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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. Tx of reiter
AS; sometime only symptom is uveitis;
Abx -bedrest - exercise
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

2. neck mass in sjogren patient
Pt with significant organ involvement and have incomplete response to prednisone alone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

3. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
PPD
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

4. colchicine
SLE - only minutes; RA; hours;
C for c ; crest syndrome
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

5. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Measure ca and ALP; increased ALP and normal ca for dx;
Osteoarthirit (bouchard at pip - b comes first);
Think about reiter (cannot see - cannot pee - cannot climb a tree)

6. allpurinol
PPD
Hyper triglyceridemia
Prophylactic agent to prevent recurrent attack; not given during acute attack
Abx -bedrest - exercise

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;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Prophylactic agent to prevent recurrent attack; not given during acute attack

8. Tx of inflammatory myositis
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Prednisone and cyclophosphamide
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

9. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Coronary atherosclerosis due to SLE
Specific of dx of SLE

10. phalen test
Arthritic sweling of DIP
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Disseminated gonoccal infection
Hyperflexion of both wrists--characteristic pain in one min

11. PIP joint involment
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Osteoarthirit (bouchard at pip - b comes first);

12. who gets reiters syndrome after chlamydia infection
Patello femoral pain syndrome
Coronary atherosclerosis due to SLE
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
If person is HLA B27 positive

13. What should be chekcked before starting infliximab
Disseminated gonoccal infection
PPD
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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.

14. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Hyperflexion of both wrists--characteristic pain in one min
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pt with significant organ involvement and have incomplete response to prednisone alone

15. SLE with pleural effusion
Supplementation ca and vitamin D
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

16. When to stop statin if cpk elevated
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Viral arthritis or RA
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

17. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Specific of dx of SLE
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
Xray every 3m

18. caplan syndrom
Nodular lung densitieis with RA;
Patello femoral pain syndrome
Coronary atherosclerosis due to SLE
Hypertriglyceridamia and hypercholesterolemia

19. Use of antibiotic in RA
C for c ; crest syndrome
Minocyclin - inhibits metalloproteases and slows joint damage
Xray every 3m
Malignancy - infection - vertebral fracture

20. inflammatory myositis
Dorsum of hands and the Achilies tendon
If symptoms persist >6weeks
Increased serum ferritin (acute phase protein)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

21. when SLE patient needs steroid
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
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

22. Rayanaud's disease vs phenomenon
Abx -bedrest - exercise
Nodular lung densitieis with RA;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If person is HLA B27 positive

23. postoeriod shoulder pain
Deposition of cholesterol in the periorbital skin
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hyper triglyceridemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

24. 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
Prednisone and cyclophosphamide
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
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

25. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
High incidence of opportunistitc infection; reactivation of TB;
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

26. How often disease activity is monitored in AS?
Arthritic sweling of DIP
Xray every 3m
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Increased serum ferritin (acute phase protein)

27. carpal tunnel syndrom
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Patello femoral pain syndrome
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

28. How to monitor disease activity in SLE
Check pedal pulses; in claudication pulses should diminish
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Order LFT - heat fractionation (bone burns and liver lives) - GGT

29. xanthomatous nodule
Coronary atherosclerosis due to SLE
Increased serum ferritin (acute phase protein)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Dorsum of hands and the Achilies tendon

30. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Prednisone and cyclophosphamide
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

31. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

32. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Nodular lung densitieis with RA;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

33. Tx of lupus nephritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Prednisone and cyclophosphamide
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Nodular lung densitieis with RA;

34. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
PPD
A for aortic regurg; s for prolapSe (MVP)

35. pain in shoulder and pelvic girdle
AS; sometime only symptom is uveitis;
Primary biliary cirrhosis
Measure ESR; polymyalgia rheumatica; tx prednisone
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

36. Low back pain
Primary biliary cirrhosis
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
AS; sometime only symptom is uveitis;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

37. Management of HTN during acute gout
Deposition of cholesterol in the periorbital skin
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

38. cylosporin used after renal transplantation
Xray every 3m
Hyper triglyceridemia
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Decrease urate secretion from kidney

39. anti-mitochondrial
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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
Primary biliary cirrhosis
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

40. patient pw groin pain; on steroid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
PPD
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
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

41. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Deposition of cholesterol in the periorbital skin
PPD
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

42. gemfibrozil
Erythematous-violaceous rash on the eyelids
Hyper triglyceridemia
Hyperflexion of both wrists--characteristic pain in one min
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

43. anti-centromere ab
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Decrease urate secretion from kidney
Malignancy - infection - vertebral fracture
C for c ; crest syndrome

44. When to order MRI in LBP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Viral arthritis or RA
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
If symptoms persist >6weeks

45. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

46. management of LBP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pseudogout/hemochromatosis;
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

47. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Deposition of cholesterol in the periorbital skin
Viral arthritis or RA

48. Raynauds phenomenon
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hypertriglyceridamia and hypercholesterolemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

49. Tx of gout in patient with ESRD or hx GI bleeding
Minocyclin - inhibits metalloproteases and slows joint damage
Primary biliary cirrhosis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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. criteria for AS
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.
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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