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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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
AS; sometime only symptom is uveitis;
Coronary atherosclerosis due to SLE
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

2. painless ulcer over glans penis and inflammatory arthritis
Increased serum ferritin (acute phase protein)
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

3. patient pw groin pain; on steroid
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.
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

4. inflammatory myositis
PPD
Nodular lung densitieis with RA;
Arthritic sweling of DIP
Increased serum ferritin (acute phase protein)

5. Low back pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

6. common valvular abnormalities with AS?
High incidence of opportunistitc infection; reactivation of TB;
A for aortic regurg; s for prolapSe (MVP)
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

7. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Measure ESR; polymyalgia rheumatica; tx prednisone
PMR and giant cell arteritis; can be seen both together;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Primary biliary cirrhosis

8. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Supplementation ca and vitamin D
Minocyclin - inhibits metalloproteases and slows joint damage

9. carpal tunnel syndrom
High incidence of opportunistitc infection; reactivation of TB;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

10. tinel sign
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Hyper triglyceridemia
SLE - only minutes; RA; hours;

11. neck mass in sjogren patient
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Prednisone and cyclophosphamide
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

12. How to differentiate radicular pain with claudication
Increased serum ferritin (acute phase protein)
Check pedal pulses; in claudication pulses should diminish
Patello femoral pain syndrome
Viral arthritis or RA

13. postoeriod shoulder pain
If symptoms persist >6weeks
Pseudogout/hemochromatosis;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

14. Use of allopurinol after kidney transplant
Prednisone and cyclophosphamide
Arthritic sweling of DIP
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;

15. heberdeen nodes
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Arthritic sweling of DIP
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

16. caplan syndrom
Nodular lung densitieis with RA;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
PPD

17. What marker is used to follow up disease activity in SLE
SLE - only minutes; RA; hours;
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

18. What is heliotrope sign
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Erythematous-violaceous rash on the eyelids

19. who gets reiters syndrome after chlamydia infection
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Arthritic sweling of DIP
If person is HLA B27 positive

20. conjunctivitis - urethritis - and spondyloarthopathy

21. MCP joint involvement
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
High incidence of opportunistitc infection; reactivation of TB;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

22. anterior shoulder pain
Pseudogout/hemochromatosis;
Measure ca and ALP; increased ALP and normal ca for dx;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Abx -bedrest - exercise

23. pagets in xray
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Measure ca and ALP; increased ALP and normal ca for dx;
Primary biliary cirrhosis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

24. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Prednisone and cyclophosphamide
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Order LFT - heat fractionation (bone burns and liver lives) - GGT

25. When to give methotrexate in SLE
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Erythematous-violaceous rash on the eyelids
Pt with significant organ involvement and have incomplete response to prednisone alone

26. Tx of lupus nephritis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
If person is HLA B27 positive
Prednisone and cyclophosphamide
Hyper triglyceridemia

27. xanthomatous nodule
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
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
Pt with significant organ involvement and have incomplete response to prednisone alone

28. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

29. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Dorsum of hands and the Achilies tendon
Xray every 3m

30. anti-ds DNA antibody
Viral arthritis or RA
PPD
Specific of dx of SLE
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

31. probenecid
Pt with significant organ involvement and have incomplete response to prednisone alone
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

32. How glucocorticoid leads to bone loss
Primary biliary cirrhosis
Erythematous-violaceous rash on the eyelids
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

33. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
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
If symptoms persist >6weeks
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

34. How to monitor disease activity in SLE
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Hyper triglyceridemia
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

35. What should be chekcked before starting infliximab
Prophylactic agent to prevent recurrent attack; not given during acute attack
Prednisone and cyclophosphamide
PPD
Primary biliary cirrhosis

36. glucocorticoid therapy
Deposition of cholesterol in the periorbital skin
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Osteoarthirit (bouchard at pip - b comes first);
Patello femoral pain syndrome

37. increased ALP; liver or bone origin?
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Primary biliary cirrhosis

38. carpal tunnel
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Deposition of cholesterol in the periorbital skin

39. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Pseudogout/hemochromatosis;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Symmetrical proximal weakness; increased CPK

40. Gait in spinal stenosis
Decrease urate secretion from kidney
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

41. primary muscle disease
Prednisone and cyclophosphamide
Deposition of cholesterol in the periorbital skin
Symmetrical proximal weakness; increased CPK
Xray every 3m

42. night back pain
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Malignancy - infection - vertebral fracture

43. tx pagets
Malignancy - infection - vertebral fracture
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Nodular lung densitieis with RA;
SLE - only minutes; RA; hours;

44. when SLE patient needs steroid
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.
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
If person is HLA B27 positive
Prophylactic agent to prevent recurrent attack; not given during acute attack

45. complications of anti-cytokine therapy
C for c ; crest syndrome
High incidence of opportunistitc infection; reactivation of TB;
PMR and giant cell arteritis; can be seen both together;
Decrease urate secretion from kidney

46. Tx of reiter
Hyperflexion of both wrists--characteristic pain in one min
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
ESRD

47. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Minocyclin - inhibits metalloproteases and slows joint damage
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Check pedal pulses; in claudication pulses should diminish

48. When to order MRI in LBP
If symptoms persist >6weeks
Coronary atherosclerosis due to SLE
Specific of dx of SLE
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

49. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Supplementation ca and vitamin D
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
C for c ; crest syndrome

50. anti-mitochondrial
Order LFT - heat fractionation (bone burns and liver lives) - GGT
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Primary biliary cirrhosis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm