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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. SLE with pleural effusion
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Disseminated gonoccal infection

2. anterior shoulder pain
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

3. nicotinic acid
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Hyper triglyceridemia
Hypertriglyceridamia and hypercholesterolemia
Think about reiter (cannot see - cannot pee - cannot climb a tree)

4. When to stop statin if cpk elevated
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
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
PPD
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

5. Tx of lupus nephritis
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 urate secretion from kidney
Prednisone and cyclophosphamide
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

6. heberdeen nodes
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Arthritic sweling of DIP
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

7. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
PMR and giant cell arteritis; can be seen both together;
Dorsum of hands and the Achilies tendon

8. xanthelasma
Hypertriglyceridamia and hypercholesterolemia
Deposition of cholesterol in the periorbital skin
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

9. night back pain
Specific of dx of SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Malignancy - infection - vertebral fracture
Prophylactic agent to prevent recurrent attack; not given during acute attack

10. 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.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
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

11. When to start DMARD in RA
Measure ca and ALP; increased ALP and normal ca for dx;
SLE - only minutes; RA; hours;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

12. bouchard nodule
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

13. What is heliotrope sign
Viral arthritis or RA
Pseudogout/hemochromatosis;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Erythematous-violaceous rash on the eyelids

14. phalen 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.
Hyperflexion of both wrists--characteristic pain in one min
Decrease urate secretion from kidney
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

15. probenecid
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Prednisone and cyclophosphamide
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

16. Use of allopurinol after kidney transplant
Pt with significant organ involvement and have incomplete response to prednisone alone
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

17. Finding of MRI in stenosis
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hypertriglyceridamia and hypercholesterolemia

18. criteria for AS
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Primary biliary cirrhosis

19. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Deposition of cholesterol in the periorbital skin
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Think about reiter (cannot see - cannot pee - cannot climb a tree)

20. 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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Hyperflexion of both wrists--characteristic pain in one min
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

21. right anterior knee pain and provoked by climbing stairs or prolong sitting
Arthritic sweling of DIP
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Patello femoral pain syndrome

22. carpal tunnel
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Dorsum of hands and the Achilies tendon

23. when SLE patient needs steroid
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
Arthritic sweling of DIP
Minocyclin - inhibits metalloproteases and slows joint damage

24. Gait in spinal stenosis
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
Disseminated gonoccal infection
Coronary atherosclerosis due to SLE
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

25. common valvular abnormalities with AS?
PPD
A for aortic regurg; s for prolapSe (MVP)
Pt with significant organ involvement and have incomplete response to prednisone alone
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

26. When to order MRI in LBP
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Measure ESR; polymyalgia rheumatica; tx prednisone
If symptoms persist >6weeks
Abx -bedrest - exercise

27. colchicine
Supplementation ca and vitamin D
Xray every 3m
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Nodular lung densitieis with RA;

28. Low back pain
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Viral arthritis or RA
Measure ESR; polymyalgia rheumatica; tx prednisone
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

29. What should be chekcked before starting infliximab
PPD
ESRD
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

30. 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
Osteoarthirit (bouchard at pip - b comes first);
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Patello femoral pain syndrome

31. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Erythematous-violaceous rash on the eyelids
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

32. patient is having pain when he moves hands above shoulder
Prednisone and cyclophosphamide
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
ESRD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

33. cylosporin used after renal transplantation
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Decrease urate secretion from kidney
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
Measure ca and ALP; increased ALP and normal ca for dx;

34. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
PPD

35. MCP joint involvement
If symptoms persist >6weeks
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

36. When to give methotrexate in SLE
Symmetrical proximal weakness; increased CPK
Pt with significant organ involvement and have incomplete response to prednisone alone
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

37. Tx of reiter
Abx -bedrest - exercise
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Hypertriglyceridamia and hypercholesterolemia
Nodular lung densitieis with RA;

38. Raynauds phenomenon
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
A for aortic regurg; s for prolapSe (MVP)
C for c ; crest syndrome

39. carpal tunnel syndrom
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
If person is HLA B27 positive
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

40. allpurinol
Prednisone and cyclophosphamide
Prophylactic agent to prevent recurrent attack; not given during acute attack
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Specific of dx of SLE

41. inflammatory myositis
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Increased serum ferritin (acute phase protein)

42. pain in shoulder and pelvic girdle
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Hyper triglyceridemia
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

43. SLE patient p/w MI - vent fibrillation
If symptoms persist >6weeks
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
A for aortic regurg; s for prolapSe (MVP)
Coronary atherosclerosis due to SLE

44. How to differentiate radicular pain with claudication
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Check pedal pulses; in claudication pulses should diminish
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

45. Tx of gout in patient with ESRD or hx GI bleeding
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Erythematous-violaceous rash on the eyelids
Check pedal pulses; in claudication pulses should diminish

46. Ca oxalate induced arthritis
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

47. anti-centromere ab
C for c ; crest syndrome
Arthritic sweling of DIP
Osteoarthirit (bouchard at pip - b comes first);
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.

48. glucocorticoid therapy
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
High incidence of opportunistitc infection; reactivation of TB;
ESRD

49. DIP joint involvement

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50. inflamed tendons in wrist - ankle - arms; sexual history
Malignancy - infection - vertebral fracture
Disseminated gonoccal infection
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm