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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. right anterior knee pain and provoked by climbing stairs or prolong sitting
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Supplementation ca and vitamin D
Patello femoral pain syndrome

2. 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
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
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

3. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
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
Pseudogout/hemochromatosis;

4. Tx of gout in patient with ESRD or hx GI bleeding
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Erythematous-violaceous rash on the eyelids

5. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

6. glucocorticoid therapy
Hyper triglyceridemia
Specific of dx of SLE
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

7. SLE with pleural effusion
Minocyclin - inhibits metalloproteases and slows joint damage
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

8. anti-mitochondrial
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

9. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Symmetrical proximal weakness; increased CPK
Xray every 3m
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

10. when SLE patient needs steroid
Erythematous-violaceous rash on the eyelids
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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
If person is HLA B27 positive

11. How to prevent glucocorticoid induced bone loss
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Supplementation ca and vitamin D

12. What marker is used to follow up disease activity in SLE
Primary biliary cirrhosis
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

13. bouchard nodule
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
Pt with significant organ involvement and have incomplete response to prednisone alone
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

14. painless ulcer over glans penis and inflammatory arthritis
AS; sometime only symptom is uveitis;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

15. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
AS; sometime only symptom is uveitis;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

16. Use of antibiotic in RA
If symptoms persist >6weeks
Malignancy - infection - vertebral fracture
Arthritic sweling of DIP
Minocyclin - inhibits metalloproteases and slows joint damage

17. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Minocyclin - inhibits metalloproteases and slows joint damage
Prophylactic agent to prevent recurrent attack; not given during acute attack
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

18. increased ALP; liver or bone origin?
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

19. neck mass in sjogren patient
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Disseminated gonoccal infection
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

20. pagets in xray
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Hypertriglyceridamia and hypercholesterolemia

21. When to stop statin if cpk elevated
ESRD
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
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

22. night back pain
Malignancy - infection - vertebral fracture
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
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

23. gemfibrozil
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
Hyper triglyceridemia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

24. probenecid
Viral arthritis or RA
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;
Xray every 3m

25. How to monitor disease activity in SLE
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

26. How often disease activity is monitored in AS?
Xray every 3m
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Specific of dx of SLE
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

27. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pseudogout/hemochromatosis;
Pt with significant organ involvement and have incomplete response to prednisone alone

28. Rayanaud's disease vs phenomenon
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If symptoms persist >6weeks
Erythematous-violaceous rash on the eyelids

29. tx pagets
ESRD
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Think about reiter (cannot see - cannot pee - cannot climb a tree)

30. Gait in spinal stenosis
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Abx -bedrest - exercise

31. tinel sign
High incidence of opportunistitc infection; reactivation of TB;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Check pedal pulses; in claudication pulses should diminish
PMR and giant cell arteritis; can be seen both together;

32. phalen test
Xray every 3m
Measure ca and ALP; increased ALP and normal ca for dx;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyperflexion of both wrists--characteristic pain in one min

33. When to order MRI in LBP
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Dorsum of hands and the Achilies tendon
If symptoms persist >6weeks
Prednisone and cyclophosphamide

34. Tx of reiter
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;
Abx -bedrest - exercise
Malignancy - infection - vertebral fracture

35. 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.
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hyperflexion of both wrists--characteristic pain in one min
Measure ESR; polymyalgia rheumatica; tx prednisone

36. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Minocyclin - inhibits metalloproteases and slows joint damage
PMR and giant cell arteritis; can be seen both together;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dorsum of hands and the Achilies tendon

37. How to differentiate radicular pain with claudication
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Check pedal pulses; in claudication pulses should diminish
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

38. xanthomatous nodule
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
If symptoms persist >6weeks
Dorsum of hands and the Achilies tendon
Osteoarthirit (bouchard at pip - b comes first);

39. PIP joint involment
If symptoms persist >6weeks
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);
Measure ca and ALP; increased ALP and normal ca for dx;

40. cylosporin used after renal transplantation
Check pedal pulses; in claudication pulses should diminish
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
Hyperflexion of both wrists--characteristic pain in one min
Decrease urate secretion from kidney

41. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Pseudogout/hemochromatosis;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Minocyclin - inhibits metalloproteases and slows joint damage

42. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Check pedal pulses; in claudication pulses should diminish
Disseminated gonoccal infection

43. Tx of RA
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Hyperflexion of both wrists--characteristic pain in one min
Osteoarthirit (bouchard at pip - b comes first);

44. anti-ds DNA antibody
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;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Specific of dx of SLE

45. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
High incidence of opportunistitc infection; reactivation of TB;
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

46. criteria for AS
Think about reiter (cannot see - cannot pee - cannot climb a tree)
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

47. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Abx -bedrest - exercise
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)

48. carpal tunnel
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
Abx -bedrest - exercise
Arthritic sweling of DIP

49. postoeriod shoulder pain
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

50. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Patello femoral pain syndrome
Malignancy - infection - vertebral fracture
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss