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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. xanthelasma
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
Deposition of cholesterol in the periorbital skin
Osteoarthirit (bouchard at pip - b comes first);
Symmetrical proximal weakness; increased CPK

2. Use of antibiotic in RA
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Minocyclin - inhibits metalloproteases and slows joint damage
C for c ; crest syndrome

3. schirmer test
Supplementation ca and vitamin D
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
C for c ; crest syndrome
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.

4. DIP joint involvement

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5. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
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.

6. What should be chekcked before starting infliximab
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
PPD
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

7. Tx of gout
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
PPD
Order LFT - heat fractionation (bone burns and liver lives) - GGT

8. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

9. role HLA B27 in dx of ankylosing spondylitis
If person is HLA B27 positive
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Prednisone and cyclophosphamide

10. When to order MRI in LBP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If symptoms persist >6weeks
Measure ca and ALP; increased ALP and normal ca for dx;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

11. anti-ds DNA antibody
Primary biliary cirrhosis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Specific of dx of SLE
ESRD

12. 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
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;
Arthritic sweling of DIP

13. glucocorticoid therapy
ESRD
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
Measure ca and ALP; increased ALP and normal ca for dx;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

14. How to monitor disease activity in SLE
Measure ca and ALP; increased ALP and normal ca for dx;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Decrease urate secretion from kidney
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

15. morning stiffness hand joints
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
SLE - only minutes; RA; hours;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

16. How to perform schober 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.
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
Decrease urate secretion from kidney

17. nicotinic acid
Abx -bedrest - exercise
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Hypertriglyceridamia and hypercholesterolemia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

18. inflammatory myositis
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
Increased serum ferritin (acute phase protein)
Supplementation ca and vitamin D

19. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

20. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Hyperflexion of both wrists--characteristic pain in one min
AS; sometime only symptom is uveitis;
Osteoarthirit (bouchard at pip - b comes first);

21. night back pain
Symmetrical proximal weakness; increased CPK
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Disseminated gonoccal infection
Malignancy - infection - vertebral fracture

22. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Hyperflexion of both wrists--characteristic pain in one min
Coronary atherosclerosis due to SLE

23. who gets reiters syndrome after chlamydia infection
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Nodular lung densitieis with RA;
If person is HLA B27 positive
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

24. tinel sign
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
ESRD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

25. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Abx -bedrest - exercise

26. conjunctivitis - urethritis - and spondyloarthopathy

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27. patient is having pain when he moves hands above shoulder
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If person is HLA B27 positive
Primary biliary cirrhosis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

28. How glucocorticoid leads to 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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hypertriglyceridamia and hypercholesterolemia
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

29. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

30. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
PMR and giant cell arteritis; can be seen both together;
High incidence of opportunistitc infection; reactivation of TB;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

31. How to differentiate radicular pain with claudication
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Check pedal pulses; in claudication pulses should diminish
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

32. phalen test
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hyperflexion of both wrists--characteristic pain in one min
Increased serum ferritin (acute phase protein)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

33. pagets in xray
Disseminated gonoccal infection
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Malignancy - infection - vertebral fracture
Measure ca and ALP; increased ALP and normal ca for dx;

34. neck mass in sjogren patient
Disseminated gonoccal infection
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Viral arthritis or RA
Prophylactic agent to prevent recurrent attack; not given during acute attack

35. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

36. allpurinol
High incidence of opportunistitc infection; reactivation of TB;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pseudogout/hemochromatosis;
SLE - only minutes; RA; hours;

37. Finding of MRI in stenosis
Malignancy - infection - vertebral fracture
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.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

38. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Prednisone and cyclophosphamide
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

39. carpal tunnel syndrom
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 - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
SLE - only minutes; RA; hours;
Abx -bedrest - exercise

40. How often disease activity is monitored in AS?
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Xray every 3m
Arthritic sweling of DIP

41. Ca oxalate induced arthritis
ESRD
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disseminated gonoccal infection
Arthritic sweling of DIP

42. Tx of inflammatory myositis
Supplementation ca and vitamin D
High incidence of opportunistitc infection; reactivation of TB;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

43. patient pw groin pain; on steroid
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
C for c ; crest syndrome
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Prednisone and cyclophosphamide

44. carpal tunnel
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

45. heberdeen nodes
Arthritic sweling of DIP
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
A for aortic regurg; s for prolapSe (MVP)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

46. When to stop statin if cpk elevated
Dorsum of hands and the Achilies tendon
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
ESRD

47. probenecid
PPD
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

48. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Viral arthritis or RA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Think about reiter (cannot see - cannot pee - cannot climb a tree)

49. Management of HTN during acute gout
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
PMR and giant cell arteritis; can be seen both together;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

50. management of LBP
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
Arthritic sweling of DIP
Hyper triglyceridemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;