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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. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

2. painless ulcer over glans penis and inflammatory arthritis
Measure ca and ALP; increased ALP and normal ca for dx;
Arthritic sweling of DIP
Prednisone and cyclophosphamide
Think about reiter (cannot see - cannot pee - cannot climb a tree)

3. patient is having pain when he moves hands above shoulder
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

4. patient pw groin pain; on steroid
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
C for c ; crest syndrome

5. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Deposition of cholesterol in the periorbital skin
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

6. Use of antibiotic in RA
Malignancy - infection - vertebral fracture
Minocyclin - inhibits metalloproteases and slows joint damage
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prophylactic agent to prevent recurrent attack; not given during acute attack

7. anterior shoulder pain
High incidence of opportunistitc infection; reactivation of TB;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

8. When to order MRI in LBP
Deposition of cholesterol in the periorbital skin
Pseudogout/hemochromatosis;
If symptoms persist >6weeks
If person is HLA B27 positive

9. criteria for AS
PPD
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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

10. Low back pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Specific of dx of SLE
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

11. When to stop statin if cpk elevated
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Decrease urate secretion from kidney
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

12. nicotinic acid
Xray every 3m
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hypertriglyceridamia and hypercholesterolemia
Symmetrical proximal weakness; increased CPK

13. What marker is used to follow up disease activity in SLE
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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-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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

14. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If person is HLA B27 positive
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

15. How glucocorticoid leads to bone loss
Specific of dx of SLE
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Patello femoral pain syndrome

16. What is heliotrope sign
PPD
Supplementation ca and vitamin D
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Erythematous-violaceous rash on the eyelids

17. SLE with pleural effusion
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

18. anti-mitochondrial
Viral arthritis or RA
Hyper triglyceridemia
Measure ca and ALP; increased ALP and normal ca for dx;
Primary biliary cirrhosis

19. How to prevent glucocorticoid induced bone loss
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
If person is HLA B27 positive
Supplementation ca and vitamin D
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

20. role HLA B27 in dx of ankylosing spondylitis
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Coronary atherosclerosis due to SLE

21. postoeriod shoulder pain
Check pedal pulses; in claudication pulses should diminish
Malignancy - infection - vertebral fracture
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Arthritic sweling of DIP

22. Ca oxalate induced arthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ESRD
Decrease urate secretion from kidney
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

23. mcp and PIP joint involvement
If person is HLA B27 positive
Xray every 3m
Viral arthritis or RA
Measure ca and ALP; increased ALP and normal ca for dx;

24. What should be chekcked before starting infliximab
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
PPD
Nodular lung densitieis with RA;

25. xanthelasma
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
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

26. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Symmetrical proximal weakness; increased CPK
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
AS; sometime only symptom is uveitis;

27. night back pain
Xray every 3m
Hypertriglyceridamia and hypercholesterolemia
Check pedal pulses; in claudication pulses should diminish
Malignancy - infection - vertebral fracture

28. Tx of gout
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

29. glucocorticoid therapy
Hyper triglyceridemia
Check pedal pulses; in claudication pulses should diminish
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)

30. colchicine
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

31. inflamed tendons in wrist - ankle - arms; sexual history
Pt with significant organ involvement and have incomplete response to prednisone alone
A for aortic regurg; s for prolapSe (MVP)
Disseminated gonoccal infection
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

32. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
High incidence of opportunistitc infection; reactivation of TB;
Hyperflexion of both wrists--characteristic pain in one min

33. tx pagets
Prednisone and cyclophosphamide
Symmetrical proximal weakness; increased CPK
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

34. neck mass in sjogren patient
Viral arthritis or RA
Hyperflexion of both wrists--characteristic pain in one min
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

35. pagets in xray
Dorsum of hands and the Achilies tendon
Measure ca and ALP; increased ALP and normal ca for dx;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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

36. complications of anti-cytokine therapy
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
High incidence of opportunistitc infection; reactivation of TB;
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

37. gemfibrozil
Hyper triglyceridemia
AS; sometime only symptom is uveitis;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Viral arthritis or RA

38. tinel sign
ESRD
Symmetrical proximal weakness; increased CPK
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

39. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pseudogout/hemochromatosis;
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
Deposition of cholesterol in the periorbital skin

40. morning stiffness hand joints
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Abx -bedrest - exercise
If symptoms persist >6weeks
SLE - only minutes; RA; hours;

41. When to give methotrexate in SLE
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pt with significant organ involvement and have incomplete response to prednisone alone
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Check pedal pulses; in claudication pulses should diminish

42. DIP joint involvement

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43. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

44. Tx of inflammatory myositis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Patello femoral pain syndrome

45. phalen test
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hyperflexion of both wrists--characteristic pain in one min

46. Tx of gout in patient with ESRD or hx GI bleeding
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
A for aortic regurg; s for prolapSe (MVP)
Primary biliary cirrhosis

47. pain in shoulder and pelvic girdle
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
Measure ESR; polymyalgia rheumatica; tx prednisone

48. who gets reiters syndrome after chlamydia infection
Nodular lung densitieis with RA;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
If person is HLA B27 positive

49. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
AS; sometime only symptom is uveitis;
Xray every 3m
C for c ; crest syndrome

50. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Xray every 3m
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood