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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. conjunctivitis - urethritis - and spondyloarthopathy

2. inflamed tendons in wrist - ankle - arms; sexual history
Patello femoral pain syndrome
Coronary atherosclerosis due to SLE
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Disseminated gonoccal infection

3. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Specific of dx of SLE
Disseminated gonoccal infection
Supplementation ca and vitamin D

4. mcp and PIP joint involvement
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Viral arthritis or RA
Coronary atherosclerosis due to SLE

5. What marker is used to follow up disease activity in SLE
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
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
Prednisone and cyclophosphamide
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

6. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Dorsum of hands and the Achilies tendon
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

7. anti-centromere ab
Deposition of cholesterol in the periorbital skin
Coronary atherosclerosis due to SLE
Osteoarthirit (bouchard at pip - b comes first);
C for c ; crest syndrome

8. Raynauds phenomenon
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

9. caplan syndrom
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Nodular lung densitieis with RA;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

10. What should be chekcked before starting infliximab
PPD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Coronary atherosclerosis due to SLE

11. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Prophylactic agent to prevent recurrent attack; not given during acute attack
Primary biliary cirrhosis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

12. 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.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Minocyclin - inhibits metalloproteases and slows joint damage
Check pedal pulses; in claudication pulses should diminish

13. Gait in spinal stenosis
Erythematous-violaceous rash on the eyelids
Xray every 3m
Specific of dx of SLE
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

14. How glucocorticoid leads to bone loss
Prednisone and cyclophosphamide
Deposition of cholesterol in the periorbital skin
SLE - only minutes; RA; hours;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

15. xanthomatous nodule
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Dorsum of hands and the Achilies tendon
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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

16. When to start DMARD in RA
Prednisone and cyclophosphamide
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

17. carpal tunnel syndrom
Nodular lung densitieis with RA;
SLE - only minutes; RA; hours;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

18. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Measure ca and ALP; increased ALP and normal ca for dx;

19. heberdeen nodes
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Patello femoral pain syndrome
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Arthritic sweling of DIP

20. anti-ds DNA antibody
Viral arthritis or RA
Specific of dx of SLE
Deposition of cholesterol in the periorbital skin
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

21. Finding of MRI in stenosis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

22. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pseudogout/hemochromatosis;
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

23. When to stop statin if cpk elevated
Pt with significant organ involvement and have incomplete response to prednisone alone
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
If person is HLA B27 positive
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

24. gemfibrozil
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Hyper triglyceridemia

25. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Abx -bedrest - exercise
Nodular lung densitieis with RA;

26. Tx of reiter
Abx -bedrest - exercise
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
High incidence of opportunistitc infection; reactivation of TB;
Increased serum ferritin (acute phase protein)

27. night back pain
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
ESRD
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Malignancy - infection - vertebral fracture

28. Management of HTN during acute gout
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Increased serum ferritin (acute phase protein)
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

29. management of LBP
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

30. How to prevent glucocorticoid induced bone loss
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Supplementation ca and vitamin D
Decrease urate secretion from kidney
PPD

31. When to order MRI in LBP
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Check pedal pulses; in claudication pulses should diminish
If symptoms persist >6weeks
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

32. What is heliotrope sign
Deposition of cholesterol in the periorbital skin
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Erythematous-violaceous rash on the eyelids
Osteoarthirit (bouchard at pip - b comes first);

33. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
High incidence of opportunistitc infection; reactivation of TB;
AS; sometime only symptom is uveitis;
Disseminated gonoccal infection
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

34. patient pw groin pain; on steroid
Hyperflexion of both wrists--characteristic pain in one min
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Primary biliary cirrhosis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

35. complications of anti-cytokine therapy
Patello femoral pain syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
High incidence of opportunistitc infection; reactivation of TB;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

36. primary muscle disease
C for c ; crest syndrome
Symmetrical proximal weakness; increased CPK
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

37. tinel sign
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Malignancy - infection - vertebral fracture

38. Tx of gout
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 symptoms persist >6weeks
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

39. Low back pain
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Arthritic sweling of DIP

40. patient is having pain when he moves hands above shoulder
Primary biliary cirrhosis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Coronary atherosclerosis due to SLE
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

41. Use of antibiotic in RA
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Minocyclin - inhibits metalloproteases and slows joint damage
Check pedal pulses; in claudication pulses should diminish

42. Tx of inflammatory myositis
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.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

43. who gets reiters syndrome after chlamydia infection
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
If person is HLA B27 positive

44. role HLA B27 in dx of ankylosing spondylitis
If person is HLA B27 positive
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hyperflexion of both wrists--characteristic pain in one min

45. inflammatory myositis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Increased serum ferritin (acute phase protein)
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Primary biliary cirrhosis

46. SLE with pleural effusion
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
Symmetrical proximal weakness; increased CPK
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

47. colchicine
Primary biliary cirrhosis
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
Hypertriglyceridamia and hypercholesterolemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

48. DIP joint involvement

49. postoeriod shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
ESRD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

50. anterior shoulder pain
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
SLE - only minutes; RA; hours;