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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. 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.
If symptoms persist >6weeks
Coronary atherosclerosis due to SLE
Disseminated gonoccal infection

2. Tx of reiter
Abx -bedrest - exercise
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

3. pain in shoulder and pelvic girdle
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Symmetrical proximal weakness; increased CPK
Measure ESR; polymyalgia rheumatica; tx prednisone

4. Gait in spinal stenosis
Supplementation ca and vitamin D
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Abx -bedrest - exercise
Xray every 3m

5. nicotinic acid
PPD
Hypertriglyceridamia and hypercholesterolemia
Disseminated gonoccal infection
Patello femoral pain syndrome

6. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Think about reiter (cannot see - cannot pee - cannot climb a tree)

7. glucocorticoid therapy
Primary biliary cirrhosis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Malignancy - infection - vertebral fracture

8. anti-centromere ab
Pt with significant organ involvement and have incomplete response to prednisone alone
C for c ; crest syndrome
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
Specific of dx of SLE

9. How to differentiate radicular pain with claudication
Patello femoral pain syndrome
Check pedal pulses; in claudication pulses should diminish
Abx -bedrest - exercise
Arthritic sweling of DIP

10. 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.
Disseminated gonoccal infection
If symptoms persist >6weeks
Deposition of cholesterol in the periorbital skin

11. xanthelasma
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Deposition of cholesterol in the periorbital skin
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Dorsum of hands and the Achilies tendon

12. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
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
Primary biliary cirrhosis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

13. spondyloarthopathy
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.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Supplementation ca and vitamin D

14. inflammatory myositis
Hypertriglyceridamia and hypercholesterolemia
Increased serum ferritin (acute phase protein)
Prophylactic agent to prevent recurrent attack; not given during acute attack
Dorsum of hands and the Achilies tendon

15. MCP joint involvement
PPD
SLE - only minutes; RA; hours;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

16. Raynauds phenomenon
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`
Symmetrical proximal weakness; increased CPK
Hypertriglyceridamia and hypercholesterolemia

17. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hypertriglyceridamia and hypercholesterolemia

18. How to perform schober test
AS; sometime only symptom is uveitis;
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

19. Finding of MRI in stenosis
High incidence of opportunistitc infection; reactivation of TB;
Malignancy - infection - vertebral fracture
Dorsum of hands and the Achilies tendon
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

20. inflamed tendons in wrist - ankle - arms; sexual history
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Disseminated gonoccal infection
ESRD

21. What marker is used to follow up disease activity in SLE
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
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
Pt with significant organ involvement and have incomplete response to prednisone alone

22. mcp and PIP joint involvement
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
C for c ; crest syndrome
Viral arthritis or RA
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

23. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
Malignancy - infection - vertebral fracture

24. When to order MRI in LBP
PMR and giant cell arteritis; can be seen both together;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Check pedal pulses; in claudication pulses should diminish
If symptoms persist >6weeks

25. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Arthritic sweling of DIP
Osteoarthirit (bouchard at pip - b comes first);
Deposition of cholesterol in the periorbital skin

26. xanthomatous nodule
Prednisone and cyclophosphamide
Dorsum of hands and the Achilies tendon
Coronary atherosclerosis due to SLE
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

27. when SLE patient needs steroid
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
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
A for aortic regurg; s for prolapSe (MVP)

28. pagets in xray
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Measure ca and ALP; increased ALP and normal ca for dx;
Xray every 3m

29. Management of HTN during acute gout
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Nodular lung densitieis with RA;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

30. When to give methotrexate in SLE
Check pedal pulses; in claudication pulses should diminish
Pt with significant organ involvement and have incomplete response to prednisone alone
If symptoms persist >6weeks
Coronary atherosclerosis due to SLE

31. anterior shoulder pain
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Dorsum of hands and the Achilies tendon
Measure ESR; polymyalgia rheumatica; tx prednisone
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

32. painless ulcer over glans penis and inflammatory arthritis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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)
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

33. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Prophylactic agent to prevent recurrent attack; not given during acute attack

34. Tx of gout
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
PMR and giant cell arteritis; can be seen both together;
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

35. Tx of inflammatory myositis
Prednisone and cyclophosphamide
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Coronary atherosclerosis due to SLE

36. How to monitor disease activity in SLE
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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

37. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

38. Low back pain
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Xray every 3m
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. PIP joint involment
Prophylactic agent to prevent recurrent attack; not given during acute attack
Osteoarthirit (bouchard at pip - b comes first);
Viral arthritis or RA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

40. tinel sign
Xray every 3m
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Minocyclin - inhibits metalloproteases and slows joint damage

41. morning stiffness hand joints
SLE - only minutes; RA; hours;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Specific of dx of SLE
High incidence of opportunistitc infection; reactivation of TB;

42. management of LBP
ESRD
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

43. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Viral arthritis or RA

44. anti-mitochondrial
Primary biliary cirrhosis
Specific of dx of SLE
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Coronary atherosclerosis due to SLE

45. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
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
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

46. allpurinol
Symmetrical proximal weakness; increased CPK
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prophylactic agent to prevent recurrent attack; not given during acute attack

47. anti-ds DNA antibody
Specific of dx of SLE
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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. cylosporin used after renal transplantation
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
High incidence of opportunistitc infection; reactivation of TB;
Decrease urate secretion from kidney

49. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Symmetrical proximal weakness; increased CPK
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

50. postoeriod shoulder pain
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
If symptoms persist >6weeks