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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.
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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. criteria for AS
Deposition of cholesterol in the periorbital skin
AS; sometime only symptom is uveitis;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Measure ESR; polymyalgia rheumatica; tx prednisone

2. painless ulcer over glans penis and inflammatory arthritis
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Decrease urate secretion from kidney
A for aortic regurg; s for prolapSe (MVP)
Think about reiter (cannot see - cannot pee - cannot climb a tree)

3. How to perform schober test
SLE - only minutes; RA; hours;
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
Abx -bedrest - exercise
AS; sometime only symptom is uveitis;

4. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Measure ca and ALP; increased ALP and normal ca for dx;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

5. pagets in xray
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Measure ca and ALP; increased ALP and normal ca for dx;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Osteoarthirit (bouchard at pip - b comes first);

6. anti-mitochondrial
Primary biliary cirrhosis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Measure ESR; polymyalgia rheumatica; tx prednisone
Pseudogout/hemochromatosis;

7. SLE with pleural effusion
Malignancy - infection - vertebral fracture
Primary biliary cirrhosis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

8. 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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Minocyclin - inhibits metalloproteases and slows joint damage
Supplementation ca and vitamin D

9. Tx of inflammatory myositis
Dorsum of hands and the Achilies tendon
Think about reiter (cannot see - cannot pee - cannot climb a tree)
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Malignancy - infection - vertebral fracture

10. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

11. What marker is used to follow up disease activity in SLE
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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

12. carpal tunnel
Osteoarthirit (bouchard at pip - b comes first);
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

13. Tx of lupus nephritis
Prednisone and cyclophosphamide
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

14. tinel sign
Symmetrical proximal weakness; increased CPK
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

15. DIP joint involvement

16. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Pseudogout/hemochromatosis;
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
Check pedal pulses; in claudication pulses should diminish

17. Low back pain
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 ESR; polymyalgia rheumatica; tx prednisone
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hyper triglyceridemia

18. xanthelasma
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
Deposition of cholesterol in the periorbital skin
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

19. Ca oxalate induced arthritis
ESRD
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

20. heberdeen nodes
Prophylactic agent to prevent recurrent attack; not given during acute attack
Arthritic sweling of DIP
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Nodular lung densitieis with RA;

21. phalen test
C for c ; crest syndrome
Hyperflexion of both wrists--characteristic pain in one min
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

22. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Pt with significant organ involvement and have incomplete response to prednisone alone
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Viral arthritis or RA
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

23. gemfibrozil
Hyper triglyceridemia
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

24. xanthomatous nodule
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Malignancy - infection - vertebral fracture
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Dorsum of hands and the Achilies tendon

25. Tx of gout
Deposition of cholesterol in the periorbital skin
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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

26. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Decrease urate secretion from kidney
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prophylactic agent to prevent recurrent attack; not given during acute attack

27. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Arthritic sweling of DIP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

28. How to differentiate radicular pain with claudication
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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
Check pedal pulses; in claudication pulses should diminish
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

29. probenecid
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Order LFT - heat fractionation (bone burns and liver lives) - GGT

30. How to differential lumbar spinal stenosis and disc herniation pain?
Abx -bedrest - exercise
Patello femoral pain syndrome
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

31. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Hyperflexion of both wrists--characteristic pain in one min
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

32. When to stop statin if cpk elevated
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
Prednisone and cyclophosphamide
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

33. How to monitor disease activity in SLE
Malignancy - infection - vertebral fracture
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

34. 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
Xray every 3m
Disseminated gonoccal infection
Measure ESR; polymyalgia rheumatica; tx prednisone

35. complications of anti-cytokine therapy
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;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

36. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If symptoms persist >6weeks
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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. common valvular abnormalities with AS?
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
A for aortic regurg; s for prolapSe (MVP)
Decrease urate secretion from kidney

38. schirmer test
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Prednisone and cyclophosphamide
PMR and giant cell arteritis; can be seen both together;
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.

39. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Specific of dx of SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

40. morning stiffness hand joints
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
SLE - only minutes; RA; hours;
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.

41. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Abx -bedrest - exercise
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

42. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
Pseudogout/hemochromatosis;
PMR and giant cell arteritis; can be seen both together;

43. How often disease activity is monitored in AS?
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Symmetrical proximal weakness; increased CPK
Xray every 3m

44. patient is having pain when he moves hands above shoulder
PMR and giant cell arteritis; can be seen both together;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
AS; sometime only symptom is uveitis;
Viral arthritis or RA

45. Finding of MRI in stenosis
SLE - only minutes; RA; hours;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Coronary atherosclerosis due to SLE
Dorsum of hands and the Achilies tendon

46. Use of allopurinol after kidney transplant
Measure ca and ALP; increased ALP and normal ca for dx;
High incidence of opportunistitc infection; reactivation of TB;
Xray every 3m
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

47. When to order MRI in LBP
If symptoms persist >6weeks
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
SLE - only minutes; RA; hours;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

48. anti-ds DNA antibody
Think about reiter (cannot see - cannot pee - cannot climb a tree)
PPD
Specific of dx of SLE
Pt with significant organ involvement and have incomplete response to prednisone alone

49. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Increased serum ferritin (acute phase protein)
Hypertriglyceridamia and hypercholesterolemia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

50. Use of antibiotic in RA
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
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
PMR and giant cell arteritis; can be seen both together;
Minocyclin - inhibits metalloproteases and slows joint damage