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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. heberdeen nodes
Arthritic sweling of DIP
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

2. What is heliotrope sign
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Erythematous-violaceous rash on the eyelids

3. What marker is used to follow up disease activity in SLE
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
High incidence of opportunistitc infection; reactivation of TB;
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

4. mcp and PIP joint involvement
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
Viral arthritis or RA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

5. pagets in xray
Hyperflexion of both wrists--characteristic pain in one min
Measure ca and ALP; increased ALP and normal ca for dx;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
If person is HLA B27 positive

6. inflamed tendons in wrist - ankle - arms; sexual history
Specific of dx of SLE
Disseminated gonoccal infection
Primary biliary cirrhosis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

7. Ca oxalate induced arthritis
Increased serum ferritin (acute phase protein)
PMR and giant cell arteritis; can be seen both together;
ESRD
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

8. who gets reiters syndrome after chlamydia infection
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
If person is HLA B27 positive
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

9. Gait in spinal stenosis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Minocyclin - inhibits metalloproteases and slows joint damage
Pt with significant organ involvement and have incomplete response to prednisone alone
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

10. common valvular abnormalities with AS?
Hypertriglyceridamia and hypercholesterolemia
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
A for aortic regurg; s for prolapSe (MVP)
ESRD

11. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pseudogout/hemochromatosis;

12. How to prevent glucocorticoid induced bone loss
Dorsum of hands and the Achilies tendon
Pseudogout/hemochromatosis;
Pt with significant organ involvement and have incomplete response to prednisone alone
Supplementation ca and vitamin D

13. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
If person is HLA B27 positive
Viral arthritis or RA
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

14. SLE with pleural effusion
Viral arthritis or RA
Dorsum of hands and the Achilies tendon
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

15. conjunctivitis - urethritis - and spondyloarthopathy

16. inflammatory myositis
Increased serum ferritin (acute phase protein)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

17. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Viral arthritis or RA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

18. probenecid
PPD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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

19. 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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

20. 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
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
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

21. Finding of MRI in stenosis
A for aortic regurg; s for prolapSe (MVP)
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Nodular lung densitieis with RA;
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

22. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Abx -bedrest - exercise
Pt with significant organ involvement and have incomplete response to prednisone alone
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

23. Use of allopurinol after kidney transplant
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Prophylactic agent to prevent recurrent attack; not given during acute attack
Prednisone and cyclophosphamide

24. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
PMR and giant cell arteritis; can be seen both together;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

25. complications of anti-cytokine therapy
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ESR; polymyalgia rheumatica; tx prednisone
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.
High incidence of opportunistitc infection; reactivation of TB;

26. xanthomatous nodule
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dorsum of hands and the Achilies tendon

27. primary muscle disease
Symmetrical proximal weakness; increased CPK
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

28. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Increased serum ferritin (acute phase protein)
SLE - only minutes; RA; hours;

29. bouchard nodule
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

30. carpal tunnel syndrom
Prophylactic agent to prevent recurrent attack; not given during acute attack
Supplementation ca and vitamin D
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

31. painless ulcer over glans penis and inflammatory arthritis
Minocyclin - inhibits metalloproteases and slows joint damage
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Prednisone and cyclophosphamide

32. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Malignancy - infection - vertebral fracture
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

33. Use of antibiotic in RA
Dorsum of hands and the Achilies tendon
Minocyclin - inhibits metalloproteases and slows joint damage
Deposition of cholesterol in the periorbital skin
Increased serum ferritin (acute phase protein)

34. Tx of gout
Decrease urate secretion from kidney
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Prednisone and cyclophosphamide

35. schirmer test
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.
A for aortic regurg; s for prolapSe (MVP)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

36. DIP joint involvement

37. What should be chekcked before starting infliximab
Disseminated gonoccal infection
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
PPD

38. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

39. tinel sign
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.
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

40. How often disease activity is monitored in AS?
Xray every 3m
Prednisone and cyclophosphamide
Disseminated gonoccal infection
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

41. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Abx -bedrest - exercise
Symmetrical proximal weakness; increased CPK
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

42. caplan syndrom
Coronary atherosclerosis due to SLE
Disseminated gonoccal infection
Nodular lung densitieis with RA;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

43. When to order MRI in LBP
Check pedal pulses; in claudication pulses should diminish
Measure ca and ALP; increased ALP and normal ca for dx;
If symptoms persist >6weeks
ESRD

44. role HLA B27 in dx of ankylosing spondylitis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Osteoarthirit (bouchard at pip - b comes first);
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

45. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
High incidence of opportunistitc infection; reactivation of TB;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

46. When to start DMARD in RA
Coronary atherosclerosis due to SLE
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

47. cylosporin used after renal transplantation
Nodular lung densitieis with RA;
Decrease urate secretion from kidney
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

48. postoeriod shoulder pain
Check pedal pulses; in claudication pulses should diminish
AS; sometime only symptom is uveitis;
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

49. When to give methotrexate in SLE
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
ESRD
Pt with significant organ involvement and have incomplete response to prednisone alone
If person is HLA B27 positive

50. pain in shoulder and pelvic girdle
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Measure ESR; polymyalgia rheumatica; tx prednisone
Xray every 3m
High incidence of opportunistitc infection; reactivation of TB;