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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. right anterior knee pain and provoked by climbing stairs or prolong sitting
AS; sometime only symptom is uveitis;
Patello femoral pain syndrome
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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

2. xanthelasma
Malignancy - infection - vertebral fracture
Deposition of cholesterol in the periorbital skin
ESRD
Hypertriglyceridamia and hypercholesterolemia

3. How to prevent glucocorticoid induced bone loss
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Dorsum of hands and the Achilies tendon
Supplementation ca and vitamin D

4. Tx of inflammatory myositis
Deposition of cholesterol in the periorbital skin
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Abx -bedrest - exercise
Erythematous-violaceous rash on the eyelids

5. What marker is used to follow up disease activity in SLE
Abx -bedrest - exercise
Prednisone and cyclophosphamide
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
AS; sometime only symptom is uveitis;

6. bouchard nodule
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

7. carpal tunnel syndrom
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Decrease urate secretion from kidney
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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

8. Ca oxalate induced arthritis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
ESRD
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

9. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

10. PIP joint involment
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
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.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

11. tx pagets
Minocyclin - inhibits metalloproteases and slows joint damage
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

12. glucocorticoid therapy
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
If symptoms persist >6weeks

13. criteria for AS
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
PMR and giant cell arteritis; can be seen both together;
Supplementation ca and vitamin D

14. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Dorsum of hands and the Achilies tendon

15. When to stop statin if cpk elevated
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Malignancy - infection - vertebral fracture
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
Coronary atherosclerosis due to SLE

16. 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
Hyperflexion of both wrists--characteristic pain in one min
High incidence of opportunistitc infection; reactivation of TB;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

17. inflamed tendons in wrist - ankle - arms; sexual history
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Disseminated gonoccal infection
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

18. pain in shoulder and pelvic girdle
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
Disseminated gonoccal infection
Measure ESR; polymyalgia rheumatica; tx prednisone

19. night back pain
If person is HLA B27 positive
Abx -bedrest - exercise
Pt with significant organ involvement and have incomplete response to prednisone alone
Malignancy - infection - vertebral fracture

20. When to start DMARD in RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
If symptoms persist >6weeks
AS; sometime only symptom is uveitis;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

21. 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
Symmetrical proximal weakness; increased CPK
Supplementation ca and vitamin D
Xray every 3m

22. inflammatory myositis
AS; sometime only symptom is uveitis;
Increased serum ferritin (acute phase protein)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

23. who gets reiters syndrome after chlamydia infection
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If person is HLA B27 positive
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

24. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Decrease urate secretion from kidney
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Pseudogout/hemochromatosis;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

25. Raynauds phenomenon
Deposition of cholesterol in the periorbital skin
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
If symptoms persist >6weeks

26. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
A for aortic regurg; s for prolapSe (MVP)
Check pedal pulses; in claudication pulses should diminish

27. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Patello femoral pain syndrome
Coronary atherosclerosis due to SLE
Hypertriglyceridamia and hypercholesterolemia

28. morning stiffness hand joints
Pt with significant organ involvement and have incomplete response to prednisone alone
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
SLE - only minutes; RA; hours;
Decrease urate secretion from kidney

29. painless ulcer over glans penis and inflammatory arthritis
Dorsum of hands and the Achilies tendon
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
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)

30. probenecid
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
Nodular lung densitieis with RA;
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

31. Rayanaud's disease vs phenomenon
Patello femoral pain syndrome
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Specific of dx of SLE

32. role HLA B27 in dx of ankylosing spondylitis
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
High incidence of opportunistitc infection; reactivation of TB;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

33. How glucocorticoid leads to bone loss
Minocyclin - inhibits metalloproteases and slows joint damage
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
Hyperflexion of both wrists--characteristic pain in one min

34. phalen test
Malignancy - infection - vertebral fracture
If symptoms persist >6weeks
Specific of dx of SLE
Hyperflexion of both wrists--characteristic pain in one min

35. Use of antibiotic in RA
Pseudogout/hemochromatosis;
Minocyclin - inhibits metalloproteases and slows joint damage
Nodular lung densitieis with RA;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

36. when SLE patient needs steroid
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
Viral arthritis or RA
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
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

37. tinel sign
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
Hyper triglyceridemia

38. pagets in xray
Prophylactic agent to prevent recurrent attack; not given during acute attack
Measure ca and ALP; increased ALP and normal ca for dx;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Increased serum ferritin (acute phase protein)

39. Tx of lupus nephritis
Check pedal pulses; in claudication pulses should diminish
Prednisone and cyclophosphamide
Pseudogout/hemochromatosis;
Hypertriglyceridamia and hypercholesterolemia

40. primary muscle disease
AS; sometime only symptom is uveitis;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Symmetrical proximal weakness; increased CPK

41. complications of anti-cytokine therapy
ESRD
High incidence of opportunistitc infection; reactivation of TB;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Erythematous-violaceous rash on the eyelids

42. heberdeen nodes
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Malignancy - infection - vertebral fracture
Arthritic sweling of DIP

43. nicotinic acid
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
C for c ; crest syndrome
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hypertriglyceridamia and hypercholesterolemia

44. patient is having pain when he moves hands above shoulder
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Prophylactic agent to prevent recurrent attack; not given during acute attack
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

45. mcp and PIP joint involvement
Viral arthritis or RA
Xray every 3m
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
Supplementation ca and vitamin D

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

47. SLE with pleural effusion
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Viral arthritis or RA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

48. 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.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
AS; sometime only symptom is uveitis;

49. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Minocyclin - inhibits metalloproteases and slows joint damage
If person is HLA B27 positive
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

50. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
If symptoms persist >6weeks
Pseudogout/hemochromatosis;
AS; sometime only symptom is uveitis;
High incidence of opportunistitc infection; reactivation of TB;