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USMLE Step3 Rheumatology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. Rayanaud's disease vs phenomenon
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Minocyclin - inhibits metalloproteases and slows joint damage

2. role HLA B27 in dx of ankylosing spondylitis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

3. When to give methotrexate in SLE
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hyperflexion of both wrists--characteristic pain in one min
Pt with significant organ involvement and have incomplete response to prednisone alone

4. xanthelasma
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
High incidence of opportunistitc infection; reactivation of TB;
ESRD
Deposition of cholesterol in the periorbital skin

5. Finding of MRI in stenosis
Symmetrical proximal weakness; increased CPK
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Erythematous-violaceous rash on the eyelids

6. Gait in spinal stenosis
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyper triglyceridemia
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

7. Tx of lupus nephritis
Increased serum ferritin (acute phase protein)
Pt with significant organ involvement and have incomplete response to prednisone alone
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prednisone and cyclophosphamide

8. allpurinol
Coronary atherosclerosis due to SLE
Prophylactic agent to prevent recurrent attack; not given during acute attack
Measure ca and ALP; increased ALP and normal ca for dx;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

9. How to differentiate radicular pain with claudication
No NSAID - no colchicine (CI-ARF); r/o septic arthritis - similar presentation; give intraarticular corticosteroid if one joint involvement; if multiple joint involved give oral prednisone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Supplementation ca and vitamin D
Check pedal pulses; in claudication pulses should diminish

10. primary muscle disease
Symmetrical proximal weakness; increased CPK
A for aortic regurg; s for prolapSe (MVP)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
To test adequate tear production in sjogren syndrome; filter paper is placed along lower eyelid and wetting of paper measured after a defined period of time.

11. When to start DMARD in RA
Osteoarthirit (bouchard at pip - b comes first);
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
If person is HLA B27 positive

12. schirmer test
Anti-ds DNA; the levels have been associated iwth development of lupus nephritis; immune complexes of these antibodies are seen glomeruli of patient with lupus nephriis
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
To test adequate tear production in sjogren syndrome; filter paper is placed along lower eyelid and wetting of paper measured after a defined period of time.

13. Raynauds phenomenon
If more than 10 times about the upper limit of normal range; chances of statin myopathy higher if statin is used in combination with fibric acid derivative
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Xray every 3m

14. SLE with pleural effusion
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
PPD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

15. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Osteoarthirit (bouchard at pip - b comes first);
Nodular lung densitieis with RA;
Disseminated gonoccal infection

16. When to stop statin if cpk elevated
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If more than 10 times about the upper limit of normal range; chances of statin myopathy higher if statin is used in combination with fibric acid derivative
Pseudogout/hemochromatosis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

17. DIP joint involvement

18. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Supplementation ca and vitamin D
Minocyclin - inhibits metalloproteases and slows joint damage
Patello femoral pain syndrome

19. increased ALP; liver or bone origin?
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pseudogout/hemochromatosis;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

20. Tx of gout in patient with ESRD or hx GI bleeding
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Dorsum of hands and the Achilies tendon
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
No NSAID - no colchicine (CI-ARF); r/o septic arthritis - similar presentation; give intraarticular corticosteroid if one joint involvement; if multiple joint involved give oral prednisone

21. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Check pedal pulses; in claudication pulses should diminish
AS; sometime only symptom is uveitis;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

22. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

23. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Disseminated gonoccal infection
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

24. when SLE patient needs steroid
Renal biopsy is needed when kidney is involved; Type 1 and type 2 need no tx; type 3 and 4 need immunosuppresion cyclophosphamide; more frequent patter; type 5 needs tx when it is proliferative
Increased serum ferritin (acute phase protein)
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

25. patient pw groin pain; on steroid
Nodular lung densitieis with RA;
AS; sometime only symptom is uveitis;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Think about reiter (cannot see - cannot pee - cannot climb a tree)

26. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

27. gemfibrozil
Hyper triglyceridemia
Check pedal pulses; in claudication pulses should diminish
Minocyclin - inhibits metalloproteases and slows joint damage
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

28. inflamed tendons in wrist - ankle - arms; sexual history
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Disseminated gonoccal infection
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

29. phalen test
Osteoarthirit (bouchard at pip - b comes first);
Hyperflexion of both wrists--characteristic pain in one min
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
AS; sometime only symptom is uveitis;

30. patient is having pain when he moves hands above shoulder
SLE - only minutes; RA; hours;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
No benefit of nsaid; firstline therapy night time splinting; oral corticosteroid for short term improvment; surgery for moderate to severe symptoms; occupational rehab before surgery eg less typing - less wrist flexion-extension
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

31. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Renal biopsy is needed when kidney is involved; Type 1 and type 2 need no tx; type 3 and 4 need immunosuppresion cyclophosphamide; more frequent patter; type 5 needs tx when it is proliferative
Malignancy - infection - vertebral fracture
Spinous process of 5th lumbar disc identified and maked; a point 10cm above the first mark. the patient is asked bend forward; then two points are measured. normal 15 cm

32. criteria for AS
Hyperflexion of both wrists--characteristic pain in one min
Increased serum ferritin (acute phase protein)
No benefit of nsaid; firstline therapy night time splinting; oral corticosteroid for short term improvment; surgery for moderate to severe symptoms; occupational rehab before surgery eg less typing - less wrist flexion-extension
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

33. tx pagets
No NSAID - no colchicine (CI-ARF); r/o septic arthritis - similar presentation; give intraarticular corticosteroid if one joint involvement; if multiple joint involved give oral prednisone
Decrease urate secretion from kidney
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

34. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Spinous process of 5th lumbar disc identified and maked; a point 10cm above the first mark. the patient is asked bend forward; then two points are measured. normal 15 cm
To test adequate tear production in sjogren syndrome; filter paper is placed along lower eyelid and wetting of paper measured after a defined period of time.
Measure ESR; polymyalgia rheumatica; tx prednisone

35. morning stiffness hand joints
If person is HLA B27 positive
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
SLE - only minutes; RA; hours;
Osteoarthirit (bouchard at pip - b comes first);

36. What should be chekcked before starting infliximab
PMR and giant cell arteritis; can be seen both together;
PPD
NSAID if kidney function is OK and no hx of GI bleeding; very important; in kidney transplant patient - NSAID decrease renal PG production - other immunosuppresive like cyclosporine also decreases renal PG; concomitant use will compromise renal funct
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

37. Tx of RA
Supplementation ca and vitamin D
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
NSAID if kidney function is OK and no hx of GI bleeding; very important; in kidney transplant patient - NSAID decrease renal PG production - other immunosuppresive like cyclosporine also decreases renal PG; concomitant use will compromise renal funct
Order LFT - heat fractionation (bone burns and liver lives) - GGT

38. Tx of inflammatory myositis
Patello femoral pain syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

39. conjunctivitis - urethritis - and spondyloarthopathy

40. Tx of reiter
Order LFT - heat fractionation (bone burns and liver lives) - GGT
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Abx -bedrest - exercise
No benefit of nsaid; firstline therapy night time splinting; oral corticosteroid for short term improvment; surgery for moderate to severe symptoms; occupational rehab before surgery eg less typing - less wrist flexion-extension

41. colchicine
Hyperflexion of both wrists--characteristic pain in one min
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

42. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Patello femoral pain syndrome
Pt with significant organ involvement and have incomplete response to prednisone alone
Reactive arthritis (reiter's syndrome); 80% HLA b27 positive - preceding genitourinary or gi infection eg chlamydia cervicitis or urethritis or shigella salmonesll and campylobacter infection

43. who gets reiters syndrome after chlamydia infection
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
If person is HLA B27 positive
A for aortic regurg; s for prolapSe (MVP)
Viral arthritis or RA

44. glucocorticoid therapy
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pt with significant organ involvement and have incomplete response to prednisone alone
If person is HLA B27 positive
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

45. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Prednisone and cyclophosphamide

46. carpal tunnel
Check pedal pulses; in claudication pulses should diminish
No benefit of nsaid; firstline therapy night time splinting; oral corticosteroid for short term improvment; surgery for moderate to severe symptoms; occupational rehab before surgery eg less typing - less wrist flexion-extension
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Arthritic sweling of DIP

47. Tx of gout
NSAID if kidney function is OK and no hx of GI bleeding; very important; in kidney transplant patient - NSAID decrease renal PG production - other immunosuppresive like cyclosporine also decreases renal PG; concomitant use will compromise renal funct
No NSAID - no colchicine (CI-ARF); r/o septic arthritis - similar presentation; give intraarticular corticosteroid if one joint involvement; if multiple joint involved give oral prednisone
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
High incidence of opportunistitc infection; reactivation of TB;

48. Use of allopurinol after kidney transplant
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Malignancy - infection - vertebral fracture
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
A for aortic regurg; s for prolapSe (MVP)

49. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
If more than 10 times about the upper limit of normal range; chances of statin myopathy higher if statin is used in combination with fibric acid derivative
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

50. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prophylactic agent to prevent recurrent attack; not given during acute attack
Hypertriglyceridamia and hypercholesterolemia
If more than 10 times about the upper limit of normal range; chances of statin myopathy higher if statin is used in combination with fibric acid derivative