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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. pain in shoulder and pelvic girdle
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

2. complications of anti-cytokine therapy
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
Hyperflexion of both wrists--characteristic pain in one min
High incidence of opportunistitc infection; reactivation of TB;
Osteoarthirit (bouchard at pip - b comes first);

3. phalen test
Osteoarthirit (bouchard at pip - b comes first);
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;
Hyperflexion of both wrists--characteristic pain in one min

4. When to give methotrexate in 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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pt with significant organ involvement and have incomplete response to prednisone alone
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

5. probenecid
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Hypertriglyceridamia and hypercholesterolemia

6. glucocorticoid therapy
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

7. when SLE patient needs steroid
Prophylactic agent to prevent recurrent attack; not given during acute attack
Primary biliary cirrhosis
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
Osteoarthirit (bouchard at pip - b comes first);

8. How to perform schober test
A for aortic regurg; s for prolapSe (MVP)
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
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

9. carpal tunnel syndrom
Erythematous-violaceous rash on the eyelids
Xray every 3m
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)

10. cylosporin used after renal transplantation
Increased serum ferritin (acute phase protein)
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Measure ESR; polymyalgia rheumatica; tx prednisone
Decrease urate secretion from kidney

11. Management of HTN during acute gout
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Symmetrical proximal weakness; increased CPK

12. What should be chekcked before starting infliximab
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
PPD
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

13. schirmer test
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

14. mcp and PIP joint involvement
PMR and giant cell arteritis; can be seen both together;
Viral arthritis or RA
Measure ESR; polymyalgia rheumatica; tx prednisone
Think about reiter (cannot see - cannot pee - cannot climb a tree)

15. nicotinic acid
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
If symptoms persist >6weeks
Hypertriglyceridamia and hypercholesterolemia
Prednisone and cyclophosphamide

16. Ca oxalate induced arthritis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
ESRD

17. patient is having pain when he moves hands above shoulder
Hyper triglyceridemia
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

18. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Disseminated gonoccal infection
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Minocyclin - inhibits metalloproteases and slows joint damage

19. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pseudogout/hemochromatosis;
Osteoarthirit (bouchard at pip - b comes first);
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

20. Tx of gout in patient with ESRD or hx GI bleeding
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
A for aortic regurg; s for prolapSe (MVP)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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

21. How to differential lumbar spinal stenosis and disc herniation pain?
Supplementation ca and vitamin D
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hypertriglyceridamia and hypercholesterolemia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

22. proximal muscle weakness; decreased tendon reflex; normal creat and ck
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

23. What marker is used to follow up disease activity in 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
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Measure ca and ALP; increased ALP and normal ca for dx;

24. Low back pain
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
SLE - only minutes; RA; hours;
Coronary atherosclerosis due to SLE
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

25. How glucocorticoid leads to 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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
PPD

26. Tx of RA
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Deposition of cholesterol in the periorbital skin
Arthritic sweling of DIP

27. anti-centromere ab
Pt with significant organ involvement and have incomplete response to prednisone alone
Increased serum ferritin (acute phase protein)
Think about reiter (cannot see - cannot pee - cannot climb a tree)
C for c ; crest syndrome

28. night back pain
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.
Measure ca and ALP; increased ALP and normal ca for dx;
Decrease urate secretion from kidney
Malignancy - infection - vertebral fracture

29. When to stop statin if cpk elevated
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
If symptoms persist >6weeks
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
Abx -bedrest - exercise

30. bouchard nodule
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Specific of dx of SLE
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

31. What is heliotrope sign
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Hyperflexion of both wrists--characteristic pain in one min
Erythematous-violaceous rash on the eyelids

32. xanthomatous nodule
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Hyper triglyceridemia
Xray every 3m
Dorsum of hands and the Achilies tendon

33. Use of allopurinol after kidney transplant
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Prednisone and cyclophosphamide
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

34. patient pw groin pain; on steroid
A for aortic regurg; s for prolapSe (MVP)
Coronary atherosclerosis due to SLE
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

35. anterior shoulder pain
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Increased serum ferritin (acute phase protein)
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

36. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Coronary atherosclerosis due to SLE
Measure ESR; polymyalgia rheumatica; tx prednisone

37. Raynauds phenomenon
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

38. SLE with pleural effusion
Erythematous-violaceous rash on the eyelids
Coronary atherosclerosis due to SLE
Measure ca and ALP; increased ALP and normal ca for dx;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

39. Tx of lupus nephritis
Prednisone and cyclophosphamide
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
If symptoms persist >6weeks
PPD

40. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

41. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Erythematous-violaceous rash on the eyelids
Increased serum ferritin (acute phase protein)
Order LFT - heat fractionation (bone burns and liver lives) - GGT

42. Finding of MRI in stenosis
Check pedal pulses; in claudication pulses should diminish
If symptoms persist >6weeks
Erythematous-violaceous rash on the eyelids
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

43. increased ALP; liver or bone origin?
Specific of dx of SLE
Symmetrical proximal weakness; increased CPK
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Order LFT - heat fractionation (bone burns and liver lives) - GGT

44. conjunctivitis - urethritis - and spondyloarthopathy

45. management of LBP
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

46. postoeriod shoulder pain
High incidence of opportunistitc infection; reactivation of TB;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

47. criteria for AS
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
High incidence of opportunistitc infection; reactivation of TB;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

48. Gait in spinal stenosis
Malignancy - infection - vertebral fracture
C for c ; crest syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

49. Use of antibiotic in RA
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Minocyclin - inhibits metalloproteases and slows joint damage

50. heberdeen nodes
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
Specific of dx of SLE
Arthritic sweling of DIP
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;