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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. nicotinic acid
PMR and giant cell arteritis; can be seen both together;
Xray every 3m
Hypertriglyceridamia and hypercholesterolemia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

2. criteria for AS
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

3. Tx of gout in patient with ESRD or hx GI bleeding
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

4. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Viral arthritis or RA
Increased serum ferritin (acute phase protein)
Hyperflexion of both wrists--characteristic pain in one min

5. glucocorticoid therapy
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Increased serum ferritin (acute phase protein)

6. xanthomatous nodule
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Dorsum of hands and the Achilies tendon
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

7. When to stop statin if cpk elevated
Abx -bedrest - exercise
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
C for c ; crest 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

8. carpal tunnel
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disseminated gonoccal infection

9. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Measure ESR; polymyalgia rheumatica; tx prednisone
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
If person is HLA B27 positive

10. inflamed tendons in wrist - ankle - arms; sexual history
Minocyclin - inhibits metalloproteases and slows joint damage
ESRD
Disseminated gonoccal infection
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

11. caplan syndrom
Dorsum of hands and the Achilies tendon
Nodular lung densitieis with RA;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pseudogout/hemochromatosis;

12. primary muscle disease
Measure ca and ALP; increased ALP and normal ca for dx;
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
Nodular lung densitieis with RA;
Symmetrical proximal weakness; increased CPK

13. right anterior knee pain and provoked by climbing stairs or prolong sitting
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Patello femoral pain syndrome
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Increased serum ferritin (acute phase protein)

14. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Decrease urate secretion from kidney
PMR and giant cell arteritis; can be seen both together;
Hypertriglyceridamia and hypercholesterolemia
If person is HLA B27 positive

15. Rayanaud's disease vs phenomenon
If person is HLA B27 positive
Arthritic sweling of DIP
SLE - only minutes; RA; hours;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

16. anti-centromere ab
ESRD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
C for c ; crest syndrome
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

17. How glucocorticoid leads to bone loss
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;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

18. PIP joint involment
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Osteoarthirit (bouchard at pip - b comes first);
Disseminated gonoccal infection
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.

19. 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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

20. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Patello femoral pain syndrome
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

21. Use of allopurinol after kidney transplant
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Prophylactic agent to prevent recurrent attack; not given during acute attack
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

22. 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
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.
Coronary atherosclerosis due to SLE
PPD

23. Tx of RA
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Dorsum of hands and the Achilies tendon
Specific of dx of SLE

24. night back pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Prophylactic agent to prevent recurrent attack; not given during acute attack
Malignancy - infection - vertebral fracture
Specific of dx of SLE

25. cylosporin used after renal transplantation
Specific of dx of SLE
Decrease urate secretion from kidney
Abx -bedrest - exercise
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

26. tinel sign
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
Minocyclin - inhibits metalloproteases and slows joint damage
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

27. when SLE patient needs steroid
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
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
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

28. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Pseudogout/hemochromatosis;
Measure ESR; polymyalgia rheumatica; tx prednisone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
AS; sometime only symptom is uveitis;

29. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Supplementation ca and vitamin D

30. painless ulcer over glans penis and inflammatory arthritis
Specific of dx of SLE
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Think about reiter (cannot see - cannot pee - cannot climb a tree)

31. How to monitor disease activity in SLE
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

32. SLE patient p/w MI - vent fibrillation
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
Coronary atherosclerosis due to SLE
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

33. pagets in xray
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Measure ca and ALP; increased ALP and normal ca for dx;
Erythematous-violaceous rash on the eyelids
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

34. postoeriod shoulder pain
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

35. 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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pt with significant organ involvement and have incomplete response to prednisone alone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

36. anterior shoulder pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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.
High incidence of opportunistitc infection; reactivation of TB;

37. anti-ds DNA antibody
Disseminated gonoccal infection
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Specific of dx of SLE
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

38. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

39. How to perform schober test
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hypertriglyceridamia and hypercholesterolemia
Measure ca and ALP; increased ALP and normal ca for dx;

40. patient pw groin pain; on steroid
Abx -bedrest - exercise
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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

41. How often disease activity is monitored in AS?
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Xray every 3m

42. morning stiffness hand joints
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
SLE - only minutes; RA; hours;
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.
Check pedal pulses; in claudication pulses should diminish

43. common valvular abnormalities with AS?
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
SLE - only minutes; RA; hours;
Deposition of cholesterol in the periorbital skin
A for aortic regurg; s for prolapSe (MVP)

44. mcp and PIP joint involvement
Viral arthritis or RA
Malignancy - infection - vertebral fracture
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

45. Use of antibiotic in RA
Prednisone and cyclophosphamide
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Minocyclin - inhibits metalloproteases and slows joint damage

46. carpal tunnel syndrom
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
PMR and giant cell arteritis; can be seen both together;

47. spondyloarthopathy
Patello femoral pain syndrome
Malignancy - infection - vertebral fracture
Osteoarthirit (bouchard at pip - b comes first);
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

48. xanthelasma
Hyperflexion of both wrists--characteristic pain in one min
Patello femoral pain syndrome
Deposition of cholesterol in the periorbital skin
Order LFT - heat fractionation (bone burns and liver lives) - GGT

49. Tx of reiter
Abx -bedrest - exercise
PPD
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Coronary atherosclerosis due to SLE

50. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Xray every 3m
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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