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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.
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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. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Hyper triglyceridemia
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
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

2. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
C for c ; crest syndrome
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

3. xanthelasma
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Deposition of cholesterol in the periorbital skin
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

4. 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
Dorsum of hands and the Achilies tendon
AS; sometime only symptom is uveitis;
Coronary atherosclerosis due to SLE

5. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
ESRD
High incidence of opportunistitc infection; reactivation of TB;
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

6. Tx of gout
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
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
SLE - only minutes; RA; hours;

7. 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.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
High incidence of opportunistitc infection; reactivation of TB;
PPD

8. Tx of RA
Specific of dx of SLE
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.
Prophylactic agent to prevent recurrent attack; not given during acute attack
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

9. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Viral arthritis or RA
Supplementation ca and vitamin D
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Order LFT - heat fractionation (bone burns and liver lives) - GGT

10. neck mass in sjogren patient
Prednisone and cyclophosphamide
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

11. Tx of lupus nephritis
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
Prednisone and cyclophosphamide
A for aortic regurg; s for prolapSe (MVP)

12. xanthomatous nodule
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
C for c ; crest syndrome
Dorsum of hands and the Achilies tendon
High incidence of opportunistitc infection; reactivation of TB;

13. anti-mitochondrial
AS; sometime only symptom is uveitis;
Primary biliary cirrhosis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

14. painless ulcer over glans penis and inflammatory arthritis
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
C for c ; crest syndrome
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)

15. 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
Disseminated gonoccal infection
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
AS; sometime only symptom is uveitis;

16. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Minocyclin - inhibits metalloproteases and slows joint damage
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
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

17. What should be chekcked before starting infliximab
PPD
Pt with significant organ involvement and have incomplete response to prednisone alone
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

18. Ca oxalate induced arthritis
ESRD
Check pedal pulses; in claudication pulses should diminish
Measure ESR; polymyalgia rheumatica; tx prednisone
Primary biliary cirrhosis

19. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

20. When to give methotrexate in SLE
Patello femoral pain syndrome
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pt with significant organ involvement and have incomplete response to prednisone alone
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

21. when SLE patient needs steroid
PMR and giant cell arteritis; can be seen both together;
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

22. SLE patient p/w MI - vent fibrillation
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pseudogout/hemochromatosis;
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

23. When to order MRI in LBP
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
If symptoms persist >6weeks
Xray every 3m

24. When to stop statin if cpk elevated
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
ESRD
Supplementation ca and vitamin D
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

25. colchicine
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

26. What is heliotrope sign
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Erythematous-violaceous rash on the eyelids
Viral arthritis or RA
Xray every 3m

27. nicotinic acid
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hypertriglyceridamia and hypercholesterolemia
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Primary biliary cirrhosis

28. anti-centromere ab
Minocyclin - inhibits metalloproteases and slows joint damage
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
C for c ; crest syndrome
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

29. DIP joint involvement

30. spondyloarthopathy
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Measure ca and ALP; increased ALP and normal ca for dx;

31. caplan syndrom
Nodular lung densitieis with RA;
AS; sometime only symptom is uveitis;
Hyper triglyceridemia
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

32. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Osteoarthirit (bouchard at pip - b comes first);
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Malignancy - infection - vertebral fracture

33. Low back pain
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;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

34. MCP joint involvement
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

35. cylosporin used after renal transplantation
Decrease urate secretion from kidney
High incidence of opportunistitc infection; reactivation of TB;
If person is HLA B27 positive
Viral arthritis or RA

36. glucocorticoid therapy
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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
High incidence of opportunistitc infection; reactivation of TB;

37. heberdeen nodes
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pt with significant organ involvement and have incomplete response to prednisone alone
Arthritic sweling of DIP
Check pedal pulses; in claudication pulses should diminish

38. When to start DMARD in RA
Pseudogout/hemochromatosis;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

39. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Think about reiter (cannot see - cannot pee - cannot climb a tree)

40. morning stiffness hand joints
SLE - only minutes; RA; hours;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
C for c ; crest syndrome

41. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ESR; polymyalgia rheumatica; tx prednisone

42. How to differentiate radicular pain with claudication
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Check pedal pulses; in claudication pulses should diminish

43. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Hypertriglyceridamia and hypercholesterolemia
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Erythematous-violaceous rash on the eyelids

44. PIP joint involment
Pseudogout/hemochromatosis;
Osteoarthirit (bouchard at pip - b comes first);
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
A for aortic regurg; s for prolapSe (MVP)

45. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
SLE - only minutes; RA; hours;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

46. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Minocyclin - inhibits metalloproteases and slows joint damage
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

47. Tx of reiter
Abx -bedrest - exercise
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
Nodular lung densitieis with RA;

48. mcp and PIP joint involvement
Viral arthritis or RA
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
Deposition of cholesterol in the periorbital skin
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

49. How to monitor 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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Coronary atherosclerosis due to SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

50. Tx of gout in patient with ESRD or hx GI bleeding
Abx -bedrest - exercise
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
Arthritic sweling of DIP
Check pedal pulses; in claudication pulses should diminish