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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. anterior shoulder pain
Arthritic sweling of DIP
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Minocyclin - inhibits metalloproteases and slows joint damage

2. glucocorticoid therapy
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
Deposition of cholesterol in the periorbital skin
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Abx -bedrest - exercise

3. schirmer test
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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.
Pseudogout/hemochromatosis;
Think about reiter (cannot see - cannot pee - cannot climb a tree)

4. xanthomatous nodule
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Dorsum of hands and the Achilies tendon
Nodular lung densitieis with RA;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

5. Use of antibiotic in RA
Minocyclin - inhibits metalloproteases and slows joint damage
C for c ; crest syndrome
Hyper triglyceridemia
If symptoms persist >6weeks

6. MCP joint involvement
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

7. allpurinol
Coronary atherosclerosis due to SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Osteoarthirit (bouchard at pip - b comes first);
Prophylactic agent to prevent recurrent attack; not given during acute attack

8. painless ulcer over glans penis and inflammatory arthritis
Nodular lung densitieis with RA;
PPD
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

9. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Pt with significant organ involvement and have incomplete response to prednisone alone
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

10. Management of HTN during acute gout
Xray every 3m
C for c ; crest syndrome
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

11. Low back pain
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Viral arthritis or RA

12. Tx of gout
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Minocyclin - inhibits metalloproteases and slows joint damage
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. anti-ds DNA antibody
SLE - only minutes; RA; hours;
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;
Specific of dx of SLE

14. Ca oxalate induced arthritis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
ESRD
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.

15. management of LBP
Pt with significant organ involvement and have incomplete response to prednisone alone
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Measure ca and ALP; increased ALP and normal ca for dx;
If symptoms persist >6weeks

16. anti-mitochondrial
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hyper triglyceridemia
Malignancy - infection - vertebral fracture
Primary biliary cirrhosis

17. common valvular abnormalities with AS?
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
A for aortic regurg; s for prolapSe (MVP)

18. Rayanaud's disease vs phenomenon
SLE - only minutes; RA; hours;
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
Viral arthritis or RA

19. What is heliotrope sign
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Erythematous-violaceous rash on the eyelids
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

20. anti-centromere ab
C for c ; crest syndrome
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

21. role HLA B27 in dx of ankylosing spondylitis
If person is HLA B27 positive
High incidence of opportunistitc infection; reactivation of TB;
Hyper triglyceridemia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

22. What marker is used to follow up disease activity in SLE
Xray every 3m
Patello femoral pain syndrome
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

23. who gets reiters syndrome after chlamydia infection
A for aortic regurg; s for prolapSe (MVP)
If person is HLA B27 positive
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Pseudogout/hemochromatosis;

24. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
PPD
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Abx -bedrest - exercise

25. Raynauds phenomenon
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Viral arthritis or RA
PPD
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

26. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

27. Tx of reiter
If symptoms persist >6weeks
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Abx -bedrest - exercise

28. caplan syndrom
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Nodular lung densitieis with RA;

29. Tx of gout in patient with ESRD or hx GI bleeding
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Primary biliary cirrhosis
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
PPD

30. What should be chekcked before starting infliximab
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
Minocyclin - inhibits metalloproteases and slows joint damage
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
PPD

31. Tx of inflammatory myositis
Primary biliary cirrhosis
AS; sometime only symptom is uveitis;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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

32. How to differential lumbar spinal stenosis and disc herniation pain?
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
AS; sometime only symptom is uveitis;

33. colchicine
Supplementation ca and vitamin D
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Prednisone and cyclophosphamide

34. mcp and PIP joint involvement
Viral arthritis or RA
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
Deposition of cholesterol in the periorbital skin
Disseminated gonoccal infection

35. When to give methotrexate in SLE
Check pedal pulses; in claudication pulses should diminish
Pt with significant organ involvement and have incomplete response to prednisone alone
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Erythematous-violaceous rash on the eyelids

36. patient pw groin pain; on steroid
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
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

37. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
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
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

38. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
PMR and giant cell arteritis; can be seen both together;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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

39. How often disease activity is monitored in AS?
Hyperflexion of both wrists--characteristic pain in one min
Increased serum ferritin (acute phase protein)
Xray every 3m
Viral arthritis or RA

40. When to order MRI in LBP
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If symptoms persist >6weeks
Minocyclin - inhibits metalloproteases and slows joint damage
Think about reiter (cannot see - cannot pee - cannot climb a tree)

41. spondyloarthopathy
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

42. 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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
C for c ; crest syndrome

43. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Decrease urate secretion from kidney
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Minocyclin - inhibits metalloproteases and slows joint damage

44. gemfibrozil
Hyper triglyceridemia
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
PPD

45. inflammatory myositis
PMR and giant cell arteritis; can be seen both together;
Increased serum ferritin (acute phase protein)
Coronary atherosclerosis due to SLE
Xray every 3m

46. 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
SLE - only minutes; RA; hours;
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

47. probenecid
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
SLE - only minutes; RA; hours;
Symmetrical proximal weakness; increased CPK

48. neck mass in sjogren patient
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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

49. How glucocorticoid leads to bone loss
Disseminated gonoccal infection
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Measure ca and ALP; increased ALP and normal ca for dx;

50. How to differentiate radicular pain with claudication
Minocyclin - inhibits metalloproteases and slows joint damage
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
Check pedal pulses; in claudication pulses should diminish
SLE - only minutes; RA; hours;