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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. SLE with pleural effusion
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.
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hyper triglyceridemia

2. heberdeen nodes
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Arthritic sweling of DIP
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

3. Gait in spinal stenosis
Primary biliary cirrhosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Viral arthritis or RA
AS; sometime only symptom is uveitis;

4. who gets reiters syndrome after chlamydia infection
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
If person is HLA B27 positive
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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.

5. 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.
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
Supplementation ca and vitamin D
PMR and giant cell arteritis; can be seen both together;

6. What marker is used to follow up disease activity in SLE
Prophylactic agent to prevent recurrent attack; not given during acute attack
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
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. common valvular abnormalities with AS?
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
A for aortic regurg; s for prolapSe (MVP)
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

8. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
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
Malignancy - infection - vertebral fracture
If person is HLA B27 positive

9. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
A for aortic regurg; s for prolapSe (MVP)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

10. postoeriod shoulder pain
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

11. How to prevent glucocorticoid induced bone loss
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
Arthritic sweling of DIP
Supplementation ca and vitamin D
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

12. anti-ds DNA antibody
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
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Specific of dx of SLE

13. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Deposition of cholesterol in the periorbital skin
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hyperflexion of both wrists--characteristic pain in one min

14. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hypertriglyceridamia and hypercholesterolemia

15. 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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
ESRD

16. How to differential lumbar spinal stenosis and disc herniation pain?
Check pedal pulses; in claudication pulses should diminish
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

17. Use of antibiotic in RA
SLE - only minutes; RA; hours;
Minocyclin - inhibits metalloproteases and slows joint damage
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

18. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
A for aortic regurg; s for prolapSe (MVP)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Xray every 3m

19. when SLE patient needs steroid
Hypertriglyceridamia and hypercholesterolemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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

20. Ca oxalate induced arthritis
High incidence of opportunistitc infection; reactivation of TB;
ESRD
Measure ESR; polymyalgia rheumatica; tx prednisone
PPD

21. colchicine
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.
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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

22. Management of HTN during acute gout
Pseudogout/hemochromatosis;
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
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

23. When to give methotrexate in SLE
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
Pt with significant organ involvement and have incomplete response to prednisone alone
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

24. SLE patient p/w MI - vent fibrillation
Measure ca and ALP; increased ALP and normal ca for dx;
Coronary atherosclerosis due to SLE
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

25. right anterior knee pain and provoked by climbing stairs or prolong sitting
Abx -bedrest - exercise
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
Patello femoral pain syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

26. How to monitor disease activity in SLE
AS; sometime only symptom is uveitis;
If person is HLA B27 positive
PMR and giant cell arteritis; can be seen both together;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

27. caplan syndrom
Prophylactic agent to prevent recurrent attack; not given during acute attack
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Nodular lung densitieis with RA;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

28. Raynauds phenomenon
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
Measure ca and ALP; increased ALP and normal ca for dx;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

29. Finding of MRI in stenosis
Symmetrical proximal weakness; increased CPK
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

30. allpurinol
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Abx -bedrest - exercise

31. tx pagets
If person is HLA B27 positive
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Check pedal pulses; in claudication pulses should diminish
Hyperflexion of both wrists--characteristic pain in one min

32. carpal tunnel syndrom
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
C for c ; crest syndrome
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.

33. When to order MRI in LBP
If symptoms persist >6weeks
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Minocyclin - inhibits metalloproteases and slows joint damage
Measure ca and ALP; increased ALP and normal ca for dx;

34. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
AS; sometime only symptom is uveitis;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

35. conjunctivitis - urethritis - and spondyloarthopathy

36. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

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

38. When to stop statin if cpk elevated
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Hyper triglyceridemia
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
Hypertriglyceridamia and hypercholesterolemia

39. Tx of gout
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
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

40. MCP joint involvement
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

41. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Viral arthritis or RA
Deposition of cholesterol in the periorbital skin

42. mcp and PIP joint involvement
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Viral arthritis or RA
Symmetrical proximal weakness; increased CPK

43. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Prophylactic agent to prevent recurrent attack; not given during acute attack
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
A for aortic regurg; s for prolapSe (MVP)

44. 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;
Pt with significant organ involvement and have incomplete response to prednisone alone
Supplementation ca and vitamin D

45. When to start DMARD in RA
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
Abx -bedrest - exercise
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

46. How often disease activity is monitored in AS?
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
Xray every 3m
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

47. complications of anti-cytokine therapy
Coronary atherosclerosis due to SLE
High incidence of opportunistitc infection; reactivation of TB;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Dorsum of hands and the Achilies tendon

48. inflammatory myositis
Increased serum ferritin (acute phase protein)
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Abx -bedrest - exercise
Prednisone and cyclophosphamide

49. bouchard nodule
If person is HLA B27 positive
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Abx -bedrest - exercise
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

50. patient is having pain when he moves hands above shoulder
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
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.
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis