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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. pagets in xray
If symptoms persist >6weeks
Measure ca and ALP; increased ALP and normal ca for dx;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Think about reiter (cannot see - cannot pee - cannot climb a tree)

2. xanthelasma
Erythematous-violaceous rash on the eyelids
Deposition of cholesterol in the periorbital skin
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

3. Tx of lupus nephritis
Pt with significant organ involvement and have incomplete response to prednisone alone
Prednisone and cyclophosphamide
Supplementation ca and vitamin D
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

4. caplan syndrom
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Deposition of cholesterol in the periorbital skin
Nodular lung densitieis with RA;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

5. cylosporin used after renal transplantation
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Decrease urate secretion from kidney
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;

6. Gait in spinal stenosis
PPD
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Viral arthritis or RA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

7. neck mass in sjogren patient
PPD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
A for aortic regurg; s for prolapSe (MVP)
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

8. night back pain
Malignancy - infection - vertebral fracture
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
Xray every 3m
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

9. Rayanaud's disease vs phenomenon
A for aortic regurg; s for prolapSe (MVP)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

10. How to perform schober test
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Dorsum of hands and the Achilies tendon

11. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Malignancy - infection - vertebral fracture
Disseminated gonoccal 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

12. Tx of reiter
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pt with significant organ involvement and have incomplete response to prednisone alone
Abx -bedrest - exercise

13. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Nodular lung densitieis with RA;
If person is HLA B27 positive
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

14. conjunctivitis - urethritis - and spondyloarthopathy

15. How often disease activity is monitored in AS?
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Abx -bedrest - exercise
Xray every 3m
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

16. gemfibrozil
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
C for c ; crest syndrome
Hyper triglyceridemia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

17. When to start DMARD in RA
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Erythematous-violaceous rash on the eyelids
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

18. tinel sign
C for c ; crest syndrome
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Viral arthritis or RA
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

19. inflammatory myositis
Check pedal pulses; in claudication pulses should diminish
Pseudogout/hemochromatosis;
Increased serum ferritin (acute phase protein)
Order LFT - heat fractionation (bone burns and liver lives) - GGT

20. Ca oxalate induced arthritis
Hyperflexion of both wrists--characteristic pain in one min
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
ESRD
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

21. phalen test
Hyperflexion of both wrists--characteristic pain in one min
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
C for c ; crest syndrome
If symptoms persist >6weeks

22. carpal tunnel
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Deposition of cholesterol in the periorbital skin

23. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
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
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.
PMR and giant cell arteritis; can be seen both together;
A for aortic regurg; s for prolapSe (MVP)

24. patient is having pain when he moves hands above shoulder
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Coronary atherosclerosis due to SLE
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hyperflexion of both wrists--characteristic pain in one min

25. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Prednisone and cyclophosphamide
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

26. xanthomatous nodule
ESRD
High incidence of opportunistitc infection; reactivation of TB;
Dorsum of hands and the Achilies tendon
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

27. nicotinic acid
Malignancy - infection - vertebral fracture
Hypertriglyceridamia and hypercholesterolemia
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.
Pt with significant organ involvement and have incomplete response to prednisone alone

28. Raynauds phenomenon
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Check pedal pulses; in claudication pulses should diminish
Viral arthritis or RA

29. Tx of gout in patient with ESRD or hx GI bleeding
Abx -bedrest - exercise
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
Primary biliary cirrhosis

30. How to differentiate radicular pain with claudication
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
Pseudogout/hemochromatosis;
Check pedal pulses; in claudication pulses should diminish
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

31. When to give methotrexate in SLE
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Pt with significant organ involvement and have incomplete response to prednisone alone
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

32. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
C for c ; crest syndrome
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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

33. colchicine
If person is HLA B27 positive
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
PMR and giant cell arteritis; can be seen both together;

34. What should be chekcked before starting infliximab
Disseminated gonoccal infection
PPD
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

35. 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
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

36. primary muscle disease
PMR and giant cell arteritis; can be seen both together;
A for aortic regurg; s for prolapSe (MVP)
Pseudogout/hemochromatosis;
Symmetrical proximal weakness; increased CPK

37. right anterior knee pain and provoked by climbing stairs or prolong sitting
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Symmetrical proximal weakness; increased CPK
Patello femoral pain syndrome

38. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Measure ESR; polymyalgia rheumatica; tx prednisone
High incidence of opportunistitc infection; reactivation of TB;
Measure ca and ALP; increased ALP and normal ca for dx;

39. anterior shoulder pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

40. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Coronary atherosclerosis due to SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

41. Use of antibiotic in RA
Erythematous-violaceous rash on the eyelids
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

42. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Specific of dx of SLE
Measure ESR; polymyalgia rheumatica; tx prednisone

43. mcp and PIP joint involvement
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Osteoarthirit (bouchard at pip - b comes first);
Viral arthritis or RA
Abx -bedrest - exercise

44. anti-mitochondrial
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
Primary biliary cirrhosis
Increased serum ferritin (acute phase protein)

45. tx pagets
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Specific of dx of SLE

46. When to order MRI in LBP
Decrease urate secretion from kidney
Symmetrical proximal weakness; increased CPK
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

47. proximal muscle weakness; decreased tendon reflex; normal creat and ck
PPD
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Hyperflexion of both wrists--characteristic pain in one min
C for c ; crest syndrome

48. 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.
Erythematous-violaceous rash on the eyelids
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Viral arthritis or RA

49. Tx of inflammatory myositis
Symmetrical proximal weakness; increased CPK
Xray every 3m
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

50. What marker is used to follow up disease activity in SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
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