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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. How often disease activity is monitored in AS?
Xray every 3m
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Abx -bedrest - exercise

2. neck mass in sjogren patient
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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

3. How to differentiate radicular pain with claudication
Arthritic sweling of DIP
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.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

4. schirmer test
If person is HLA B27 positive
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.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Nodular lung densitieis with RA;

5. criteria for AS
PPD
ESRD
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

6. spondyloarthopathy
Symmetrical proximal weakness; increased CPK
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
PMR and giant cell arteritis; can be seen both together;

7. bouchard nodule
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

8. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hyperflexion of both wrists--characteristic pain in one min
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

9. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Prednisone and cyclophosphamide
Erythematous-violaceous rash on the eyelids
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

10. heberdeen nodes
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
Abx -bedrest - exercise
Arthritic sweling of DIP

11. 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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Minocyclin - inhibits metalloproteases and slows joint damage

12. 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
Supplementation ca and vitamin D
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

13. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
High incidence of opportunistitc infection; reactivation of TB;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pseudogout/hemochromatosis;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

14. xanthomatous nodule
Abx -bedrest - exercise
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Dorsum of hands and the Achilies tendon
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

15. management of LBP
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
SLE - only minutes; RA; hours;
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

16. painless ulcer over glans penis and inflammatory arthritis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Think about reiter (cannot see - cannot pee - cannot climb a tree)
ESRD
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

17. When to order MRI in LBP
PMR and giant cell arteritis; can be seen both together;
Measure ca and ALP; increased ALP and normal ca for dx;
Disseminated gonoccal infection
If symptoms persist >6weeks

18. Gait in spinal stenosis
AS; sometime only symptom is uveitis;
PMR and giant cell arteritis; can be seen both together;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

19. MCP joint involvement
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Symmetrical proximal weakness; increased CPK
Hyperflexion of both wrists--characteristic pain in one min
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

20. What should be chekcked before starting infliximab
Hyperflexion of both wrists--characteristic pain in one min
Hyper triglyceridemia
Viral arthritis or RA
PPD

21. Raynauds phenomenon
Increased serum ferritin (acute phase protein)
Arthritic sweling of DIP
SLE - only minutes; RA; hours;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

22. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Think about reiter (cannot see - cannot pee - cannot climb a tree)
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

23. postoeriod shoulder pain
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
AS; sometime only symptom is uveitis;

24. xanthelasma
Deposition of cholesterol in the periorbital skin
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
AS; sometime only symptom is uveitis;
Hyperflexion of both wrists--characteristic pain in one min

25. conjunctivitis - urethritis - and spondyloarthopathy

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26. nicotinic acid
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
Minocyclin - inhibits metalloproteases and slows joint damage
Hyperflexion of both wrists--characteristic pain in one min

27. caplan syndrom
Nodular lung densitieis with RA;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Prednisone and cyclophosphamide
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

28. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Measure ESR; polymyalgia rheumatica; tx prednisone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

29. inflamed tendons in wrist - ankle - arms; sexual history
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;
Disseminated gonoccal infection
Coronary atherosclerosis due to SLE

30. cylosporin used after renal transplantation
Patello femoral pain syndrome
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Decrease urate secretion from kidney
Osteoarthirit (bouchard at pip - b comes first);

31. common valvular abnormalities with AS?
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Coronary atherosclerosis due to SLE
A for aortic regurg; s for prolapSe (MVP)
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

32. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

33. tx pagets
Abx -bedrest - exercise
Hypertriglyceridamia and hypercholesterolemia
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

34. night back pain
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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.
Malignancy - infection - vertebral fracture
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

35. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Prednisone and cyclophosphamide
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Malignancy - infection - vertebral fracture

36. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Erythematous-violaceous rash on the eyelids

37. inflammatory myositis
Increased serum ferritin (acute phase protein)
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Deposition of cholesterol in the periorbital skin

38. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Abx -bedrest - exercise
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

39. Tx of reiter
Xray every 3m
Abx -bedrest - exercise
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Patello femoral pain syndrome

40. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Increased serum ferritin (acute phase protein)
Deposition of cholesterol in the periorbital skin
Prednisone and cyclophosphamide

41. Finding of MRI in stenosis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Viral arthritis or RA
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

42. glucocorticoid therapy
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
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.

43. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
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)

44. tinel sign
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Measure ESR; polymyalgia rheumatica; tx prednisone
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

45. When to stop statin if cpk elevated
Hyper triglyceridemia
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

46. What is heliotrope sign
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
ESRD
Erythematous-violaceous rash on the eyelids

47. carpal tunnel syndrom
Osteoarthirit (bouchard at pip - b comes first);
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Disseminated gonoccal infection
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

48. primary muscle disease
Hypertriglyceridamia and hypercholesterolemia
Hyper triglyceridemia
Symmetrical proximal weakness; increased CPK
ESRD

49. How to differential lumbar spinal stenosis and disc herniation 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
Arthritic sweling of DIP
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

50. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Hyper triglyceridemia
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm