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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. cylosporin used after renal transplantation
Decrease urate secretion from kidney
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

2. Ca oxalate induced arthritis
If symptoms persist >6weeks
ESRD
Hyperflexion of both wrists--characteristic pain in one min
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

3. 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.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Hyperflexion of both wrists--characteristic pain in one min

4. conjunctivitis - urethritis - and spondyloarthopathy

5. How often disease activity is monitored in AS?
Xray every 3m
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

6. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Hyper triglyceridemia
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hyperflexion of both wrists--characteristic pain in one min

7. Tx of gout
Specific of dx of SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Deposition of cholesterol in the periorbital skin
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

8. anti-centromere ab
Hypertriglyceridamia and hypercholesterolemia
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Dorsum of hands and the Achilies tendon
C for c ; crest syndrome

9. DIP joint involvement

10. anti-ds DNA antibody
AS; sometime only symptom is uveitis;
Specific of dx of SLE
PPD
Measure ca and ALP; increased ALP and normal ca for dx;

11. Tx of lupus nephritis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Prednisone and cyclophosphamide
Patello femoral pain syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

12. tx pagets
AS; sometime only symptom is uveitis;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Check pedal pulses; in claudication pulses should diminish
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

13. When to stop statin if cpk elevated
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Hyperflexion of both wrists--characteristic pain in one min
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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

14. 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.
If person is HLA B27 positive
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Disseminated gonoccal infection

15. morning stiffness hand joints
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
SLE - only minutes; RA; hours;
Dorsum of hands and the Achilies tendon

16. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Erythematous-violaceous rash on the eyelids
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

17. xanthelasma
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
C for c ; crest syndrome
High incidence of opportunistitc infection; reactivation of TB;
Deposition of cholesterol in the periorbital skin

18. glucocorticoid therapy
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Patello femoral pain syndrome

19. Low back pain
High incidence of opportunistitc infection; reactivation of TB;
Pseudogout/hemochromatosis;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

20. 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
Deposition of cholesterol in the periorbital skin
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

21. nicotinic acid
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hypertriglyceridamia and hypercholesterolemia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

22. phalen test
Specific of dx of SLE
Hyperflexion of both wrists--characteristic pain in one min
Abx -bedrest - exercise
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

23. SLE patient p/w MI - vent fibrillation
Increased serum ferritin (acute phase protein)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Coronary atherosclerosis due to SLE
PMR and giant cell arteritis; can be seen both together;

24. Tx of RA
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
Decrease urate secretion from kidney

25. neck mass in sjogren patient
Decrease urate secretion from kidney
ESRD
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Abx -bedrest - exercise

26. when SLE patient needs steroid
PMR and giant cell arteritis; can be seen both together;
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
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

27. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
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
PMR and giant cell arteritis; can be seen both together;
Hyperflexion of both wrists--characteristic pain in one min

28. How to prevent glucocorticoid induced bone loss
Check pedal pulses; in claudication pulses should diminish
Supplementation ca and vitamin D
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
If person is HLA B27 positive

29. carpal tunnel syndrom
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

30. right anterior knee pain and provoked by climbing stairs or prolong sitting
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

31. How to monitor disease activity in SLE
Viral arthritis or RA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hypertriglyceridamia and hypercholesterolemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

32. patient pw groin pain; on steroid
If person is HLA B27 positive
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Deposition of cholesterol in the periorbital skin

33. What is heliotrope sign
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Erythematous-violaceous rash on the eyelids
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Primary biliary cirrhosis

34. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
Disseminated gonoccal infection
Patello femoral pain syndrome
Hypertriglyceridamia and hypercholesterolemia

35. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Xray every 3m

36. Use of allopurinol after kidney transplant
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Prednisone and cyclophosphamide
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

37. complications of anti-cytokine therapy
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Symmetrical proximal weakness; increased CPK
High incidence of opportunistitc infection; reactivation of TB;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

38. spondyloarthopathy
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

39. bouchard nodule
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Deposition of cholesterol in the periorbital skin
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

40. pagets in xray
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Arthritic sweling of DIP
If person is HLA B27 positive
Measure ca and ALP; increased ALP and normal ca for dx;

41. heberdeen nodes
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Arthritic sweling of DIP

42. increased ALP; liver or bone origin?
Nodular lung densitieis with RA;
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

43. allpurinol
Primary biliary cirrhosis
Prophylactic agent to prevent recurrent attack; not given during acute attack
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

44. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Check pedal pulses; in claudication pulses should diminish
Supplementation ca and vitamin D
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

45. pain in shoulder and pelvic girdle
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Check pedal pulses; in claudication pulses should diminish
Measure ESR; polymyalgia rheumatica; tx prednisone
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

46. inflammatory myositis
Arthritic sweling of DIP
Increased serum ferritin (acute phase protein)
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Disseminated gonoccal infection

47. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Disseminated gonoccal infection
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
ESRD

48. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
If person is HLA B27 positive
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Prophylactic agent to prevent recurrent attack; not given during acute attack

49. When to order MRI in LBP
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
If symptoms persist >6weeks
Erythematous-violaceous rash on the eyelids
Coronary atherosclerosis due to SLE

50. Gait in spinal stenosis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Check pedal pulses; in claudication pulses should diminish
Supplementation ca and vitamin D
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine