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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.
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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. phalen test
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Prednisone and cyclophosphamide
Hyperflexion of both wrists--characteristic pain in one min

2. Management of HTN during acute gout
Specific of dx of SLE
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

3. 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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
A for aortic regurg; s for prolapSe (MVP)
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

4. conjunctivitis - urethritis - and spondyloarthopathy

5. When to order MRI in LBP
If symptoms persist >6weeks
If person is HLA B27 positive
Hyper triglyceridemia
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

6. criteria for AS
Nodular lung densitieis with RA;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

7. How glucocorticoid leads to bone loss
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
If person is HLA B27 positive
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

8. How to monitor disease activity in SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

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

10. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
If symptoms persist >6weeks
AS; sometime only symptom is uveitis;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

11. Gait in spinal stenosis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prophylactic agent to prevent recurrent attack; not given during acute attack
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

12. bouchard nodule
Erythematous-violaceous rash on the eyelids
Hypertriglyceridamia and hypercholesterolemia
Pseudogout/hemochromatosis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

13. DIP joint involvement

14. PIP joint involment
Increased serum ferritin (acute phase protein)
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

15. SLE with pleural effusion
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

16. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
Symmetrical proximal weakness; increased CPK

17. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Xray every 3m
High incidence of opportunistitc infection; reactivation of TB;
Hyper triglyceridemia

18. inflamed tendons in wrist - ankle - arms; sexual history
Hyperflexion of both wrists--characteristic pain in one min
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
C for c ; crest syndrome
Disseminated gonoccal infection

19. when SLE patient needs steroid
Coronary atherosclerosis due to SLE
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

20. Tx of inflammatory myositis
A for aortic regurg; s for prolapSe (MVP)
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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

21. colchicine
AS; sometime only symptom is uveitis;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Primary biliary cirrhosis
Disseminated gonoccal infection

22. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
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
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
Arthritic sweling of DIP
AS; sometime only symptom is uveitis;

23. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
SLE - only minutes; RA; hours;
Symmetrical proximal weakness; increased CPK
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

24. caplan syndrom
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
Nodular lung densitieis with RA;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Abx -bedrest - exercise

25. tinel sign
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Xray every 3m
Pseudogout/hemochromatosis;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

26. who gets reiters syndrome after chlamydia infection
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
Malignancy - infection - vertebral fracture
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If person is HLA B27 positive

27. painless ulcer over glans penis and inflammatory arthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
PPD
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Nodular lung densitieis with RA;

28. pagets in xray
Erythematous-violaceous rash on the eyelids
Measure ca and ALP; increased ALP and normal ca for dx;
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
Supplementation ca and vitamin D

29. Tx of lupus nephritis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Coronary atherosclerosis due to SLE
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
Prednisone and cyclophosphamide

30. xanthelasma
Hyperflexion of both wrists--characteristic pain in one min
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Deposition of cholesterol in the periorbital skin

31. right anterior knee pain and provoked by climbing stairs or prolong sitting
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Patello femoral pain syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Symmetrical proximal weakness; increased CPK

32. heberdeen nodes
Arthritic sweling of DIP
Supplementation ca and vitamin D
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

33. increased ALP; liver or bone origin?
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

34. anti-mitochondrial
Primary biliary cirrhosis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Increased serum ferritin (acute phase protein)
Nodular lung densitieis with RA;

35. management of LBP
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
Hyperflexion of both wrists--characteristic pain in one min
SLE - only minutes; RA; hours;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

36. postoeriod shoulder pain
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Osteoarthirit (bouchard at pip - b comes first);

37. How to differential lumbar spinal stenosis and disc herniation pain?
Supplementation ca and vitamin D
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

38. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Arthritic sweling of DIP
Pseudogout/hemochromatosis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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

39. Ca oxalate induced arthritis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
ESRD
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Osteoarthirit (bouchard at pip - b comes first);

40. morning stiffness hand joints
Primary biliary cirrhosis
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.
SLE - only minutes; RA; hours;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

41. nicotinic acid
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hypertriglyceridamia and hypercholesterolemia
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Prednisone and cyclophosphamide

42. When to stop statin if cpk elevated
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Hypertriglyceridamia and hypercholesterolemia
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
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

43. Tx of RA
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Malignancy - infection - vertebral fracture

44. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Deposition of cholesterol in the periorbital skin
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

45. cylosporin used after renal transplantation
Hypertriglyceridamia and hypercholesterolemia
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Malignancy - infection - vertebral fracture
Decrease urate secretion from kidney

46. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Osteoarthirit (bouchard at pip - b comes first);
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

47. pain in shoulder and pelvic girdle
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.
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.

48. carpal tunnel
Measure ca and ALP; increased ALP and normal ca for dx;
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
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

49. role HLA B27 in dx of ankylosing spondylitis
Coronary atherosclerosis due to SLE
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ESR; polymyalgia rheumatica; tx prednisone
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

50. carpal tunnel syndrom
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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