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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. Tx of lupus nephritis
Osteoarthirit (bouchard at pip - b comes first);
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
Decrease urate secretion from kidney
Prednisone and cyclophosphamide

2. Tx of reiter
Abx -bedrest - exercise
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
Supplementation ca and vitamin D
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

3. anti-ds DNA antibody
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Specific of dx of SLE

4. DIP joint involvement

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5. Raynauds phenomenon
Osteoarthirit (bouchard at pip - b comes first);
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

6. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Erythematous-violaceous rash on the eyelids
Osteoarthirit (bouchard at pip - b comes first);
AS; sometime only symptom is uveitis;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

7. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Xray every 3m
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

8. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Order LFT - heat fractionation (bone burns and liver lives) - GGT
AS; sometime only symptom is uveitis;
Viral arthritis or RA

9. allpurinol
Check pedal pulses; in claudication pulses should diminish
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Measure ESR; polymyalgia rheumatica; tx prednisone
Prophylactic agent to prevent recurrent attack; not given during acute attack

10. anti-centromere ab
Decrease urate secretion from kidney
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
C for c ; crest syndrome
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

11. neck mass in sjogren patient
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Primary biliary cirrhosis

12. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
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 ESR; polymyalgia rheumatica; tx prednisone
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

13. 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
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;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

14. gemfibrozil
Hyper triglyceridemia
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
ESRD
C for c ; crest syndrome

15. criteria for AS
A for aortic regurg; s for prolapSe (MVP)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

16. How glucocorticoid leads to bone loss
Dorsum of hands and the Achilies tendon
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

17. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
C for c ; crest syndrome
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

18. role HLA B27 in dx of ankylosing spondylitis
Malignancy - infection - vertebral fracture
Osteoarthirit (bouchard at pip - b comes first);
Dorsum of hands and the Achilies tendon
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

19. anterior shoulder pain
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

20. SLE patient p/w MI - vent fibrillation
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Coronary atherosclerosis due to SLE
Prednisone and cyclophosphamide
Pseudogout/hemochromatosis;

21. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Dorsum of hands and the Achilies tendon

22. Use of antibiotic in RA
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prednisone and cyclophosphamide
Minocyclin - inhibits metalloproteases and slows joint damage

23. How to prevent glucocorticoid induced bone loss
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Supplementation ca and vitamin D
A for aortic regurg; s for prolapSe (MVP)
Hypertriglyceridamia and hypercholesterolemia

24. How to differential lumbar spinal stenosis and disc herniation pain?
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Viral arthritis or RA
Patello femoral pain syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

25. inflamed tendons in wrist - ankle - arms; sexual history
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
SLE - only minutes; RA; hours;
Disseminated gonoccal infection
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

26. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Arthritic sweling of DIP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Specific of dx of SLE

27. anti-mitochondrial
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hyperflexion of both wrists--characteristic pain in one min
Pt with significant organ involvement and have incomplete response to prednisone alone
Primary biliary cirrhosis

28. How often disease activity is monitored in AS?
Xray every 3m
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
ESRD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

29. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Osteoarthirit (bouchard at pip - b comes first);
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

30. Tx of gout in patient with ESRD or hx GI bleeding
PPD
Hyperflexion of both wrists--characteristic pain in one min
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

31. inflammatory myositis
Xray every 3m
Increased serum ferritin (acute phase protein)
Deposition of cholesterol in the periorbital skin
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

32. What marker is used to follow up disease activity in SLE
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Coronary atherosclerosis due to 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

33. 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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Primary biliary cirrhosis

34. management of LBP
Increased serum ferritin (acute phase protein)
Dorsum of hands and the Achilies tendon
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

35. probenecid
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

36. How to perform schober test
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Patello femoral pain syndrome
PMR and giant cell arteritis; can be seen both together;

37. Ca oxalate induced arthritis
ESRD
Symmetrical proximal weakness; increased CPK
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

38. What should be chekcked before starting infliximab
Decrease urate secretion from kidney
High incidence of opportunistitc infection; reactivation of TB;
PPD
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

39. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Supplementation ca and vitamin D
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Prednisone and cyclophosphamide
Nodular lung densitieis with RA;

40. 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.
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

41. nicotinic acid
PMR and giant cell arteritis; can be seen both together;
Nodular lung densitieis with RA;
Hypertriglyceridamia and hypercholesterolemia
Prophylactic agent to prevent recurrent attack; not given during acute attack

42. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pt with significant organ involvement and have incomplete response to prednisone alone

43. when SLE patient needs steroid
Osteoarthirit (bouchard at pip - b comes first);
Hyperflexion of both wrists--characteristic pain in one min
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

44. Tx of gout
Disseminated gonoccal infection
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
ESRD
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

45. morning stiffness hand joints
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.
A for aortic regurg; s for prolapSe (MVP)
SLE - only minutes; RA; hours;

46. carpal tunnel syndrom
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.
Check pedal pulses; in claudication pulses should diminish
SLE - only minutes; RA; hours;

47. MCP joint involvement
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Specific of dx of SLE
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

48. schirmer test
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.
PMR and giant cell arteritis; can be seen both together;
Decrease urate secretion from kidney
Coronary atherosclerosis due to SLE

49. conjunctivitis - urethritis - and spondyloarthopathy

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50. tinel sign
Primary biliary cirrhosis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Minocyclin - inhibits metalloproteases and slows joint damage
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;