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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. SLE patient p/w MI - vent fibrillation
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Coronary atherosclerosis due to SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

2. role HLA B27 in dx of ankylosing spondylitis
PPD
Hyper triglyceridemia
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

3. complications of anti-cytokine therapy
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
High incidence of opportunistitc infection; reactivation of TB;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

4. conjunctivitis - urethritis - and spondyloarthopathy

5. mcp and PIP joint involvement
Viral arthritis or RA
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

6. MCP joint involvement
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Order LFT - heat fractionation (bone burns and liver lives) - GGT
A for aortic regurg; s for prolapSe (MVP)

7. How to perform schober test
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

8. primary muscle disease
If person is HLA B27 positive
Symmetrical proximal weakness; increased CPK
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

9. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Prophylactic agent to prevent recurrent attack; not given during acute attack
If symptoms persist >6weeks
Symmetrical proximal weakness; increased CPK

10. phalen test
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.
Hyper triglyceridemia
Hyperflexion of both wrists--characteristic pain in one min

11. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
If person is HLA B27 positive
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
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
Pseudogout/hemochromatosis;

12. Tx of gout
Decrease urate secretion from kidney
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

13. What should be chekcked before starting infliximab
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Measure ca and ALP; increased ALP and normal ca for dx;
PPD
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

14. Finding of MRI in stenosis
Decrease urate secretion from kidney
ESRD
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

15. xanthelasma
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Deposition of cholesterol in the periorbital skin

16. allpurinol
Hypertriglyceridamia and hypercholesterolemia
Prophylactic agent to prevent recurrent attack; not given during acute attack
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
PPD

17. How glucocorticoid leads to bone loss
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hyperflexion of both wrists--characteristic pain in one min
AS; sometime only symptom is uveitis;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

18. Ca oxalate induced arthritis
Hypertriglyceridamia and hypercholesterolemia
ESRD
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

19. caplan syndrom
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
Pseudogout/hemochromatosis;
Nodular lung densitieis with RA;

20. colchicine
Arthritic sweling of DIP
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

21. inflamed tendons in wrist - ankle - arms; sexual history
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disseminated gonoccal infection

22. Tx of inflammatory myositis
Osteoarthirit (bouchard at pip - b comes first);
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

23. PIP joint involment
Check pedal pulses; in claudication pulses should diminish
Decrease urate secretion from kidney
Osteoarthirit (bouchard at pip - b comes first);
If person is HLA B27 positive

24. glucocorticoid therapy
SLE - only minutes; RA; hours;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
If person is HLA B27 positive
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

25. schirmer test
Erythematous-violaceous rash on the eyelids
Prophylactic agent to prevent recurrent attack; not given during acute attack
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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.

26. anti-mitochondrial
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Dorsum of hands and the Achilies tendon
Primary biliary cirrhosis
Specific of dx of SLE

27. When to stop statin if cpk elevated
SLE - only minutes; RA; hours;
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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

28. inflammatory myositis
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
Increased serum ferritin (acute phase protein)
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Measure ca and ALP; increased ALP and normal ca for dx;

29. How to prevent glucocorticoid induced bone loss
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
If symptoms persist >6weeks
Supplementation ca and vitamin D
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

30. How to differential lumbar spinal stenosis and disc herniation pain?
Deposition of cholesterol in the periorbital skin
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Abx -bedrest - exercise

31. 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
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

32. Low back pain
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
High incidence of opportunistitc infection; reactivation of TB;

33. right anterior knee pain and provoked by climbing stairs or prolong sitting
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
C for c ; crest syndrome
Patello femoral pain syndrome
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

34. When to start DMARD in RA
AS; sometime only symptom is uveitis;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

35. How often disease activity is monitored in AS?
Xray every 3m
Think about reiter (cannot see - cannot pee - cannot climb a tree)
AS; sometime only symptom is uveitis;
Supplementation ca and vitamin D

36. 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
Malignancy - infection - vertebral fracture
AS; sometime only symptom is uveitis;
If person is HLA B27 positive

37. Tx of lupus nephritis
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Prednisone and cyclophosphamide
Dorsum of hands and the Achilies tendon

38. When to order MRI in LBP
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Check pedal pulses; in claudication pulses should diminish
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
If symptoms persist >6weeks

39. How to monitor disease activity in SLE
Xray every 3m
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

40. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
High incidence of opportunistitc infection; reactivation of TB;
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

41. carpal tunnel syndrom
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Prophylactic agent to prevent recurrent attack; not given during acute attack
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

42. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Check pedal pulses; in claudication pulses should diminish
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Abx -bedrest - exercise

43. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
High incidence of opportunistitc infection; reactivation of TB;
Hyperflexion of both wrists--characteristic pain in one min
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

44. pain in shoulder and pelvic girdle
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyper triglyceridemia

45. Use of allopurinol after kidney transplant
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Disseminated gonoccal infection

46. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Measure ca and ALP; increased ALP and normal ca for dx;

47. What marker is used to follow up disease activity in SLE
C for c ; crest syndrome
Hyper triglyceridemia
Measure ca and ALP; increased ALP and normal ca for dx;
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. when SLE patient needs steroid
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Malignancy - infection - vertebral fracture

49. criteria for AS
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
Xray every 3m
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

50. morning stiffness hand joints
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
SLE - only minutes; RA; hours;
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