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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. neck mass in sjogren patient
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Specific of dx of SLE

2. How often disease activity is monitored in AS?
Coronary atherosclerosis due to SLE
Deposition of cholesterol in the periorbital skin
Xray every 3m
If symptoms persist >6weeks

3. anti-ds DNA antibody
Specific of dx of SLE
PPD
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Nodular lung densitieis with RA;

4. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
SLE - only minutes; RA; hours;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Coronary atherosclerosis due to SLE

5. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Erythematous-violaceous rash on the eyelids

6. tinel sign
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Malignancy - infection - vertebral fracture

7. When to order MRI in LBP
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
If symptoms persist >6weeks
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

8. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pseudogout/hemochromatosis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
AS; sometime only symptom is uveitis;

9. How glucocorticoid leads to bone loss
Deposition of cholesterol in the periorbital skin
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
SLE - only minutes; RA; hours;
Hypertriglyceridamia and hypercholesterolemia

10. postoeriod shoulder pain
PPD
Supplementation ca and vitamin D
Check pedal pulses; in claudication pulses should diminish
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

11. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
PPD
Prophylactic agent to prevent recurrent attack; not given during acute attack
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

12. 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.
Patello femoral pain syndrome
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Check pedal pulses; in claudication pulses should diminish

13. Low back pain
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
AS; sometime only symptom is uveitis;
Nodular lung densitieis with RA;

14. When to start DMARD in RA
Deposition of cholesterol in the periorbital skin
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Decrease urate secretion from kidney
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

15. criteria for AS
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

16. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Order LFT - heat fractionation (bone burns and liver lives) - GGT
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

17. schirmer test
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Symmetrical proximal weakness; increased CPK
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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.

18. Finding of MRI in stenosis
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
PMR and giant cell arteritis; can be seen both together;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

19. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
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
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

20. spondyloarthopathy
PMR and giant cell arteritis; can be seen both together;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

21. How to perform schober test
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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
Increased serum ferritin (acute phase protein)

22. carpal tunnel
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Pt with significant organ involvement and have incomplete response to prednisone alone

23. mcp and PIP joint involvement
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Viral arthritis or RA
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
High incidence of opportunistitc infection; reactivation of TB;

24. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

25. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
PPD
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

26. role HLA B27 in dx of ankylosing spondylitis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Order LFT - heat fractionation (bone burns and liver lives) - GGT

27. xanthelasma
Hyperflexion of both wrists--characteristic pain in one min
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Deposition of cholesterol in the periorbital skin

28. primary muscle disease
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Primary biliary cirrhosis
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
Symmetrical proximal weakness; increased CPK

29. Ca oxalate induced arthritis
Hypertriglyceridamia and hypercholesterolemia
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
SLE - only minutes; RA; hours;
ESRD

30. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Increased serum ferritin (acute phase protein)
Pt with significant organ involvement and have incomplete response to prednisone alone

31. heberdeen nodes
Check pedal pulses; in claudication pulses should diminish
SLE - only minutes; RA; hours;
Erythematous-violaceous rash on the eyelids
Arthritic sweling of DIP

32. When to give methotrexate in SLE
Xray every 3m
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Hyper triglyceridemia

33. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
AS; sometime only symptom is uveitis;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
High incidence of opportunistitc infection; reactivation of TB;

35. Tx of gout in patient with ESRD or hx GI bleeding
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Hypertriglyceridamia and hypercholesterolemia
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
Disseminated gonoccal infection

36. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
PPD

37. inflammatory myositis
C for c ; crest syndrome
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Increased serum ferritin (acute phase protein)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

38. How to differentiate radicular pain with claudication
If person is HLA B27 positive
Check pedal pulses; in claudication pulses should diminish
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

39. xanthomatous nodule
Hypertriglyceridamia and hypercholesterolemia
Specific of dx of SLE
ESRD
Dorsum of hands and the Achilies tendon

40. caplan syndrom
Nodular lung densitieis with RA;
AS; sometime only symptom is uveitis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hyper triglyceridemia

41. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Pt with significant organ involvement and have incomplete response to prednisone alone
Hyper triglyceridemia
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

42. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

43. anti-centromere ab
C for c ; crest syndrome
Osteoarthirit (bouchard at pip - b comes first);
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

44. anti-mitochondrial
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Decrease urate secretion from kidney
Primary biliary cirrhosis

45. 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
Dorsum of hands and the Achilies tendon
Malignancy - infection - vertebral fracture
Disseminated gonoccal infection

46. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Increased serum ferritin (acute phase protein)
Measure ESR; polymyalgia rheumatica; tx prednisone

47. Tx of reiter
Abx -bedrest - exercise
Osteoarthirit (bouchard at pip - b comes first);
PPD
Arthritic sweling of DIP

48. Tx of lupus nephritis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
PMR and giant cell arteritis; can be seen both together;
Prednisone and cyclophosphamide
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

49. conjunctivitis - urethritis - and spondyloarthopathy

50. allpurinol
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Check pedal pulses; in claudication pulses should diminish
Increased serum ferritin (acute phase protein)
Prophylactic agent to prevent recurrent attack; not given during acute attack