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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. carpal tunnel syndrom
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Erythematous-violaceous rash on the eyelids
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

2. Tx of lupus nephritis
PMR and giant cell arteritis; can be seen both together;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Prednisone and cyclophosphamide

3. patient is having pain when he moves hands above shoulder
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

4. bouchard nodule
Primary biliary cirrhosis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

5. How to perform schober test
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
A for aortic regurg; s for prolapSe (MVP)
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

6. probenecid
Erythematous-violaceous rash on the eyelids
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Coronary atherosclerosis due to SLE

7. Tx of reiter
Measure ca and ALP; increased ALP and normal ca for dx;
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Abx -bedrest - exercise

8. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Patello femoral pain syndrome
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Osteoarthirit (bouchard at pip - b comes first);
Pseudogout/hemochromatosis;

9. Use of antibiotic in RA
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
Minocyclin - inhibits metalloproteases and slows joint damage
Hypertriglyceridamia and hypercholesterolemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

10. tx pagets
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

11. neck mass in sjogren patient
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

12. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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

13. SLE with pleural effusion
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
ESRD
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

14. What should be chekcked before starting infliximab
Xray every 3m
Supplementation ca and vitamin D
PPD
Osteoarthirit (bouchard at pip - b comes first);

15. What is heliotrope sign
AS; sometime only symptom is uveitis;
PPD
Erythematous-violaceous rash on the eyelids
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

16. Management of HTN during acute gout
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Increased serum ferritin (acute phase protein)
Dorsum of hands and the Achilies tendon

17. cylosporin used after renal transplantation
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Decrease urate secretion from kidney
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.
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

18. Tx of gout in patient with ESRD or hx GI bleeding
Symmetrical proximal weakness; increased CPK
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

19. postoeriod shoulder pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Nodular lung densitieis with RA;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

20. Tx of gout
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
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
Pt with significant organ involvement and have incomplete response to prednisone alone

21. night back pain
Viral arthritis or RA
Malignancy - infection - vertebral fracture
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
AS; sometime only symptom is uveitis;

22. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Patello femoral pain syndrome
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

23. morning stiffness hand joints
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
SLE - only minutes; RA; hours;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Osteoarthirit (bouchard at pip - b comes first);

24. When to order MRI in LBP
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
If symptoms persist >6weeks
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

25. How to differentiate radicular pain with claudication
Patello femoral pain syndrome
Xray every 3m
Check pedal pulses; in claudication pulses should diminish
Increased serum ferritin (acute phase protein)

26. inflammatory myositis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Increased serum ferritin (acute phase protein)
Supplementation ca and vitamin D

27. anti-centromere ab
C for c ; crest syndrome
Pt with significant organ involvement and have incomplete response to prednisone alone
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

28. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Deposition of cholesterol in the periorbital skin
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

29. anti-ds DNA antibody
Specific of dx of SLE
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
Viral arthritis or RA
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

30. Use of allopurinol after kidney transplant
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Patello femoral pain syndrome

31. Finding of MRI in stenosis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Nodular lung densitieis with RA;
Hyperflexion of both wrists--characteristic pain in one min
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

32. nicotinic acid
Disseminated gonoccal infection
Specific of dx of SLE
Hypertriglyceridamia and hypercholesterolemia
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

33. How often disease activity is monitored in AS?
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Increased serum ferritin (acute phase protein)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Xray every 3m

34. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Dorsum of hands and the Achilies tendon
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

35. primary muscle disease
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Symmetrical proximal weakness; increased CPK
If symptoms persist >6weeks
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

36. when SLE patient needs steroid
Primary biliary cirrhosis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
PPD
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

37. When to stop statin if cpk elevated
Xray every 3m
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

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

39. SLE patient p/w MI - vent fibrillation
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Coronary atherosclerosis due to SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

40. inflamed tendons in wrist - ankle - arms; sexual history
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Disseminated gonoccal infection
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

41. How to monitor disease activity in SLE
C for c ; crest syndrome
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

42. How to differential lumbar spinal stenosis and disc herniation pain?
SLE - only minutes; RA; hours;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
C for c ; crest syndrome

43. patient pw groin pain; on steroid
Deposition of cholesterol in the periorbital skin
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Measure ca and ALP; increased ALP and normal ca for dx;
Disseminated gonoccal infection

44. When to start DMARD in RA
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
C for c ; crest syndrome
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

45. increased ALP; liver or bone origin?
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

46. How glucocorticoid leads to bone loss
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Abx -bedrest - exercise
Xray every 3m

47. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Arthritic sweling of DIP
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

48. spondyloarthopathy
Pt with significant organ involvement and have incomplete response to prednisone alone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Viral arthritis or RA
Malignancy - infection - vertebral fracture

49. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Check pedal pulses; in claudication pulses should diminish
PMR and giant cell arteritis; can be seen both together;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

50. Ca oxalate induced arthritis
Specific of dx of SLE
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
ESRD
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood