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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
Symmetrical proximal weakness; increased CPK
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

2. heberdeen nodes
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Arthritic sweling of DIP
Symmetrical proximal weakness; increased CPK
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

3. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pseudogout/hemochromatosis;

4. bouchard nodule
Prophylactic agent to prevent recurrent attack; not given during acute attack
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Supplementation ca and vitamin D
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

5. xanthelasma
Abx -bedrest - exercise
Deposition of cholesterol in the periorbital skin
Xray every 3m
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

6. Tx of reiter
Abx -bedrest - exercise
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Increased serum ferritin (acute phase protein)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

7. Finding of MRI in stenosis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Abx -bedrest - exercise

8. right anterior knee pain and provoked by climbing stairs or prolong sitting
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
Dorsum of hands and the Achilies tendon
Supplementation ca and vitamin D
Patello femoral pain syndrome

9. When to start DMARD in RA
Viral arthritis or RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Prophylactic agent to prevent recurrent attack; not given during acute attack
Prednisone and cyclophosphamide

10. night back pain
Malignancy - infection - vertebral fracture
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Decrease urate secretion from kidney

11. criteria for AS
Viral arthritis or RA
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Hyperflexion of both wrists--characteristic pain in one min
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

12. How to differential lumbar spinal stenosis and disc herniation pain?
A for aortic regurg; s for prolapSe (MVP)
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Nodular lung densitieis with RA;
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

13. xanthomatous nodule
Dorsum of hands and the Achilies tendon
A for aortic regurg; s for prolapSe (MVP)
Disseminated gonoccal infection
If person is HLA B27 positive

14. Tx of lupus nephritis
Viral arthritis or RA
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Prednisone and cyclophosphamide
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

15. inflammatory myositis
Increased serum ferritin (acute phase protein)
Hyper triglyceridemia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
C for c ; crest syndrome

16. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Xray every 3m

17. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pt with significant organ involvement and have incomplete response to prednisone alone
Order LFT - heat fractionation (bone burns and liver lives) - GGT

18. When to stop statin if cpk elevated
Decrease urate secretion from kidney
Symmetrical proximal weakness; increased CPK
Prednisone and cyclophosphamide
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

19. Use of antibiotic in RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Minocyclin - inhibits metalloproteases and slows joint damage

20. anti-ds DNA antibody
Dorsum of hands and the Achilies tendon
Coronary atherosclerosis due to SLE
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
Specific of dx of SLE

21. gemfibrozil
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hyper triglyceridemia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

22. pain in shoulder and pelvic girdle
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Measure ESR; polymyalgia rheumatica; tx prednisone
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
AS; sometime only symptom is uveitis;

23. Raynauds phenomenon
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Minocyclin - inhibits metalloproteases and slows joint damage
Patello femoral pain syndrome

24. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Abx -bedrest - exercise
Decrease urate secretion from kidney
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

25. DIP joint involvement

26. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Prophylactic agent to prevent recurrent attack; not given during acute attack
Specific of dx of SLE

27. phalen test
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;
Hypertriglyceridamia and hypercholesterolemia
Hyperflexion of both wrists--characteristic pain in one min

28. What marker is used to follow up disease activity in SLE
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Specific of dx of 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

29. How to differentiate radicular pain with claudication
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Increased serum ferritin (acute phase protein)
Minocyclin - inhibits metalloproteases and slows joint damage
Check pedal pulses; in claudication pulses should diminish

30. pagets in xray
Minocyclin - inhibits metalloproteases and slows joint damage
Measure ca and ALP; increased ALP and normal ca for dx;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

31. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Xray every 3m
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

32. 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
Nodular lung densitieis with RA;
Disseminated gonoccal infection
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

33. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Specific of dx of SLE
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
AS; sometime only symptom is uveitis;

34. increased ALP; liver or bone origin?
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

35. patient pw groin pain; on steroid
A for aortic regurg; s for prolapSe (MVP)
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Xray every 3m

36. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Primary biliary cirrhosis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

37. When to give methotrexate in SLE
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
Primary biliary cirrhosis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

38. Tx of inflammatory myositis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
PPD
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

39. When to order MRI in LBP
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
If symptoms persist >6weeks
Prophylactic agent to prevent recurrent attack; not given during acute attack
Abx -bedrest - exercise

40. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Disseminated gonoccal infection
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Viral arthritis or RA
Pseudogout/hemochromatosis;

41. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

42. cylosporin used after renal transplantation
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Decrease urate secretion from kidney
If symptoms persist >6weeks
Minocyclin - inhibits metalloproteases and slows joint damage

43. How to monitor disease activity in SLE
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
If person is HLA B27 positive
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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;
Hyper triglyceridemia
Osteoarthirit (bouchard at pip - b comes first);
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

45. Tx of gout
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
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
PMR and giant cell arteritis; can be seen both together;

46. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Prophylactic agent to prevent recurrent attack; not given during acute attack
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

47. SLE patient p/w MI - vent fibrillation
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
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Coronary atherosclerosis due to SLE

48. conjunctivitis - urethritis - and spondyloarthopathy

49. How often disease activity is monitored in AS?
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Primary biliary cirrhosis
Xray every 3m
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

50. morning stiffness hand joints
Dorsum of hands and the Achilies tendon
Measure ESR; polymyalgia rheumatica; tx prednisone
SLE - only minutes; RA; hours;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;