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USMLE Step3 Rheumatology

Subjects : health-sciences, usmle-step-3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. role HLA B27 in dx of ankylosing spondylitis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ESRD
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Patello femoral pain syndrome

2. morning stiffness hand joints
SLE - only minutes; RA; hours;
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

3. conjunctivitis - urethritis - and spondyloarthopathy

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4. primary muscle disease
Symmetrical proximal weakness; increased CPK
Disseminated gonoccal infection
Prednisone and cyclophosphamide
Arthritic sweling of DIP

5. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Pseudogout/hemochromatosis;
Dorsum of hands and the Achilies tendon
Osteoarthirit (bouchard at pip - b comes first);
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

6. carpal tunnel syndrom
Check pedal pulses; in claudication pulses should diminish
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Malignancy - infection - vertebral fracture
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

7. Tx of RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

8. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Prednisone and cyclophosphamide
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Nodular lung densitieis with RA;

9. caplan syndrom
Prednisone and cyclophosphamide
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Nodular lung densitieis with RA;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

10. How to monitor disease activity in SLE
Hyper triglyceridemia
Coronary atherosclerosis due to SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

11. xanthomatous nodule
Dorsum of hands and the Achilies tendon
A for aortic regurg; s for prolapSe (MVP)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

12. anti-centromere ab
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
C for c ; crest syndrome

13. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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

14. increased ALP; liver or bone origin?
Primary biliary cirrhosis
Minocyclin - inhibits metalloproteases and slows joint damage
Order LFT - heat fractionation (bone burns and liver lives) - GGT
A for aortic regurg; s for prolapSe (MVP)

15. night back pain
ESRD
Malignancy - infection - vertebral fracture
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

16. SLE patient p/w MI - vent fibrillation
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
If symptoms persist >6weeks
Coronary atherosclerosis due to SLE
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

17. anterior shoulder pain
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Check pedal pulses; in claudication pulses should diminish

18. How often disease activity is monitored in AS?
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Symmetrical proximal weakness; increased CPK
Prophylactic agent to prevent recurrent attack; not given during acute attack
Xray every 3m

19. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Nodular lung densitieis with RA;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

20. heberdeen nodes
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
AS; sometime only symptom is uveitis;
Arthritic sweling of DIP

21. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pseudogout/hemochromatosis;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pt with significant organ involvement and have incomplete response to prednisone alone

22. Tx of inflammatory myositis
Malignancy - infection - vertebral fracture
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Patello femoral pain syndrome

23. What should be chekcked before starting infliximab
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
PPD
Primary biliary cirrhosis
SLE - only minutes; RA; hours;

24. Finding of MRI in stenosis
Osteoarthirit (bouchard at pip - b comes first);
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
SLE - only minutes; RA; hours;
Pt with significant organ involvement and have incomplete response to prednisone alone

25. who gets reiters syndrome after chlamydia infection
Deposition of cholesterol in the periorbital skin
If person is HLA B27 positive
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

26. DIP joint involvement

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27. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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
Arthritic sweling of DIP

28. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Xray every 3m

29. inflammatory myositis
Disseminated gonoccal infection
Pt with significant organ involvement and have incomplete response to prednisone alone
Increased serum ferritin (acute phase protein)
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

30. When to order MRI in LBP
If symptoms persist >6weeks
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Pseudogout/hemochromatosis;
Order LFT - heat fractionation (bone burns and liver lives) - GGT

31. How glucocorticoid leads to bone loss
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
Check pedal pulses; in claudication pulses should diminish
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

32. probenecid
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

33. 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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

34. What marker is used to follow up disease activity in SLE
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
C for c ; crest syndrome

35. Rayanaud's disease vs phenomenon
Deposition of cholesterol in the periorbital skin
Patello femoral pain syndrome
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

36. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

37. right anterior knee pain and provoked by climbing stairs or prolong sitting
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Primary biliary cirrhosis
Patello femoral pain syndrome
PMR and giant cell arteritis; can be seen both together;

38. How to perform schober test
Think about reiter (cannot see - cannot pee - cannot climb a tree)
A for aortic regurg; s for prolapSe (MVP)
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

39. allpurinol
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
If person is HLA B27 positive
Dorsum of hands and the Achilies tendon

40. PIP joint involment
Arthritic sweling of DIP
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
Osteoarthirit (bouchard at pip - b comes first);
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

41. When to give methotrexate in SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pt with significant organ involvement and have incomplete response to prednisone alone
Pseudogout/hemochromatosis;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

42. gemfibrozil
Malignancy - infection - vertebral fracture
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
Hyper triglyceridemia
Arthritic sweling of DIP

43. complications of anti-cytokine therapy
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;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

44. inflamed tendons in wrist - ankle - arms; sexual history
ESRD
Pseudogout/hemochromatosis;
Disseminated gonoccal infection
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

45. schirmer test
Check pedal pulses; in claudication pulses should diminish
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.
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

46. patient is having pain when he moves hands above shoulder
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Specific of dx of SLE
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Measure ESR; polymyalgia rheumatica; tx prednisone

47. Ca oxalate induced arthritis
Pt with significant organ involvement and have incomplete response to prednisone alone
If person is HLA B27 positive
ESRD
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

48. glucocorticoid therapy
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 - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

49. anti-ds DNA antibody
C for c ; crest syndrome
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Specific of dx of SLE

50. tx pagets
Arthritic sweling of DIP
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

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USMLE Step3 Rheumatology

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