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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. neck mass in sjogren patient
AS; sometime only symptom is uveitis;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

2. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Nodular lung densitieis with RA;
If symptoms persist >6weeks
Specific of dx of SLE
PMR and giant cell arteritis; can be seen both together;

3. mcp and PIP joint involvement
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Osteoarthirit (bouchard at pip - b comes first);
Viral arthritis or RA

4. inflammatory myositis
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Increased serum ferritin (acute phase protein)
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

5. anterior shoulder pain
Symmetrical proximal weakness; increased CPK
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

6. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
AS; sometime only symptom is uveitis;
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

7. carpal tunnel
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
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

8. How to monitor disease activity in SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
SLE - only minutes; RA; hours;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Nodular lung densitieis with RA;

9. phalen test
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
Hyperflexion of both wrists--characteristic pain in one min
Check pedal pulses; in claudication pulses should diminish
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

10. When to start DMARD in RA
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
C for c ; crest syndrome

11. What should be chekcked before starting infliximab
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pt with significant organ involvement and have incomplete response to prednisone alone
A for aortic regurg; s for prolapSe (MVP)
PPD

12. increased ALP; liver or bone origin?
Coronary atherosclerosis due to SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Minocyclin - inhibits metalloproteases and slows joint damage

13. When to stop statin if cpk elevated
Primary biliary cirrhosis
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

14. Tx of inflammatory myositis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Dorsum of hands and the Achilies tendon
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`

15. xanthomatous nodule
Specific of dx of SLE
Dorsum of hands and the Achilies tendon
Hyper triglyceridemia
Measure ESR; polymyalgia rheumatica; tx prednisone

16. Finding of MRI in stenosis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Arthritic sweling of DIP
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

17. anti-mitochondrial
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Primary biliary cirrhosis

18. allpurinol
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Prophylactic agent to prevent recurrent attack; not given during acute attack
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

19. criteria for AS
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Supplementation ca and vitamin D

20. Rayanaud's disease vs phenomenon
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dorsum of hands and the Achilies tendon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

21. tinel sign
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
Coronary atherosclerosis due to SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT

22. PIP joint involment
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
Osteoarthirit (bouchard at pip - b comes first);
Patello femoral pain syndrome
If person is HLA B27 positive

23. Gait in spinal stenosis
Deposition of cholesterol in the periorbital skin
Xray every 3m
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

24. management of LBP
Measure ESR; polymyalgia rheumatica; tx prednisone
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`
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

25. heberdeen nodes
Viral arthritis or RA
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Arthritic sweling of DIP
Prophylactic agent to prevent recurrent attack; not given during acute attack

26. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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

27. Management of HTN during acute gout
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pseudogout/hemochromatosis;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

28. primary muscle disease
Pt with significant organ involvement and have incomplete response to prednisone alone
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Symmetrical proximal weakness; increased CPK
Patello femoral pain syndrome

29. pain in shoulder and pelvic girdle
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Measure ESR; polymyalgia rheumatica; tx prednisone
PMR and giant cell arteritis; can be seen both together;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

30. postoeriod shoulder pain
PMR and giant cell arteritis; can be seen both together;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
If symptoms persist >6weeks
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

31. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Disseminated gonoccal infection
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

32. MCP joint involvement
Patello femoral pain syndrome
Think about reiter (cannot see - cannot pee - cannot climb a tree)
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Measure ca and ALP; increased ALP and normal ca for dx;

33. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Patello femoral pain syndrome
Specific of dx of SLE
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

34. glucocorticoid therapy
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Measure ESR; polymyalgia rheumatica; tx prednisone

35. Tx of gout
Deposition of cholesterol in the periorbital skin
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
Dorsum of hands and the Achilies tendon

36. gemfibrozil
Hyper triglyceridemia
Coronary atherosclerosis due to SLE
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
Minocyclin - inhibits metalloproteases and slows joint damage

37. anti-centromere ab
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
C for c ; crest syndrome

38. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Supplementation ca and vitamin D
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

39. Tx of RA
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

40. schirmer test
AS; sometime only symptom is uveitis;
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.
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

41. Tx of reiter
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Malignancy - infection - vertebral fracture
Abx -bedrest - exercise

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

43. Tx of gout in patient with ESRD or hx GI bleeding
Pseudogout/hemochromatosis;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

44. Tx of lupus nephritis
Dorsum of hands and the Achilies tendon
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Prednisone and cyclophosphamide
Patello femoral pain syndrome

45. xanthelasma
If person is HLA B27 positive
Deposition of cholesterol in the periorbital skin
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Dorsum of hands and the Achilies tendon

46. tx pagets
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 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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
If person is HLA B27 positive

47. inflamed tendons in wrist - ankle - arms; sexual history
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
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
ESRD

48. Low back pain
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
Arthritic sweling of DIP
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

49. Ca oxalate induced arthritis
Supplementation ca and vitamin D
ESRD
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

50. morning stiffness hand joints
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
SLE - only minutes; RA; hours;