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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. spondyloarthopathy
C for c ; crest syndrome
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
If person is HLA B27 positive
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

2. PIP joint involment
ESRD
Osteoarthirit (bouchard at pip - b comes first);
Pseudogout/hemochromatosis;
Think about reiter (cannot see - cannot pee - cannot climb a tree)

3. common valvular abnormalities with AS?
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.
A for aortic regurg; s for prolapSe (MVP)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

4. How glucocorticoid leads to bone loss
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
Deposition of cholesterol in the periorbital skin
Pt with significant organ involvement and have incomplete response to prednisone alone
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

5. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
ESRD
Erythematous-violaceous rash on the eyelids

6. bouchard nodule
PPD
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
A for aortic regurg; s for prolapSe (MVP)
Measure ca and ALP; increased ALP and normal ca for dx;

7. DIP joint involvement

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8. cylosporin used after renal transplantation
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pt with significant organ involvement and have incomplete response to prednisone alone
Decrease urate secretion from kidney
Prophylactic agent to prevent recurrent attack; not given during acute attack

9. MCP joint involvement
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

10. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pseudogout/hemochromatosis;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Viral arthritis or RA

11. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Primary biliary cirrhosis
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
AS; sometime only symptom is uveitis;

12. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Order LFT - heat fractionation (bone burns and liver lives) - GGT
PMR and giant cell arteritis; can be seen both together;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

13. Tx of RA
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

14. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
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;
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

15. conjunctivitis - urethritis - and spondyloarthopathy

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16. inflammatory myositis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Increased serum ferritin (acute phase protein)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Coronary atherosclerosis due to SLE

17. 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
Pseudogout/hemochromatosis;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Xray every 3m

18. inflamed tendons in wrist - ankle - arms; sexual history
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Disseminated gonoccal infection
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

19. probenecid
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Supplementation ca and vitamin D
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

20. How to differentiate radicular pain with claudication
Coronary atherosclerosis due to SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Check pedal pulses; in claudication pulses should diminish

21. nicotinic acid
PPD
If person is HLA B27 positive
Hypertriglyceridamia and hypercholesterolemia
Order LFT - heat fractionation (bone burns and liver lives) - GGT

22. 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
Pt with significant organ involvement and have incomplete response to prednisone alone
High incidence of opportunistitc infection; reactivation of TB;
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. 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
Supplementation ca and vitamin D
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Specific of dx of SLE

24. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Check pedal pulses; in claudication pulses should diminish
Primary biliary cirrhosis
A for aortic regurg; s for prolapSe (MVP)

25. primary muscle disease
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Symmetrical proximal weakness; increased CPK
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

26. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prednisone and cyclophosphamide
Pseudogout/hemochromatosis;

27. anti-mitochondrial
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

28. heberdeen nodes
Arthritic sweling of DIP
Supplementation ca and vitamin D
Pt with significant organ involvement and have incomplete response to prednisone alone
Prednisone and cyclophosphamide

29. gemfibrozil
Hyper triglyceridemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Measure ca and ALP; increased ALP and normal ca for dx;

30. Rayanaud's disease vs phenomenon
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.
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

31. SLE with pleural effusion
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Specific of dx of SLE
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

32. xanthelasma
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
Pt with significant organ involvement and have incomplete response to prednisone alone
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Deposition of cholesterol in the periorbital skin

33. How to differential lumbar spinal stenosis and disc herniation pain?
C for c ; crest syndrome
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Decrease urate secretion from kidney

34. carpal tunnel
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
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
Minocyclin - inhibits metalloproteases and slows joint damage

35. tinel sign
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

36. patient is having pain when he moves hands above shoulder
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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.

37. anti-ds DNA antibody
C for c ; crest syndrome
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Measure ESR; polymyalgia rheumatica; tx prednisone
Specific of dx of SLE

38. Use of allopurinol after kidney transplant
Nodular lung densitieis with RA;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Measure ESR; polymyalgia rheumatica; tx prednisone

39. schirmer test
Pt with significant organ involvement and have incomplete response to prednisone alone
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.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
If symptoms persist >6weeks

40. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Arthritic sweling of DIP
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
If person is HLA B27 positive

41. Gait in spinal stenosis
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
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

42. phalen test
Supplementation ca and vitamin D
Minocyclin - inhibits metalloproteases and slows joint damage
Hyperflexion of both wrists--characteristic pain in one min
Erythematous-violaceous rash on the eyelids

43. when SLE patient needs steroid
Xray every 3m
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

44. morning stiffness hand joints
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Viral arthritis or RA
SLE - only minutes; RA; hours;
PMR and giant cell arteritis; can be seen both together;

45. tx pagets
Deposition of cholesterol in the periorbital skin
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
AS; sometime only symptom is uveitis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

46. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hyper triglyceridemia
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. What marker is used to follow up disease activity in SLE
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pseudogout/hemochromatosis;
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

48. carpal tunnel syndrom
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 symptoms persist >6weeks
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.
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

49. criteria for AS
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Prophylactic agent to prevent recurrent attack; not given during acute attack
Minocyclin - inhibits metalloproteases and slows joint damage
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

50. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Viral arthritis or RA
AS; sometime only symptom is uveitis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm