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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. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
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
Measure ca and ALP; increased ALP and normal ca for dx;
Pt with significant organ involvement and have incomplete response to prednisone alone

2. carpal tunnel syndrom
Malignancy - infection - vertebral fracture
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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

3. allpurinol
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

4. Gait in spinal stenosis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
A for aortic regurg; s for prolapSe (MVP)
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

5. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Prednisone and cyclophosphamide

6. right anterior knee pain and provoked by climbing stairs or prolong sitting
PPD
Patello femoral pain syndrome
Supplementation ca and vitamin D
Pseudogout/hemochromatosis;

7. How glucocorticoid leads to bone loss
Osteoarthirit (bouchard at pip - b comes first);
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Viral arthritis or RA
Symmetrical proximal weakness; increased CPK

8. pain in shoulder and pelvic girdle
If person is HLA B27 positive
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Measure ESR; polymyalgia rheumatica; tx prednisone
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

9. criteria for AS
If person is HLA B27 positive
PMR and giant cell arteritis; can be seen both together;
Deposition of cholesterol in the periorbital skin
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

10. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Measure ca and ALP; increased ALP and normal ca for dx;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

11. MCP joint involvement
C for c ; crest syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

12. When to stop statin if cpk elevated
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

13. bouchard nodule
Arthritic sweling of DIP
Erythematous-violaceous rash on the eyelids
Malignancy - infection - vertebral fracture
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

14. inflamed tendons in wrist - ankle - arms; sexual history
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Disseminated gonoccal infection
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

15. Tx of reiter
Abx -bedrest - exercise
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
ESRD
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

16. How to differentiate radicular pain with claudication
Abx -bedrest - exercise
Dorsum of hands and the Achilies tendon
Specific of dx of SLE
Check pedal pulses; in claudication pulses should diminish

17. caplan syndrom
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
ESRD
Nodular lung densitieis with RA;
Hypertriglyceridamia and hypercholesterolemia

18. neck mass in sjogren patient
Minocyclin - inhibits metalloproteases and slows joint damage
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Viral arthritis or RA
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

19. Tx of gout
Xray every 3m
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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

20. glucocorticoid therapy
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Specific of dx of SLE
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

21. anti-centromere ab
PMR and giant cell arteritis; can be seen both together;
SLE - only minutes; RA; hours;
Prednisone and cyclophosphamide
C for c ; crest syndrome

22. How to prevent glucocorticoid induced bone loss
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Supplementation ca and vitamin D
Nodular lung densitieis with RA;
If symptoms persist >6weeks

23. heberdeen nodes
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Coronary atherosclerosis due to SLE
Arthritic sweling of DIP
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

24. What marker is used to follow up disease activity in SLE
Malignancy - infection - vertebral fracture
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

25. schirmer test
Measure ESR; polymyalgia rheumatica; tx prednisone
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.
A for aortic regurg; s for prolapSe (MVP)
Minocyclin - inhibits metalloproteases and slows joint damage

26. DIP joint involvement

27. painless ulcer over glans penis and inflammatory arthritis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If person is HLA B27 positive

28. SLE with pleural effusion
Prophylactic agent to prevent recurrent attack; not given during acute attack
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If person is HLA B27 positive
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

29. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
Prophylactic agent to prevent recurrent attack; not given during acute attack

30. management of LBP
PMR and giant cell arteritis; can be seen both together;
Hyper triglyceridemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Symmetrical proximal weakness; increased CPK

31. inflammatory myositis
Increased serum ferritin (acute phase protein)
Abx -bedrest - exercise
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

32. patient pw groin pain; on steroid
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
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
PMR and giant cell arteritis; can be seen both together;

33. When to order MRI in LBP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pt with significant organ involvement and have incomplete response to prednisone alone
If person is HLA B27 positive
If symptoms persist >6weeks

34. conjunctivitis - urethritis - and spondyloarthopathy

35. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pseudogout/hemochromatosis;
Nodular lung densitieis with RA;

36. increased ALP; liver or bone origin?
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hyperflexion of both wrists--characteristic pain in one min
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Order LFT - heat fractionation (bone burns and liver lives) - GGT

37. Tx of inflammatory myositis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

38. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Arthritic sweling of DIP
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
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

39. pagets in xray
Abx -bedrest - exercise
Measure ca and ALP; increased ALP and normal ca for dx;
Pt with significant organ involvement and have incomplete response to prednisone alone
Check pedal pulses; in claudication pulses should diminish

40. anti-mitochondrial
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Primary biliary cirrhosis
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
Osteoarthirit (bouchard at pip - b comes first);

41. who gets reiters syndrome after chlamydia infection
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
If person is HLA B27 positive
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.

42. Use of allopurinol after kidney transplant
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
PMR and giant cell arteritis; can be seen both together;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
AS; sometime only symptom is uveitis;

43. primary muscle disease
Specific of dx of SLE
Symmetrical proximal weakness; increased CPK
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Osteoarthirit (bouchard at pip - b comes first);

44. How to perform schober test
Check pedal pulses; in claudication pulses should diminish
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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
Primary biliary cirrhosis

45. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
SLE - only minutes; RA; hours;
AS; sometime only symptom is uveitis;
Malignancy - infection - vertebral fracture
Viral arthritis or RA

46. when SLE patient needs steroid
Supplementation ca and vitamin D
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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
Measure ca and ALP; increased ALP and normal ca for dx;

47. anterior shoulder pain
Primary biliary cirrhosis
If person is HLA B27 positive
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.

48. common valvular abnormalities with AS?
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hyperflexion of both wrists--characteristic pain in one min
AS; sometime only symptom is uveitis;
A for aortic regurg; s for prolapSe (MVP)

49. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hyper triglyceridemia

50. Management of HTN during acute gout
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid