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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. heberdeen nodes
Hyper triglyceridemia
Disseminated gonoccal infection
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Arthritic sweling of DIP

2. How to monitor disease activity in SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Xray every 3m
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

3. 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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Increased serum ferritin (acute phase protein)

4. pagets in xray
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Measure ca and ALP; increased ALP and normal ca for dx;
If person is HLA B27 positive
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

5. Low back pain
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Measure ca and ALP; increased ALP and normal ca for dx;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
C for c ; crest syndrome

6. pain in shoulder and pelvic girdle
Primary biliary cirrhosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Measure ESR; polymyalgia rheumatica; tx prednisone
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

7. tx pagets
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Erythematous-violaceous rash on the eyelids
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
C for c ; crest syndrome

8. DIP joint involvement

9. carpal tunnel
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
Dorsum of hands and the Achilies tendon
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

10. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Symmetrical proximal weakness; increased CPK
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

11. morning stiffness hand joints
Pseudogout/hemochromatosis;
Supplementation ca and vitamin D
SLE - only minutes; RA; hours;
If person is HLA B27 positive

12. anti-ds DNA antibody
Specific of dx of SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Measure ESR; polymyalgia rheumatica; tx prednisone
Prednisone and cyclophosphamide

13. gemfibrozil
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Decrease urate secretion from kidney
Hyper triglyceridemia

14. Management of HTN during acute gout
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
PMR and giant cell arteritis; can be seen both together;

15. anti-centromere ab
Measure ESR; polymyalgia rheumatica; tx prednisone
C for c ; crest syndrome
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
High incidence of opportunistitc infection; reactivation of TB;

16. SLE with pleural effusion
Patello femoral pain syndrome
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pt with significant organ involvement and have incomplete response to prednisone alone

17. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Pseudogout/hemochromatosis;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Prednisone and cyclophosphamide

18. right anterior knee pain and provoked by climbing stairs or prolong sitting
AS; sometime only symptom is uveitis;
Presence not specific since it is present in other spondyloarthopathies but absence exclude 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
Patello femoral pain syndrome

19. When to start DMARD in RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Viral arthritis or RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

20. conjunctivitis - urethritis - and spondyloarthopathy

21. Use of allopurinol after kidney transplant
Measure ESR; polymyalgia rheumatica; tx prednisone
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

22. carpal tunnel syndrom
If person is HLA B27 positive
Measure ca and ALP; increased ALP and normal ca for dx;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

23. Tx of gout in patient with ESRD or hx GI bleeding
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

24. patient is having pain when he moves hands above shoulder
Malignancy - infection - vertebral fracture
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
If person is HLA B27 positive

25. 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
Osteoarthirit (bouchard at pip - b comes first);
Xray every 3m

26. who gets reiters syndrome after chlamydia infection
Deposition of cholesterol in the periorbital skin
If person is HLA B27 positive
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Supplementation ca and vitamin D

27. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Supplementation ca and vitamin D
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
SLE - only minutes; RA; hours;

28. Ca oxalate induced arthritis
ESRD
Prednisone and cyclophosphamide
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Dorsum of hands and the Achilies tendon

29. How to perform schober test
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
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
Disseminated gonoccal infection

30. cylosporin used after renal transplantation
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hyper triglyceridemia
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Decrease urate secretion from kidney

31. How to prevent glucocorticoid induced bone loss
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Supplementation ca and vitamin D
PMR and giant cell arteritis; can be seen both together;

32. neck mass in sjogren patient
Arthritic sweling of DIP
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Hypertriglyceridamia and hypercholesterolemia

33. complications of anti-cytokine therapy
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
High incidence of opportunistitc infection; reactivation of TB;
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

34. Tx of lupus nephritis
ESRD
Prednisone and cyclophosphamide
Think about reiter (cannot see - cannot pee - cannot climb a tree)
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

35. How glucocorticoid leads to bone loss
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
PPD

36. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Abx -bedrest - exercise
Hyper triglyceridemia
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.
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

37. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Xray every 3m

38. When to order MRI in LBP
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If symptoms persist >6weeks
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
SLE - only minutes; RA; hours;

39. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Check pedal pulses; in claudication pulses should diminish
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hypertriglyceridamia and hypercholesterolemia

40. anterior shoulder pain
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyperflexion of both wrists--characteristic pain in one min
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

41. What marker is used to follow up disease activity in 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
Deposition of cholesterol in the periorbital skin
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;

42. Rayanaud's disease vs phenomenon
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
If person is HLA B27 positive
Measure ca and ALP; increased ALP and normal ca for dx;

43. Use of antibiotic in RA
Check pedal pulses; in claudication pulses should diminish
Minocyclin - inhibits metalloproteases and slows joint damage
Malignancy - infection - vertebral fracture
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

44. spondyloarthopathy
Malignancy - infection - vertebral fracture
Deposition of cholesterol in the periorbital skin
Decrease urate secretion from kidney
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

45. When to give methotrexate in SLE
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
PMR and giant cell arteritis; can be seen both together;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pt with significant organ involvement and have incomplete response to prednisone alone

46. painless ulcer over glans penis and inflammatory arthritis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Increased serum ferritin (acute phase protein)

47. night back pain
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Malignancy - infection - vertebral fracture
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
AS; sometime only symptom is uveitis;

48. Gait in spinal stenosis
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
C for c ; crest syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Nodular lung densitieis with RA;

49. SLE patient p/w MI - vent fibrillation
Hypertriglyceridamia and hypercholesterolemia
Viral arthritis or RA
Coronary atherosclerosis due to SLE
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

50. postoeriod shoulder pain
Increased serum ferritin (acute phase protein)
Specific of dx of SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.