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USMLE Step3 Rheumatology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 20 minutes. 2 minutes extra for reading the instructions.
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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. caplan syndrom
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Nodular lung densitieis with RA;
Dorsum of hands and the Achilies tendon
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

2. Use of antibiotic in RA
Minocyclin - inhibits metalloproteases and slows joint damage
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pt with significant organ involvement and have incomplete response to prednisone alone

3. Tx of gout
Nodular lung densitieis with RA;
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
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
Primary biliary cirrhosis

4. SLE with pleural effusion
Nodular lung densitieis with RA;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
C for c ; crest syndrome
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

5. What is heliotrope sign
Increased serum ferritin (acute phase protein)
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Erythematous-violaceous rash on the eyelids

6. How to differential lumbar spinal stenosis and disc herniation pain?
Malignancy - infection - vertebral fracture
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Supplementation ca and vitamin D

7. criteria for AS
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Arthritic sweling of DIP
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

8. What marker is used to follow up disease activity in SLE
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
AS; sometime only symptom is uveitis;
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

9. Tx of lupus nephritis
Prednisone and cyclophosphamide
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

10. Use of allopurinol after kidney transplant
Deposition of cholesterol in the periorbital skin
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Supplementation ca and vitamin D

11. tx pagets
High incidence of opportunistitc infection; reactivation of TB;
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

12. gemfibrozil
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Measure ca and ALP; increased ALP and normal ca for dx;
Hyper triglyceridemia
Think about reiter (cannot see - cannot pee - cannot climb a tree)

13. probenecid
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

14. How often disease activity is monitored in AS?
Check pedal pulses; in claudication pulses should diminish
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
Xray every 3m
Prednisone and cyclophosphamide

15. mcp and PIP joint involvement
Dorsum of hands and the Achilies tendon
Viral arthritis or RA
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

16. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Abx -bedrest - exercise
Pseudogout/hemochromatosis;
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
Erythematous-violaceous rash on the eyelids

17. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
SLE - only minutes; RA; hours;
Hyperflexion of both wrists--characteristic pain in one min

18. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Primary biliary cirrhosis
Patello femoral pain syndrome

19. cylosporin used after renal transplantation
Patello femoral pain syndrome
Increased serum ferritin (acute phase protein)
Measure ESR; polymyalgia rheumatica; tx prednisone
Decrease urate secretion from kidney

20. night back pain
PMR and giant cell arteritis; can be seen both together;
Minocyclin - inhibits metalloproteases and slows joint damage
Malignancy - infection - vertebral fracture
Nodular lung densitieis with RA;

21. inflamed tendons in wrist - ankle - arms; sexual history
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Disseminated gonoccal infection
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

22. inflammatory myositis
Increased serum ferritin (acute phase protein)
C for c ; crest syndrome
If symptoms persist >6weeks
PMR and giant cell arteritis; can be seen both together;

23. What should be chekcked before starting infliximab
Supplementation ca and vitamin D
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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
PPD

24. Gait in spinal stenosis
ESRD
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

25. morning stiffness hand joints
Malignancy - infection - vertebral fracture
If person is HLA B27 positive
Order LFT - heat fractionation (bone burns and liver lives) - GGT
SLE - only minutes; RA; hours;

26. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
SLE - only minutes; RA; hours;
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

27. xanthelasma
Deposition of cholesterol in the periorbital skin
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

28. anti-mitochondrial
If person is HLA B27 positive
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Primary biliary cirrhosis

29. When to give methotrexate in SLE
Pseudogout/hemochromatosis;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
High incidence of opportunistitc infection; reactivation of TB;
Pt with significant organ involvement and have incomplete response to prednisone alone

30. DIP joint involvement

31. How to perform schober test
PPD
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
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

32. How to differentiate radicular pain with claudication
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Check pedal pulses; in claudication pulses should diminish

33. right anterior knee pain and provoked by climbing stairs or prolong sitting
High incidence of opportunistitc infection; reactivation of TB;
If person is HLA B27 positive
Patello femoral pain syndrome
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

34. pain in shoulder and pelvic girdle
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Measure ESR; polymyalgia rheumatica; tx prednisone
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

35. neck mass in sjogren patient
PPD
Coronary atherosclerosis due to SLE
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Nodular lung densitieis with RA;

36. patient is having pain when he moves hands above shoulder
Supplementation ca and vitamin D
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Coronary atherosclerosis due to SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

37. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
If person is HLA B27 positive
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

38. Tx of RA
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pseudogout/hemochromatosis;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

39. Rayanaud's disease vs phenomenon
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ESRD
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Arthritic sweling of DIP

40. allpurinol
Pt with significant organ involvement and have incomplete response to prednisone alone
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Prophylactic agent to prevent recurrent attack; not given during acute attack
If person is HLA B27 positive

41. Finding of MRI in stenosis
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Symmetrical proximal weakness; increased CPK
Supplementation ca and vitamin D

42. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Viral arthritis or RA
Coronary atherosclerosis due to SLE
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

43. Tx of gout in patient with ESRD or hx GI bleeding
Hyper triglyceridemia
Viral arthritis or RA
Decrease urate secretion from kidney
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

44. Raynauds phenomenon
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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

45. common valvular abnormalities with AS?
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Dorsum of hands and the Achilies tendon
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
A for aortic regurg; s for prolapSe (MVP)

46. colchicine
Disseminated gonoccal infection
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Prophylactic agent to prevent recurrent attack; not given during acute attack

47. pagets in xray
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Measure ca and ALP; increased ALP and normal ca for dx;
Pseudogout/hemochromatosis;
Decrease urate secretion from kidney

48. carpal tunnel
Specific of dx of SLE
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
PMR and giant cell arteritis; can be seen both together;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

49. glucocorticoid therapy
Deposition of cholesterol in the periorbital skin
High incidence of opportunistitc infection; reactivation of TB;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Coronary atherosclerosis due to SLE

50. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
A for aortic regurg; s for prolapSe (MVP)
Prophylactic agent to prevent recurrent attack; not given during acute attack
Order LFT - heat fractionation (bone burns and liver lives) - GGT
AS; sometime only symptom is uveitis;