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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
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.
Malignancy - infection - vertebral fracture
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

2. patient is having pain when he moves hands above shoulder
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Malignancy - infection - vertebral fracture
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Primary biliary cirrhosis

3. postoeriod shoulder pain
Coronary atherosclerosis due to SLE
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Patello femoral pain syndrome

4. heberdeen nodes
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Arthritic sweling of DIP
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

5. anti-mitochondrial
Primary biliary cirrhosis
Pseudogout/hemochromatosis;
Patello femoral pain syndrome
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

6. SLE patient p/w MI - vent fibrillation
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Specific of dx of SLE
Coronary atherosclerosis due to SLE
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

7. xanthomatous nodule
Disseminated gonoccal infection
Dorsum of hands and the Achilies tendon
Prophylactic agent to prevent recurrent attack; not given during acute attack
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

8. DIP joint involvement

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9. Tx of lupus nephritis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
If person is HLA B27 positive
Prednisone and cyclophosphamide
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

10. What marker is used to follow up disease activity in SLE
Hypertriglyceridamia and hypercholesterolemia
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

11. Tx of reiter
Abx -bedrest - exercise
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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)

12. 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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

13. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Measure ESR; polymyalgia rheumatica; tx prednisone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Coronary atherosclerosis due to SLE

14. How to perform schober test
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Symmetrical proximal weakness; increased CPK

15. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Primary biliary cirrhosis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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. complications of anti-cytokine therapy
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
High incidence of opportunistitc infection; reactivation of TB;

17. What should be chekcked before starting infliximab
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
High incidence of opportunistitc infection; reactivation of TB;
Malignancy - infection - vertebral fracture
PPD

18. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
If symptoms persist >6weeks
Symmetrical proximal weakness; increased CPK
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

19. pagets in xray
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
Dorsum of hands and the Achilies tendon
Measure ca and ALP; increased ALP and normal ca for dx;
Increased serum ferritin (acute phase protein)

20. How to differentiate radicular pain with claudication
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
High incidence of opportunistitc infection; reactivation of TB;
Check pedal pulses; in claudication pulses should diminish
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

21. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prednisone and cyclophosphamide
Increased serum ferritin (acute phase protein)
AS; sometime only symptom is uveitis;

22. spondyloarthopathy
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Measure ca and ALP; increased ALP and normal ca for dx;

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
Dorsum of hands and the Achilies tendon
PMR and giant cell arteritis; can be seen both together;
Hypertriglyceridamia and hypercholesterolemia

24. anterior shoulder pain
Abx -bedrest - exercise
Viral arthritis or RA
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

25. Ca oxalate induced arthritis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Hyper triglyceridemia
ESRD
Primary biliary cirrhosis

26. Tx of inflammatory myositis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Specific of dx of SLE
Hyper triglyceridemia

27. anti-ds DNA antibody
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;
Specific of dx of SLE
Xray every 3m

28. bouchard nodule
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.
Arthritic sweling of DIP
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

29. Use of antibiotic in RA
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hyper triglyceridemia
Minocyclin - inhibits metalloproteases and slows joint damage

30. caplan syndrom
Disseminated gonoccal infection
Nodular lung densitieis with RA;
SLE - only minutes; RA; hours;
Deposition of cholesterol in the periorbital skin

31. painless ulcer over glans penis and inflammatory arthritis
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If person is HLA B27 positive
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

32. increased ALP; liver or bone origin?
Measure ca and ALP; increased ALP and normal ca for dx;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

33. How to monitor disease activity in SLE
Viral arthritis or RA
Dorsum of hands and the Achilies tendon
Check pedal pulses; in claudication pulses should diminish
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

34. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

35. anti-centromere ab
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Nodular lung densitieis with RA;
C for c ; crest syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

36. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Hyper triglyceridemia
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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

37. probenecid
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pt with significant organ involvement and have incomplete response to prednisone alone

38. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
ESRD
Increased serum ferritin (acute phase protein)
Hypertriglyceridamia and hypercholesterolemia

39. conjunctivitis - urethritis - and spondyloarthopathy

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40. carpal tunnel syndrom
Measure ESR; polymyalgia rheumatica; tx prednisone
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

41. who gets reiters syndrome after chlamydia infection
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
If person is HLA B27 positive
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

42. colchicine
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

43. xanthelasma
Deposition of cholesterol in the periorbital skin
A for aortic regurg; s for prolapSe (MVP)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
If person is HLA B27 positive

44. 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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Patello femoral pain syndrome

45. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
PMR and giant cell arteritis; can be seen both together;
Erythematous-violaceous rash on the eyelids

46. patient pw groin pain; on steroid
Arthritic sweling of DIP
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
AS; sometime only symptom is uveitis;

47. Tx of gout
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

48. Tx of gout in patient with ESRD or hx GI bleeding
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Malignancy - infection - vertebral fracture
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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

49. inflammatory myositis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Increased serum ferritin (acute phase protein)
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
Check pedal pulses; in claudication pulses should diminish

50. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Specific of dx of SLE
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pseudogout/hemochromatosis;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion