneous hemarthrosis and hematomas of deep structures are typical features of coagulation

protein deficiency states and not platelet / vascular defects.” (Harmening, hlm 471).

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

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

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

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

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

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

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

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

42.B.jelas.

43. cytokine? Histamine

*soalnya ga jelas

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

a. Cetrizine

b. Chlorpheniramine

c. Promethazone

d. Tripelonnamine

e. Diphenylamine

jawaban: A. Cetrize

Cetirizine adalah metabolit aktif dari hidroksizin dengan kerja kuat dan panjang. Merupakan antihistamin selektif, antagonis reseptor H1 periferal dengan efek sedative yang rendah pada dosis aktif farmakologi dan mempunyai sifat tambahan sebagai anti alergi. Cetirizine menghambat pelepasan histamin pada fase awal dan mengurangi migrasi sel inflamasi.45. 70 y old with runny nose,since 10 y old,nasal blockage,sneezing,dll,what appropriate diagnostic tool?a. Nasal endoscopyb. Rhinoscopyc. Nasal cytd. Total IgEe. Skin prick testjawaban: D

49. What aeroallergens highly involved in case above?

a. Latex

b. Pollen

c. Dust mite

d. animal dander

e. Human dander

jawaban: B.Pollen

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

a. immunotherapy

b. frequent exercise

c. allergen avoidance

d. 6 month steroid nasal spray

e. 6 month antihistamine

jawaban: C. Allergen avoidance

pencegahan adalah treatment jangka panjang terbaik untuk therapy allergy

51)answer : A

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

52)answer : A

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

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

53)answer : characteristics of allergic rhinitis??

Explanation : lange,10th ed,pg 356

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

54)answer :

56)answer : A

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

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

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

58. C anaphylaxis

70. A/B

71. C

72. Zidovudine can improve cognitive function in short term

74. Corticosteroid or immunosupressant drugs

75. e. Burkitt lymphoma

- Follicular lymphoma: the most common form of NHLMorphology: two principal cell types: (1) small cells with irregular or cleaved nuclear contours and scant cytoplasm (centrocytes-small cleaved cell), and (2) larger cell with open nuclear chromatin several nucleoli, and modest amount of cytoplasm (centroblast)CF: tend to present with painless, generalized lympadenophaty, 30-50% occur histologic transformation, most commonly to diffuse large B-cell lymphoma

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

Morphology: diagnostic Reed-Sternberg cell are large (15-45µm in diameter) and have either multiple nucleoli with multiple nuclear lobes, each with a large inclusion-like nucleolus about the size of small lymphocyteMononuclear variant contain only a single round or oblong nucleus with a large inclusion-like nucleolusLacunar cell seen predominantly in nodular sclerosis subtypeReed-Sternberg present in an appropriate background of non-neoplastic inflammatory cells (lymphocytes, plasma cell, eosinophils)

- Diffuse Large B-cell Lymphoma (DLBCL)

Morphology: relatively large cell (usually 4-5 times diameter of small lymphocyte) and a diffuse pattern growthCF: rapidly enlarging, often symptomatic, mass at single nodal or extranodal site

- Burkitt lymphomaMorphology: high mitotic index is typical, as apoptotic tumor cell death, accounting for the presence of numerous tissue macrophages with ingested nuclear debrisBenign macrophage are diffusely distributed among the tumor cell and have abundant clear cytoplasm, creating characteristic “starry sky” pattern

77. b. Hodgkin

- Clinical difference between Hodgkin and NHLHodgkin NHL

More often localized to a single axial group of nodes (cervical, mediastinal, para-aortic)

More frequent involvement of multiple peripheral nodes

Orderly spread by contiguity

Noncontiguous spread

Mesenteric nodes and Waldeyer ring rarely involved

Mesenteric nodes and Waldeyer ring commonly involved

Extranodal involvement uncommon

Extranodal involvement common

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

Morphology: prolymphocyte gather together focally to form loose aggregates referred to proliferation center, because they contain large number of mitotically active cellsLymphocyte are round, fragile and frequently disrupted in the process of making smear, called smuged cellCF: asymptomatic, disrupt normal immune function through uncertain mechanism

78. a. EBV

- HodgkinEtiology: one important clue is the frequent present of EBV episomes in the

Reed-Sternberg cell of many cases of mixed cellularity HL

79. a. I A

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

Stage Distribution of DiseaseI Involvement of single lymph node

region (I) or involvement of a single extralymphatic organ or site (IE)

II Involvement of two or more lymph node region on the same side of diaphragm alone (II) or with involvement of limited contiguous extralymphatic organ or tissue (IIE)

III Involvement of lymph node region on both side of diaphragm (III), which may include spleen (IIIS) and/or limited contiguous extralymphatic organ or site (IIIE, IIIES)

IV Multiple or disseminated foci of involvement of one or more extralymphatic organ or tissue with or without lymphatic involvement

80. ???

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

Majority (85%) of ALL are precursor B-cell tumor that typically manifest as childhood acute leukemiaLess common precursor T-cell ALL tend to present in adolescent male as lymphomas often with thymic involvementMorphology: ALL with lymphomatous presentation are mostly of pre-T cell typeThe nuclear chromatin is delicate and finely stippled, and nucleoli are either absent or inconspicuousCF: abrupt stormy onset, symptoms related to depression of normal marrow function, bone pain and tenderness, generalized lymphadenopathy, splenomegaly, and hepatomegaly caused by neoplastic infiltration, CNS manifestation, headache, vomiting

Source from Robin 7thed, page 673-691

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

A. Diffuse large B cell lymphoma

B. Small lymphocytic lymphoma

C. Non-Hodgkin lymphoma

D. Lymphoblastic lymphoma

E. Follicular lymphoma

Jawab : A

Pembahasan :

Robbins edisi 7 hal. 667 pada

ETIOLOGICAL AND PATHOGENETIC FACTORS IN WHITE CELL NEOPLASIA : OVERVIEW

Environmental Agents

menyebutkan :

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

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

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

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

Lalu kita selidiki option A, B, dan E.

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

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

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

Kedua keadaan di atas cocok dengan pasien.

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

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

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

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

A. Prednisolone

B. Hydrocortisone

C. Chlorpheniramine maleate

D. Trimethoprim-sulfomethoxazole

Jawab : D

Pembahasan :

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

Jawaban D, karena :

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

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

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

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

A. erythema multiforme

B. bullous pemphigoid

C. pemphigus

Jawab : A

Pembahasan :

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

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

A. Bullous pemphigus

B. Pemphigus vulgaris

C. Erythema multiforme

D. Pemphigus folliaceus

E. Subcorneal pustular dermatosis

Jawab : A

Pembahasan :

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

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

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

Pemphigus folliaceus : -

Subcorneal pustular dermatosis : -

84. What substances are contained predominantly in subepidermal bullae ?

A. Inflammatory cell

B. Acantholysis cell

C. Spongiosis cell

D. Neutrophil cell

E. Fibrin

Jawab : A

Pembahasan :

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

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

(Robbins edisi 7 p. 1261)

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

adalah edema pada dermis). Option E salah karena tidak ada hal yg melibatkan fibrin.

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

A. clotting time

B. bleeding time

C. thrombin time

D. prothrombin time

E. activated partial thromboplastin time

Jawab : B

Pembahasan :

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

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

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

b. NADP

c. NADPH

d. Glukosa

e. 2,3 DPG Jawaban : E

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

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

a. ATP

b. NADP

c. NADPH

d. Glucose

e. 2,3 DPG

Jawaban : A

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

96. RBC maintains Fe state?

a. ATP

b. NADH

c. NADPH

d. Glucose

e. 2,3 DPG

Jawaban : B

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

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

Jawaban : antacid

Alasan : Goodman & Gillman hlm 1448

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

a. Thallasemia

b. Acquired hemolytic anemia

c. Pernicious anemia

d. Aplastic anemia

e. Iron deficiency anemia

Jawaban : E

Alasan : Harmening hlm 105 table 6-7

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

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

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

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

Normoblast= ?

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

104. ?

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

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

Manifestasi klinis : anemia = progressive fatigue, dyspnea, palpitasi

Thrombocytopenia: petechiae,purpura, ecchymoses, mucosal bleeding

Leukopenia : sign of infection (late manifest)

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

113. Most likely structure of thymus :

A. Medulla appear darker than cortexB. Large number of T-cell in cortexC. Has mesenchymal reticular cellsD. Has lymph vesselsE. The cortex has Hassal’s corpusle

Jawaban : B.

Pembahasan :

A à seharusnya lighter

C à seharusnya epithelial reticular cells

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

E à seharusnya medulla

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

(Junquiera, 266-267)

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

A. AntibodyB. ComplementC. Interleukin-1D. Class 1 interferonE. Class 2 interferon

Jawaban : ?

Pembahasan : ? (soalnya ga ada…)

117. HIV, yang benar?

A. RNA, SS, envelope (-)

B. RNA, SS, envelope (+)C. DNA, SS, envelope (-)D. DNA, DS, envelope (+)E. DNA, DS, envelope (-)

Jawaban : B.

Pembahasan :

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

118. MOA treatment HIV?

Jawaban :

Pembahasan :

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

1. Nucleoside & Nucleotide Reverse Transcriptase Inhibitor (NRTI) à inhibitor kompetitif HIV-1 reverse transcriptase, dengan bantuan aktivasi intrasitoplasmik lewat fosforilasi oleh enzim seluler menjadi bentuk triphosphate. MoA lain memasuki rantai DNA virus, lalu melakukan terminasi.

2. Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) à menempel langsung ke HIV-1 reverse transcriptase (tanpa perlu aktivasi lebih dahulu), sehingga memblok RNA- & DNA-dependent DNA polymerase.

3. Protease Inhibitor (PI) à mencegah cleavage Gag-Pol polyprotein, sehingga yang diproduksi adalah partikel virus yang imatur & non-infeksi.

4. Fusion Inhibitor à menegah perubahan bentuk (konformasi) dari virus, yang dibutuhkan untuk fusi virus dengan membran sel, sehingga mencegah masuknya virus ke dalam sel.

(Katzung, 798-811)

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

A. NK cell

B. MastocyteC. MarophageD. T-lymphocyteE. Complement

Jawaban : C. (?)

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

120.B.

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

122. sori ga ngerti maksudnya.

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

126. C (lange 103)

129. angioedema terjadi karena apa?

Mastocyte

130. pada type I hypersensitivity yang bertanggungjawab untuk perkembangan mast cell,B cell,eosinophil?a. CD4 T Lymphocyteb. CD8c. macrophaged. monocytejawaban: CD4 T lymphocyte 133. 21 y.o woman malar rash,photo distribution,derm exam: atrophic lesion on periauricular region,ANA (+),Anti DsDNA(-),No urine protein. Treatment?a. vit Cb. steroid c. retinoidd. sunblocke. antibiotic137. Most life threatening complication (ITP)?a. intracranial bleedingb. DICc. GI bleedingd. Menomethrorhagi

e. joint bleeding137. WOTF can cause death?a. Intracranial hemorrhageb. DICc. GI bleedingd. Menomethrorhagi

e. joint bleeding

138) ANS: AEXP: primary hemostasis is defined by platelet

membrane glycoprotein Ib(GPIb) and von Willebrand`s factor(vWF)

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

141) ANS : AEXP : table 17-5,staging system for chronic

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

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

144) ANS : B EXP : afibrinogenemia – it can cause profuse

bleeding after slight trauma & delay in wound healing.initial symptoms include bleeding from the umbilical cord stump.other symptoms:intracranial bleeding, epistaxis,gastrointestinal bleeding & menorrhagia.

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

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

145) QUESTION NOT COMPLETE..146) ANS : AEXP : characterized by decrease in Hb

concentration,hematocrit,MCV.REFERENCE : HARMENING,4TH ED,PG 104 (sorry

friends,but please,do explore more)

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

a. Factor deficiency

b. Factor …

c. Vit. K deficiency

Ans.

a. Factor deficiency

PT & APTT prolonged = defisiensi factor intrinsik dan ekstrinsik

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

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

a. Β thalassemia

b. Β thalassemia major

c. Iron deficiency

d. Sideroblastic anemia

e. Lead fusion

Ans.

Wah bingung sayah

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

a. IDA

b. ALL

c. Myelodysplastic syndrome

d. Aplastic anemia

e. Megaloblastic anemia

Ans.

d. Aplastic anemia

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

154. Etiology ?

a. Infiltrative malignant

b. Bone marrow failure

c. Coagulation disorder

d. Overwhelmed infection

e. Platelet disorder

Ans.

b. Bone marrow failure

Lihat pembahasan di atas

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

a. Pronormoblast

b. Normoblast acidophilic

c. Normoblast polichromatophilic

d. Normoblast basophilic

e. Reticulocyte

Ans.

a. Pronormoblast

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

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

a. Bleeding

b. Thrombosis

c. Infection

d. Anemia

e. Hemolysis

Ans.

d. Anemia

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

Komplikasi policythemia vera adalah anemia.

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

Ans.

Sayah bingung. Tapi yellowish seperti ini mungkin hemolytic anemia.

157. Neutrophil granulocytic development

Myeloblast: round nucleus, reddish-blue, nucleoli, N:C=4:1, 10-20µmPromyelocyte: primary granule, reddish-blue, N:C=3:1, 20µmN. myelocyte: secondary granule, eccentrally round nucleus, pinkish, N:C=2:1N. metamyelocyte: nucleus slightly indented, pinkish granule, N:C=1:1, 10-18µmBand netrophil: nuclear indentation greater than half, pink granule, smallerSegmented netrophil: nucleus divide into 2-5 lobes connected by thin filament

159. FAB Classification of Acute Myelogenous Leukemias (AML)

M0, Minimally differentiated AMLBlasts lack cytologic and myeloperoxidase negative but express myeloid antigens and resemble myeloblastsM1, AML without differentiationVery immature, >3% of blasts are peroxidase positive; few granules and little maturation at myeloblast stage.M2, AML with maturationFull myeloid maturation through granulocytes; Auer rods present in most casesM3, Acute promyelocytic leukemiaMost cells are hypergranular promyelocytes, often with many Auer rods per cell; patients are 35 to 40 years ageM4, Acute myelomonocytic leukemia

Myelocytic and monocytic differentiation; myeloid elements show maturation; monoblasts are positive for nonspecific esterasesM5, Acute monocytic leukemia- M5a subtype, monoblasts (peroxidase-negative, nonspecific esterase-positive) and promonocytes predominate in marrow and blood;

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

- M5a and M5b occur in older patients; characterized by incidence of organomegaly, lymphadenopathy, and tissue infiltration.M6, Acute erythroleukemiaDysplastic erythroid precursors (megaloblastoid, with giant or multiple nuclei), and within the non-erythroid cells, >30% are myeloblasts; seen in advanced age.M7, Acute megakaryocytic leukemiaBlasts of megakaryocytic predominate; blasts react with platelet-specific antibodies directed against GPIIb/IIIa or vWF; myelofibrosis or increased marrow reticulin seen in most cases.

165. ?

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

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

Worse prognosis, mungkin well differentiated lymphocyte

167. ?

- Chronic Lymphocytic Leukimia (CLL) / Small Lymphocytic Lymphoma (SLL)Merupakan peripheral B-cell Neoplasm

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

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

CF: asymptomatic, disrupt normal immune function through uncertain mechanism

- Chronic Myelogenous Leukimia (CML)Between 25-60 years of age

Patfis: merupakan chronic MPDs with presence of distinctive molecular abnormality, yaitu ABL gene on chromosome 9 and BCR gene on chromosome 22Morphology: CML marrow usually 100% cellular with mostly maturing granulocytic precursor; megakaryocyte increase; erythroid progenitor normal or decrease; pheripheral blood reveal leukocytosis; ada splenomegaly; hepatomegaly and mild lymphadenophatyCF: insidious, mild to moderate anemia, abdomen sensation caused by extreme splenomegaly

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

c. normochrom normocytic

- hypochromic: pale RBC, kekurangan Fe- anisocytosis: banyak RBC yg bervariasi ukurannya- normocytic: RBC of normal size

176.Atrophy Lingual?

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

Dimana pemeriksaan Lab IDA:- Serum Iron : Tinggi- TIBC : Tinggi- Ferritin : Rendah

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

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

Ciri-ciri urticaria:- Lesion: papule/wheal,circumscibed

lightly erythematous with central blanching/blanched with pressure.

- Location: Upper cornum of the dermis

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

For 180-182A 24 Year old man,IDU, Came to dept.internal

medicine for general check up.Labresult HIV (+) 180.WOTF cell killed by above virus?C.CD4 T-cellHIV infects primarily vital cells in the human

immune system such as T-helper cell(tobe specific, CD4 T cells), macrophage and dendritic

cell.

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

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

B.Tat

a. Gp 120: p120 is essential for virus entry into cells as it plays a vital role in seeking out specific cell surface receptors for entry.

b. Tat: Tat vastly increases the level of transcription of the HIV DNA.

c. Pol: it means polymerased. Gp41: is a glycoprotein non-covalently-

bound to gp120, and provides the second step by which HIV enters the cell. It is originally buried within the viral envelope, but, when gp120 binds to a CD4 receptor, gp120 changes its conformation, causing gp41 to become exposed, where it can assist in fusion with the host cell.

e. P11: Sorry.I haven’t find it.182.WOTF is the component above virus that

enhances penetration of virus into host cell?A.Gp120

Penjelasan lihat no 181

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

A. NK cell

B. Dendritic cell

Jawaban : B

Alasan : dendritic cell mengekspresikan protein MHC II (Lange)

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

A. Ig light chain

B. Ig heavy chain

C. Variable region of IgG heavy chain

D. Variable region of IgG light chain

E. Hinge region of the heavy chain

Jawaban : C

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

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

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

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

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

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

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

188. Diagnosis?

A. Nummular dermatitisB. Xerosis cutisC. Atopic dermatitisD. Food allergy

Jawaban : C.

Pembahasan :

Nummular dermatitisà lesi kulit berbentuk koin / diskoid

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

Food allegy à tidak disebutkan setelah makan apa

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

189. WOTF is predilection of this case?

A. Face, especially cheeksB. ScalpC. Diaper areaD. ExtensorE. Flexural fold of the extremities

Jawaban : E.

Pembahasan :

Pada bayi à terutama pipi & menyebar ke sekitarnya

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

(Fitzpatrick pocket, 36)

For number 1-3, refer to clinical scenario below28 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/mm31. What is the most possible findings on the physical exam?A. icteric scleraeB. gum hypertrophyC. atrophy of lingual papilaeD. lymphadenopathy on the neckE. mass on the abdomenJawaban : CAlasan tanda salah satu tanda iron deficiency anemia. A : koilonychia hemolytic anemia. B& tanda hepatosplenomegaly, tanda AML. E D tidak ada di kasus (Wintrobe ch 28)

2. Which of the following cells in erythropoiesis is dominant on her BM smear?A. pronormoblastB. basophilic normoblastC. polychromatophilic normoblastD. acidophilic normoblastE. reticulocyteJawaban : 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 transfusionB. iron therapyC. folate therapyD. cobalamine therapyE. eliminate the causeJawaban : BAlasan : 1st choice treatment untuk IDA adalah mengembalikan kadar Fe. A indikasi Hb <7mg/dl. C& manifestasi klinis berbeda. (WintrobeD ch 28)

For number 4-5 refer to clinical scenario belowA 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 synthesisB. vit B12 deficiencyC. A quantitative defect in Hb synthesisD. A qualitative defect in globin protein chainsE. folate deficiencyJawaban : CAlasan :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 TIBCB. Hb electrophoresisC. vit B12 deficiencyD. chromosome analysisE. flow cytometryJawaban : AAlasan : 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 deficiencyB. folic acid deficiencyC. iron deficiencyD. beta globin deficiencyE. G6PD deficiencyJawaban : C ciri IDAAlasan: microcytosis, hypochromia

7. What kind of peripheral blood smear appearances will be found?A. Hypochromic, microcytic, anisopoikilocytosis with abundant of pencil cellsB. Hypochromic, microcytic, anisopoikilocytosis with abundant of target cellsC. Normochromic, normocytic, anisopoikilocytosis with abundant of target cellsD. Normochromic, normocytic, anisopoikilocytosis with abundant of pencil cellsE. Normochromic, macrocytic, anisopoikilocytosis with abundant of target cellsJawaban : BAlasan : 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 saturationB. Low serum Fe level, increased TIBC, low transferrin saturationC. Low serum Fe level, low TIBC, increased transferrin saturationD. Increased serum Fe level, increased TIBC, increased transferrin saturationE. Increased serum Fe level, increased TIBC, increased ferritin saturationJawaban : C

Alasan : Harmening hlm 108 tabel 6-13

9. What is the most appropriate recommended treatment for this patient?A. MultivitaminB. Blood transfusionC. Oral ferrous sulphateD. An iron fortified cerealE. Intramuscular iron dextranJawaban : CAlasan : 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 keratinizedB. simple stratified nonkeratinizedC. simple squamousD. simple cuboidalE. simple ciliated columnarJawaban : BAlasan : lidah termasuk simple stratified nonkeratinized

For number 11&12, refer to clinical scenario belowA 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 : AAlasan kelainan hemostasis. Oleh karena itu perlu dicek terlebih: bruising dahulu jumlah keseluruhan dari sel darah melalui CBC (Harmening hlm 517)

12. IF the PLT count is low which will be prolonged?A. CTB. BTC. thrombin time (TT)D. PTE. aPTTJawaban : B evaluasi PLT dan fungsi vaskular untuk

membentuk PLT plug (Labman HIS)Alasan : BT

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 smearB. CytokimiaC. Factor assayD. Lupus anticoagulantE. Hb electrophoresisJawaban : CAlasan kelainan hemostasis, history of bleeding in male family: bleeding penyakit genetik, BTmember & bukan kelainan PLT ataCBC normal extrinsic dan common pathway normal, TT normal vaskular, PT normal kelainan pada intrinsic pathway common pathway normal, aPTT prolonged 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 pressureB. the PLT to resist pressureC. the capillaries to resist heatD. the PLT to resist heatE. the fibrinogen to resist heatJawaban : AAlasan : 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 belowA 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 LeidenB. antithrombin III deficiencyC. antiphospholipid syndromeD. protein C deficiencyE. protein S deficiencyJawaban : C

tanda APS (Harmening ch 27)Alasan : DVT, pulmonary emboli (di kasus ada family member)

16. What is the additional test will be suggested?A. Factor assayB. Lupus anticoagulant assayC. TPHAD. ASTOE. blood smearJawaban : BAlasan : APS biasanya disebabkan oleh lupus anticoagulant atau anticardiolipin antibodies (Harmening ch 27)

For number 17-18 refer to the scenario belowA 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 disorderB. vascular disorderC. coagulation disorderD. Quantitative PLT disorderE. Qualitative PLT disorderJawaban : D menandakan kompensasi jumlah PLT yang kurangAlasan : giant PLT

18. What is most likely appearance of the bone marrow smear of this patient?A. large promegakaryocyteB. large megakaryoblastC. small promegakaryocyteD. megakaryocyte with PLT formationE. megakaryocyte without PLT formationJawaban : DAlasan : megakaryocyte with increased or normal number (Harmening hlm 474-475)

19. What is PLT receptor for von Willebrand factor?A. glycoprotein IaB. glycoprotein IbC. glycoprotein IIaD. glycoprotein IibE. glycoprotein IIIJawaban : BAlasan : 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 normalB. CT normal, BT normalC. BT prolonged, CT normalD. PT normal, aPTT prolongedE. PT normal, aPTT normalJawaban :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 VIII23. 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 . jelas ya dari hasil pemeriksaan dan eksklusi dari option yang24.D Hemophillia 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 K28. 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 VIIIag33. C34. 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 150rb36.B37.D, karena ga ada tanda2 lymphadenopathy38. C39.D. karena ada keterlibatan hematopoietic cellskecurigaannya adalah CLL 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 IVPenjelasan :Penyakit yang dimaksud adalah CLL (Chronic Lymphocytic Leukemia).Staging menurut Rai System :0 : lymphocytosis in peripheral blood & bone marrowI : + lymphadenopathyII : + splenomegalyIII : + anemiaIV : + thrombocytopenia(Harmening, 310)

42. Jawaban : B/C/E(?) tapi akademik 2006 jawab A. hyperkalemiaPenjelasan :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 erythropoietinPenjelasan :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. PhlebotomyPenjelasan :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 phasePenjelasan :“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-differentiatedPenjelasan :“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 lymphomaPenjelasan :“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 lymphaticsPenjelasan :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-1Penjelasan :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 lymphocytesPenjelasan :“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 BPenjelasan :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 nodesTambahan : 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. RadiationPenjelasan : “Current modalities for the therapy of Hodgkin’s lymphoma are radiation, chemotherapy, or combination.” (Harmening, 403)

60. Jawaban : A G6PD-deficiencyPenjelasan :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, hypochromic63. D jelas64. 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 anemia66. A. Sign symptoms mengarah pada megaloblastic anemia ( terutama : malnourished). Di peripheral blood smear ditemukan : pancytopenia, macro-ovalocytes, hypersegmented neutrophils67. 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..sorii78. 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 IDA80. B. Ferric iron is typically converted into ferrous state by the ACID of the stomach. (Harmening 101)81. A.Folic AcidThat 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. CyanocobalamineIt 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 TransfusionThe 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. UrokinaseIt 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 complete87. A. Decrese of basophilic colorThe 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 marrowSee harmening page 989. B. Briliant cresyl blue stainingSee harmening page 8090. C. Tissue hypoxiaSee harmening page 1591. B. Pelger-huetanomalyNetrophil that has a bilobus nuclei or monolobed/round93. B. ITPMore closed diagnose from the option is ITP96. 98. 99. mechanism of action of allopurinolInhibitor to enzyme xanthin oxidase in uric acid production to treat of gout.

101)

102) ANS : Dincompletely encapsulated,each tonsil has 10-20EXP : tonsil 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 : DEXP : 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 : CEXP : 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 : Eadvantages :EXP : corticosteroid• Promote normal intermediary metabolismincrease resistance to stress(exp;trauma,fright,infection)give high energy• Increase resistance to stress – high glucose• 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 : CEXP : 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 : Chyperglycemia may developEXP : side effects of glucocorticoid & lead to DM,other side-osteoporosis,increase risk of infection & classic Cushing-like syndrome

(pharmacology,Lippincott,3rd ed,pg 312)

116)

117) ANS : AEXP : 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 : DEXP : refer to explanation of the answer above

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

120) ANS : BEXP :

121. Which of the following is the best place in-patient care ?a. burn unit roomb. recovery roomc. high care unit roomd. standard in-patient roome. intensive care unit roomAns.a/eSince 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 saluteb. Dennie-Morgan foldsc. facial twitching or grimacingd. hyperemic nasal mucouse. transverse nasal crease Ans.dPE pada allergic rhinitis :- facial twitching or grimacing- allergic salute- dennie-morgan folds

- transverse nasal crease123. 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. cataractb. corneal ulcerc. glaucomad. herpes simplex virus infectione. sight threatening side effectAns.cTopical intraocular pressure in normal eyesglucocorticoid therapy frequently 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 dermatitisb. irritant dermatitisc. atopic dermatitisd. Steven Johnson’s Syndromee. Streptococcal skin scalded syndromeAns.cTerjadi akibat konsumsi susu sapi.125. Which one of the following is the most likely cause of this baby’s disease ?a. house dustb. house dust mitec. wheatd. cow’s milke. breast milkAns.dTelah 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/ml129. Runny nose. Major substance release ?

Ans.IgE130. for the above case, what is the most suitable H. I. Antihistamine for this patient ?a. ceftrizine hydrochlorideb. chlorpheniramine maleatc. promethazine hydrochlorided. tripehennamite hydrochloridee. diphenhydramine hydrochlorideAns.aSesuai 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. estrogenb. bradykininc. prostaglandind. progesteronee. leukotrienesAns. eMenampakkan 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 mucosab. post nasal dripc. pseudomembraned. hyperemic mucosae. cobblestone appearanceAns.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 shockc. shrimp in throatd. laryngeal edemae. asthmaAns.b141. 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 urticariab. cholinergic urticariac. heat urticariad. psychogenic urticariae. solar urticariaAns.bCholinergic 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 NLEA. Cutaneous lesionB. Congenital heart blockC. Pulmonary involvementD. Neurologic involvementE. ThrombocytosisJawab : B

162. Major cause of death to chronic corticosteroid administration ?A. InfectionB. NephritisC. CNS diseaseD. Pulmonary hemorrhageE. Myocardial infarctionJawab : AKenapa 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 infectionB. Risk of myocardial infarctionC. Risk of autoimmune diseaseD. Risk of hematological diseaseE. Risk of drug allergyJawab : A

164. 30 y.o. male had symptom of anemia, diagnosed as megaloblastic anemia. Drug avoided through …A. OralB. IntravenousC. IntravascularD. SubcutaneousE. IntracutaneousJawab : BPenyebab 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. DLEB. SLEC. CLED. Acute SLEE. Acute CLEJawab : EDari 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 symptomB. Swan neck appearanceC. Rheumatoid nodulesD. OligoarthritisE. OsteosclerosisJawab : maaf, saya kurang tahu maksud pertanyaannya >.< diagnosis RA) :Kriteria diagnosis untuk RA dari American College of Rheumatology (minimal 4 terpenuhi 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 weeks3. Arthritis of hand joints, present for at least 6 weeks4. Symmetric arthritis, present for at least 6 weeks5. Subcutaneous nodules in specific places6. Rheumatoid factor at level above 95th percentile7. Radiological changes suggestive of joint erosions

169. –

170. Histopathology for above case :

171. Chief complaint : difficulty of breathing3 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 36.7Neurological exam : symmetrical and bilateral tetraplegic, flaccid, gloves & stocking anesthetic.Physiologic reflex absentOxygen saturation is decreasedCSF analysis : cytoalbuminic dissociationWhich of the following type of hypersensitivity is the most likely occur in this case ?A. 1B. 2C. 3D. 4E. 1 – 4Jawab : DDari 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 yearsCD4 = 65Difficulty in breathing.Which one is true ?A. High risk for infectionB. High risk for myocardial infection (infarction mgkn maksudnya)C. High risk for hematologic diseaseD. High risk for drug allergyJawab : A

174. Which of the following causes that can proceed to respiratory failure in this case ?A. Ascending paralysis

B. Descending paralysisC. Uncal herniationD. Rostrocaudal herniationE. Transtentorial herniationJawab : kalau ini kasus GBS, jawabnya A.

175. –

176. –

177. Appropriate tools to confirm diagnostic for baby’s HIV infection state ?A. HIV DNA PCRB. HIV RNA PCRC. HIV cultureD. HIV p24 Ag exE. Anti-HIV-1Jawab : B

178. Based on Indonesian Medical, what is appropriate drug for treatment for neonatal HIV infection ?A. AZT + 3TC + NVP, 6 weeksB. AZT + 3TC + ZDV, 6 weeksC. AZT + ZDVD. AZT + ZDVE. AntimycoticJawab : Auntuk 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. ProstaglandinB. LeukotrieneC. PAFD. TryptaseE. IL-4Jawab : DDegranulasi 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. IgAB. IgGC. IgED. CRPE. IFJawab : 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+splenomegalib. moderate anemia+ hepatosplenomegalic. severe anemia+ hepatomegalid. severe anemia+ splenomegalie. severe anemia+ hepatosplenomegali

182.which of following is present to facilitate efficient phagocytosis of microbe by neutrophil and macrophagea.IgA d.CRPb.IgG e.IFc.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 riska.he is at risk getting oppurtunistic infectionb.he is at risk of getting traumac.he is at big risk of getting malformationd.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 antigenb.positive IgG specific to streptococcalc.positive anti-double stranded DNAd.positive rheumatoid factore.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 dayDimana 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 casea.snRNP (small nuclear ribonucleoprotein)b.Mrnac.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 soala.hair fall d.difficult concentrationb.skin rash e.symetrical polyarticular inflamationc.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 casea.SLE d.artritis reactiveb.Rheumatoid artritis e.osteomyelitisc.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 artritisa.systemic symptom d.oligoartritisb.swan neck deformities e.osteoslerosisc.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 patientA.gouty artritis and osteoartritisb.rheumatoid artritis and spondyloartritisc.septic artritis and rheumatoid artritis d.osteoartritis and rheumatoid artritise.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 artritisa.low dose aspirin d.paracetamolb.allupurinol e.prednisonec.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 cellsb.monocyte e.dendritic cellc.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 mechanisma.neutrophle d.NK cellsb.monocyte e.basophilec.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 abovea.spongiosis within epidermisb.superficial perivascular lymphocytic infiltratec.intraepidermal blister with acantholiticd.dermal and epidermal edema and mast cell degranulatione.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 acida.pyrimidine d.thymineb.purine e.uracilc.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 abovea.inhibit degradation of guanosine to guanineb.inhibits degradation of guanine to xanthinec.increase excretion of hypoxanthined.activates degradation of uric acid to allantoine.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.albuminb.acid phosphatase e.globulinc.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 waysa.interfering with spermmatozoa productionb.interfering with spermatozoa capacitationc.reducing the amount of spermatozoad.reducing the mobility of spermatozoae.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 transplantationb. antigens in the HLA system are controlled by cromosome 8c. alleles of the genotype maybe homoxygous and heteroxygousd. alleles of the genotype are always homozygouse. 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.

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MDE HIS 2007-2

1. Jawaban : CAlasan : soal kurang lengkap, klo hanya segini

harusnya bisa semua. Tapi klo ada hemarthrosis (bleeding in joint) biasanya karena masalah koagulasi.

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

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

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

5. Jawaban : C/DAlasan : 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 peningkatan jumlah megakaryocyte (harmening hlm 444)Alasan : BM smear

7. Jawaban : AAlasan : Harmening hlm 444

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

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

10. Jawaban : DAlasan : Robbins hlm 688

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

12. Jawaban : EAlasan : 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 : IDAAlasan : 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 multiple coagulation factor disorder kelainan pada intrinsic dan extrinsic pathway Alasan : prolonged PT dan aPTT

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

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

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

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

20. Jawaban : D kelainan faktor VIIIAlasan : hemophilia A

21. E. jelas ya, liat penjelasan no 24 tahun 2007-122. E. pasien kita ini kemungkinan dikarenakan DIC (salah satu etiologynya terjadi peningkatan konsumsi dari faktor2 koagulasiadalah sepsis) 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 26.4Note: 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? pale yang disertai icterus, splenomegaly (SII)29. E. jelas ada tanda2 hemolytic anemia 30. splenectomy; untuk Thalasemia danagak ga jelas. Untuk H.spherocyte transfusion PRC, hydroxyurea atau bone marrowSickle Cell disease dikasihtransplantation. Untuk hemolytic anemia karena autoimmune 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 67640.?? 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. cryoprecipitatePembahasan :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. scafferinPembahasan :“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 stainingPembahasan :“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 potassiumPembahasan :

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

46. Jawaban : pronormoblast / rubriblastPembahasan :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.countPembahasan :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 anemiaPembahasan :(Harmening, tabel4-3, 77)MCV (80-100 fL) -> turun, microcyticMCH (22-31 pg)MCHC (32-36%) -> turun, hypochromicPada kasus, ketiganya turun, maka microcytic hypochromic anemia.

50. Jawaban : B. iron deficiency anemiaPembahasan :MCV, MCH, MCHC turun -> microcytic hypochromic anemia.A. megaloblastic anemia -> macrocytic normochromicB. IDA -> microcytic hypochromic (V)C. hemolytic anemia -> normocytic normochromicD. aplastic anemia -> normocytic normochromicE. 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 pemphigoidPembahasan :“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 chainPembahasan :“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 cellPembahasan :Karena terdapat defek pada pembentukan rantai globin dari Hb, dari RBC. Maka transfusi yang sesuai adalah packed red cell.

58. Jawaban : E. aplastic anemiaPembahasan :“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 TIBC63. E. seperti case IDA kita (no hepatosplenomegaly)64. D65. C66. 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 M369. B.70. ga nyambung soalnya71. A73. E74.C75. C78. A79. D 80. ga jelas soalnya100) A101) C102) A103) D104) D105) 106) A107) E108) C109) A110) D111) C112) D124. 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. Exocrine126. 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 papillaris128. 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 lymphocyte132. 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 cell134. after binding to its specific antigen, a B lymphocyte may switch which of the following component ?Ans.B. Immunoglobulin heavy chain class135. which of the following must be exposed on the surface of APC that activate T helper ?Ans.D. Class II antigen136. 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 it139. 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

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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 disorderB. qualitative PLT disorderC. coagulation disorderD. thrombotic disorderE. vascular disorderJawaban : CAlasan : karakteristik coagulation disorder : hemarthrosis dan hematoma. A, B, PLT ↓qualitative primary hemostasis disorder E & ↑quantitative, vasculat defect. (Harmening hlm 471-472)

2. Lab test apa untuk konfirmasi diagnosis?

3. Diagnosis?A. ITPB. henoch S purpuraC. von Willebrand diseaseD. DICE. Acute leukemiaJawaban : CAlasan : 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 remissionB. mostly will need splenectomyC. mostly will need IV IgD. about half respond to corticosteroidE. about half will change to leukemiaJawaban : DAlasan : 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. thrombocyteB. reticulocyteC. magakaryocyteD. myeloblastE. normoblastJawaban : C dikompensasi dengan bentuk dan ukuran yang besar dikarenakan pembentukan yang belum sempurnaAlasan : jumlah PLT ↓

8. In primary hemostasis, what mediates the PLT adhesion to expose collagen within the endothelium of the vessel wall?A. GpIbB. fibrinogenC. plasminD. PDGFE. kininJawaban : AAlasan : 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. InflammationB. InfectionC. Metastasis malignancyD. Lymph nodeE. AutoimmuneJawaban : C kemungkinan besar ada keganasanAlasan : ada mass, fever, night sweat, weight loss

10. The most appropriate exam :A. lymph node biopsyB. Abdomen USGC. LDHD. Bone marrow aspirationE. PBSJawaban : AAlasan : untuk memeriksa jenis jaringan lymph

yang terkena diperlukan biopsy

11. Clinical stage :A. IAB. IBC. IIAD. IIBE. IIIAJawaban : DAlasan : 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 organsThe 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. HeadB. Oral cavityC. ThoraxD. InguinalE. Inferior extremityJawaban : AAlasan : Cervical adenopathy is a common feature of many viral/bacterial infections

13. What is the positive factor to determine prognosis?A. Liver enzyme levelB. Creatine levelC. LDH levelD. Uric acid levelE. Hb levelJawaban :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 transferrin14. Diagnosis?A. ThalassemiaB. Acquired hemolytic anemiaC. Pernicious anemiaD. Aplastic anemiaE. Iron deficinecy anemiaJawaban : EAlasan : karena ada increase TIBC, decrease ferritin and transferrin

15. What cell that will be difficult to found in bone marrow smear?A. Basophilic normoblastB. Polychromatophilic normoblastC. Acidophilic normoblastD. ReticulocyteE. PronormoblastJawaban : 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. HemophiliaB. von Willebrand diseaseC. ITPD. Hemorrhagic disease for newbornE. DICJawaban : CAlasan : 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. ↑ PLTB. ↑ plasma fibrinogenC. ↑ factor VIIID. ↑ tPAE. ↑ D-dimerJawaban : E akan menghasilkan D-dimer (Harmening hlm 463) menandakan banyak pemecahan fibrinogen Alasan : penurunan fibrinogen

18. unconscious for the 3rd day of life. CT scan :a previous healthy baby intrasranial bleeding. Lab : HB 11, WBC 6000, PLT 117.500, PT dan aPTT ↑, BP normal.A. ↓ PLTB. ↓ fibrinogenC. ↓ AHFD. ↓ factor II, VII, IX, XE. ↓ nature inhibitor of coagulationJawaban : DAlasan gangguan extrinsic/common pathway. Peningkatan aPTT : peningkatan PT gangguan intrinsic/common pathway. Kemungkinan mengalami gangguan multifactor.

19. Diagnosis :A. HemophiliaB. DICC. Hemorrhagic disease in newbornD. congenital hypofibrinogenemiaE. von Willebrand diseaseJawaban : CAlasan : gangguan koagulasi akibat kurangnya vit K untuk pembentukan faktor koagulasi (Wintrobe ch )60

20. Vitamin yang dibutuhkan?A. Vit AB. Vit BC. Vit KJawaban : CAlasan : 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 yaituPeripheral blood smear : microcytic,hypochrome, aniso-poikilocytosis, terdapat pencil shape, juga terdapat target cellBone marrow smear : mild-moderate erythrocytosis, decrease-depleted dari sideroblastic cells appearance, bahkan bisa sampai nuclear distortion, nuclear budding, karyohexis, dan nuclear fragmentation of normoblastic cells23. 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.. sorii26. A. hypovolemic condition.. berdasarkan wintrobe pada babpendarahan 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 2233. 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 kecurigaan hemolytickompensasi anemia, yaitu peningkatan retikulosit 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 ferritinPembahasan :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 CPembahasan :Menurut internet, vitamin C memang membantu absorbsi non-heme iron.

43. Jawaban : A. vitamin B12Pembahasan :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 hemolyticPembahasan :Subiteric sclera -> banyak bilirubin di darah -> banyak pemecahan RBC (hemolytic) -> splenomegaly (kerja berat, tempat pemecahan RBC)

46. Jawaban : E. glossitisPembahasan :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 cellPembahasan :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. gasterPembahasan :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 lymphomaPembahasan :Penyakit yang histopatologinya ada “rossete-like formation” = ?

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

51. Jawaban : C. observePembahasan :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. G6PDSulfamethoxazole has side effect that cause deficiency of glucose 6 phosphate. Deficiency of this enzyme can cause breakdown of RBC (hemolisys)86. C. Normochromic normocyticHemolityc blood smear87.

88. B. Type B child89. D. Father Rr90. C. Palatine tonsilThe 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 1:1000Ephinephrine 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 shockThe most frequent cause of death in the case of anaphylaxis97. D. IgGIgG is the autoantibody of SLE so it can cross placenta98. D. between 12-16 week of gestation99. A. congenital heart block100. A. infectionOne of effext of steroid administration is immunosuppressant. It is increase the r isk of infection.

100) D103) A104) B105) A106)107) A108) hypersensitivity type 1109) A110) B111) 112)113)Ig E (+) = atopy114) B115) A116) 117)118) D (I think)119) C120) A126. 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 papillaris127. 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. Capillary128. 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 lymphocyte129. most likely characteristic above virus ?Ans.C. Have single stranded RNA130. what gene is likely needed for replication for above virus ?Ans.B. Tat133. 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 cell134. after binding to its specific antigen, B lymphocytes may switch t which of the following component ?Ans.C. Variable region of the Ig heavy chain135. which one of the following must be expressed on the surface of APC that activate T helper cells ?Ans.D. Class II MHC antigen136. which of the following class of immunoglobulin is present in highest concentration in the blood of a newborn ?Ans.A. IgG137. which of the following statement is the response of macrophage for antibody reaction ?Ans.A. Lysing virus infected cell138. 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 arthritis141. 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. PGI2B. PGE2C. PGD2D. PGF2E. TXA2Jawab : EHipersensitivitas 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 cyclaseB. Guanylate cyclaseC. Thymidine cyclaseD. Uridine cyclaseE. Cystosine cyclase?

163. Which mediator is inhibited on this phase ?A. HistamineB. LeukotrieneC. ProstaglandinD. ProstacyclinE. ThromboxaneJawab : 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. IgGB. IgAC. IgED. IgME. IgDJawab : C IgE-mediated Allergic rhinitis

165. Malar rash especially on photosensitivity area, caused by immune complex. What type of hypersensitivity responsible ?A. IB. IIC. IIID. IVE. All aboveJawab : 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 IgEB. Decrease basophilic histamine releaseC. Decrease IL-13 by TH1D. Increase IFN gamma by TH-2E. Increase soluble IL-2 receptorJawab : CDiagnosisnya 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 conjunctivitisB. Atopic conjunctivitisC. Acute conjunctivitisD. Flictenuralis conjunctivitisE. Follicle conjunctivitisJawab : AKata “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 IIB. Type I and IIIC. Type I and IVD. Type II and IIIE. Type II and IV

Jawab : ADi 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 uveitisB. VitritisC. ChoroiditisD. EndophthalmitisE. Pars planitisJawab : AUveitis 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 ulcerB. Herpetic ulcerC. Geographian ulcerD. Fungal ulcerE. Maroon ulcer?

See the case below :A worst and numbness. 10 days ago, he had20-year-old man. Weakness 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 proteinB. Increase glucose with normal cellC. Increase glucose with normal glucose?

173. What microbe can cause this case ?A. H. influenzaB. Campylobacter jejuniC. CytomegalovirusD. S. typhii

E. Herpes zosterJawab : BGuillain-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 paralysisB. Metabolic acidosisC. Pulmonary distressD. Laryngeal spasmE. Metabolic alkalosisJawab : AGuillain-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. EEGB. EMGC. NCSD. Evoked potentialE. TCDJawab : NCS atau EMGDi 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. CorticosteroidB. ImmunoglobulinC. PlasmapharesisD. NeurotrophicE. NeuroprotectedJawab : BTreatmentnya 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

Diposkan oleh superstar2007 di 05:34 0 komentar

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) B101) A102) A103) C104) 105) D106) C107) C108) A 111) A112) E113) C114) E115) C116) A117) E118) A

119) D120) 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:

A. Secondary trombocytopeniaB. Thrombotic trombocytopenia purpuraC. Dengue hemorhagic feverD. Immune trombocytopenic purpuraE. 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: IAIO + IBIO > IAIB (AB), IAIO (A), IOIB (B), IOIO (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