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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. anterior shoulder pain
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
Check pedal pulses; in claudication pulses should diminish
Osteoarthirit (bouchard at pip - b comes first);
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

2. cylosporin used after renal transplantation
Minocyclin - inhibits metalloproteases and slows joint damage
Decrease urate secretion from kidney
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. When to give methotrexate in SLE
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
A for aortic regurg; s for prolapSe (MVP)
Pt with significant organ involvement and have incomplete response to prednisone alone
Coronary atherosclerosis due to SLE

4. when SLE patient needs steroid
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;
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)

5. When to stop statin if cpk elevated
Measure ca and ALP; increased ALP and normal ca for dx;
Coronary atherosclerosis due to SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

6. probenecid
Minocyclin - inhibits metalloproteases and slows joint damage
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Osteoarthirit (bouchard at pip - b comes first);
A for aortic regurg; s for prolapSe (MVP)

7. anti-centromere ab
C for c ; crest syndrome
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

8. patient is having pain when he moves hands above shoulder
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Xray every 3m
Disseminated gonoccal infection
If symptoms persist >6weeks

9. mcp and PIP joint involvement
High incidence of opportunistitc infection; reactivation of TB;
Viral arthritis or RA
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

10. pain in shoulder and pelvic girdle
Check pedal pulses; in claudication pulses should diminish
Disseminated gonoccal infection
Supplementation ca and vitamin D
Measure ESR; polymyalgia rheumatica; tx prednisone

11. PIP joint involment
Disseminated gonoccal infection
Osteoarthirit (bouchard at pip - b comes first);
Patello femoral pain syndrome
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

12. Finding of MRI in stenosis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

13. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Patello femoral pain syndrome

14. SLE with pleural effusion
Viral arthritis or RA
ESRD
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Dorsum of hands and the Achilies tendon

15. bouchard nodule
A for aortic regurg; s for prolapSe (MVP)
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disseminated gonoccal infection

16. spondyloarthopathy
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
SLE - only minutes; RA; hours;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

17. patient pw groin pain; on steroid
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

18. Tx of gout
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hyper triglyceridemia
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. night back pain
Malignancy - infection - vertebral fracture
High incidence of opportunistitc infection; reactivation of TB;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

20. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Viral arthritis or RA
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

21. 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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Specific of dx of SLE
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

22. xanthomatous nodule
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Dorsum of hands and the Achilies tendon
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

23. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

24. right anterior knee pain and provoked by climbing stairs or prolong sitting
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Malignancy - infection - vertebral fracture
Patello femoral pain syndrome
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

25. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Supplementation ca and vitamin D
Viral arthritis or RA
If person is HLA B27 positive

26. Tx of gout in patient with ESRD or hx GI bleeding
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Increased serum ferritin (acute phase protein)
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

27. painless ulcer over glans penis and inflammatory arthritis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Increased serum ferritin (acute phase protein)
Think about reiter (cannot see - cannot pee - cannot climb a tree)

28. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Prophylactic agent to prevent recurrent attack; not given during acute attack

29. SLE patient p/w MI - vent fibrillation
AS; sometime only symptom is uveitis;
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

30. schirmer test
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.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Primary biliary cirrhosis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

31. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Coronary atherosclerosis due to SLE
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

32. allpurinol
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
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.
Prophylactic agent to prevent recurrent attack; not given during acute attack

33. Gait in spinal stenosis
Decrease urate secretion from kidney
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Dorsum of hands and the Achilies tendon

34. anti-ds DNA antibody
Coronary atherosclerosis due to SLE
Specific of dx of SLE
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

35. tx pagets
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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

36. conjunctivitis - urethritis - and spondyloarthopathy

37. How to differentiate radicular pain with claudication
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
Check pedal pulses; in claudication pulses should diminish
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Osteoarthirit (bouchard at pip - b comes first);

38. caplan syndrom
PMR and giant cell arteritis; can be seen both together;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Nodular lung densitieis with RA;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

39. xanthelasma
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Malignancy - infection - vertebral fracture
Xray every 3m
Deposition of cholesterol in the periorbital skin

40. carpal tunnel
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

41. How to perform schober test
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
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

42. Tx of inflammatory myositis
Abx -bedrest - exercise
Nodular lung densitieis with RA;
Osteoarthirit (bouchard at pip - b comes first);
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

43. How often disease activity is monitored in AS?
Viral arthritis or RA
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Xray every 3m
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

44. management of LBP
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Viral arthritis or RA

45. How to monitor disease activity in SLE
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
Hypertriglyceridamia and hypercholesterolemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

46. gemfibrozil
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Hyper triglyceridemia
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
A for aortic regurg; s for prolapSe (MVP)

47. inflammatory myositis
Prednisone and cyclophosphamide
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Increased serum ferritin (acute phase protein)

48. anti-mitochondrial
Primary biliary cirrhosis
Increased serum ferritin (acute phase protein)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

49. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Decrease urate secretion from kidney
If person is HLA B27 positive

50. heberdeen nodes
Arthritic sweling of DIP
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Coronary atherosclerosis due to SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT