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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. xanthomatous nodule
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Dorsum of hands and the Achilies tendon

2. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Increased serum ferritin (acute phase protein)
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

3. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Measure ca and ALP; increased ALP and normal ca for dx;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

4. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Erythematous-violaceous rash on the eyelids
Hypertriglyceridamia and hypercholesterolemia

5. Tx of reiter
Measure ESR; polymyalgia rheumatica; tx prednisone
Increased serum ferritin (acute phase protein)
Abx -bedrest - exercise
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

6. Use of allopurinol after kidney transplant
Disseminated gonoccal infection
Nodular lung densitieis with RA;
High incidence of opportunistitc infection; reactivation of TB;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

7. painless ulcer over glans penis and inflammatory arthritis
Nodular lung densitieis with RA;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

8. criteria for AS
Order LFT - heat fractionation (bone burns and liver lives) - GGT
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

9. 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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Arthritic sweling of DIP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

10. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
High incidence of opportunistitc infection; reactivation of TB;
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

11. When to start DMARD in RA
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
Check pedal pulses; in claudication pulses should diminish
A for aortic regurg; s for prolapSe (MVP)
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

12. spondyloarthopathy
Abx -bedrest - exercise
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Measure ESR; polymyalgia rheumatica; tx prednisone

13. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Supplementation ca and vitamin D
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Coronary atherosclerosis due to SLE

14. night back pain
C for c ; crest syndrome
Deposition of cholesterol in the periorbital skin
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Malignancy - infection - vertebral fracture

15. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Supplementation ca and vitamin D
Hyperflexion of both wrists--characteristic pain in one min
Hypertriglyceridamia and hypercholesterolemia

16. How to monitor disease activity in SLE
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ca and ALP; increased ALP and normal ca for dx;
Prednisone and cyclophosphamide
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

17. when SLE patient needs steroid
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Patello femoral pain syndrome
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

18. schirmer test
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Patello femoral pain syndrome
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.
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

19. caplan syndrom
Nodular lung densitieis with RA;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

20. MCP joint involvement
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
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

21. Tx of gout
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Viral arthritis or RA
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

22. primary muscle disease
Arthritic sweling of DIP
Symmetrical proximal weakness; increased CPK
Hyper triglyceridemia
Dorsum of hands and the Achilies tendon

23. How glucocorticoid leads to bone loss
Hyperflexion of both wrists--characteristic pain in one min
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Prednisone and cyclophosphamide
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

24. pain in shoulder and pelvic girdle
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
C for c ; crest syndrome
Measure ESR; polymyalgia rheumatica; tx prednisone

25. inflamed tendons in wrist - ankle - arms; sexual history
Check pedal pulses; in claudication pulses should diminish
Xray every 3m
Disseminated gonoccal infection
Patello femoral pain syndrome

26. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
AS; sometime only symptom is uveitis;
Hypertriglyceridamia and hypercholesterolemia
SLE - only minutes; RA; hours;

27. PIP joint involment
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
Osteoarthirit (bouchard at pip - b comes first);
High incidence of opportunistitc infection; reactivation of TB;
Symmetrical proximal weakness; increased CPK

28. Ca oxalate induced arthritis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
If symptoms persist >6weeks
ESRD
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

29. allpurinol
Check pedal pulses; in claudication pulses should diminish
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Prophylactic agent to prevent recurrent attack; not given during acute attack

30. probenecid
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

31. How to perform schober test
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
PPD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

32. anti-ds DNA antibody
Prednisone and cyclophosphamide
Specific of dx of SLE
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

33. Tx of lupus nephritis
Prednisone and cyclophosphamide
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Supplementation ca and vitamin D
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

34. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Order LFT - heat fractionation (bone burns and liver lives) - GGT

35. When to give methotrexate in SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pt with significant organ involvement and have incomplete response to prednisone alone
Patello femoral pain syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

36. How to differentiate radicular pain with claudication
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
Check pedal pulses; in claudication pulses should diminish

37. anti-mitochondrial
Erythematous-violaceous rash on the eyelids
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Primary biliary cirrhosis
Nodular lung densitieis with RA;

38. carpal tunnel
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Abx -bedrest - exercise
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

39. cylosporin used after renal transplantation
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)
Prednisone and cyclophosphamide
Decrease urate secretion from kidney

40. patient is having pain when he moves hands above shoulder
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
If symptoms persist >6weeks
If person is HLA B27 positive

41. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
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
Supplementation ca and vitamin D
AS; sometime only symptom is uveitis;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

42. patient pw groin pain; on steroid
Abx -bedrest - exercise
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

43. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

44. SLE patient p/w MI - vent fibrillation
AS; sometime only symptom is uveitis;
Coronary atherosclerosis due to SLE
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Disseminated gonoccal infection

45. What marker is used to follow up disease activity in SLE
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Hyper triglyceridemia

46. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Osteoarthirit (bouchard at pip - b comes first);
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

47. who gets reiters syndrome after chlamydia infection
High incidence of opportunistitc infection; reactivation of TB;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
If person is HLA B27 positive

48. increased ALP; liver or bone origin?
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

49. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Supplementation ca and vitamin D
PMR and giant cell arteritis; can be seen both together;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Viral arthritis or RA

50. Use of antibiotic in RA
Minocyclin - inhibits metalloproteases and slows joint damage
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Nodular lung densitieis with RA;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma