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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. Tx of lupus nephritis
Symmetrical proximal weakness; increased CPK
Pt with significant organ involvement and have incomplete response to prednisone alone
Prophylactic agent to prevent recurrent attack; not given during acute attack
Prednisone and cyclophosphamide

2. mcp and PIP joint involvement
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Minocyclin - inhibits metalloproteases and slows joint damage
Viral arthritis or RA
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

3. complications of anti-cytokine therapy
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
High incidence of opportunistitc infection; reactivation of TB;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Measure ca and ALP; increased ALP and normal ca for dx;

4. role HLA B27 in dx of ankylosing spondylitis
Pseudogout/hemochromatosis;
Deposition of cholesterol in the periorbital skin
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

5. probenecid
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)
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
AS; sometime only symptom is uveitis;

6. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Check pedal pulses; in claudication pulses should diminish

7. glucocorticoid therapy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

8. conjunctivitis - urethritis - and spondyloarthopathy

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9. xanthelasma
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Measure ESR; polymyalgia rheumatica; tx prednisone
Deposition of cholesterol in the periorbital skin

10. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Hyperflexion of both wrists--characteristic pain in one min
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
AS; sometime only symptom is uveitis;

11. How to monitor disease activity in SLE
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
Erythematous-violaceous rash on the eyelids
If person is HLA B27 positive

12. Use of allopurinol after kidney transplant
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;
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

13. What should be chekcked before starting infliximab
Xray every 3m
Order LFT - heat fractionation (bone burns and liver lives) - GGT
PPD
Erythematous-violaceous rash on the eyelids

14. right anterior knee pain and provoked by climbing stairs or prolong sitting
Measure ESR; polymyalgia rheumatica; tx prednisone
Supplementation ca and vitamin D
Patello femoral pain syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

15. When to order MRI in LBP
Patello femoral pain syndrome
Malignancy - infection - vertebral fracture
Deposition of cholesterol in the periorbital skin
If symptoms persist >6weeks

16. anti-centromere ab
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
C for c ; crest syndrome
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

17. SLE with pleural effusion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
PPD
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

18. anterior shoulder pain
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

19. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Malignancy - infection - vertebral fracture
Deposition of cholesterol in the periorbital skin
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

20. anti-mitochondrial
Dorsum of hands and the Achilies tendon
Erythematous-violaceous rash on the eyelids
Primary biliary cirrhosis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

21. Raynauds phenomenon
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
Hyperflexion of both wrists--characteristic pain in one min
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

22. inflamed tendons in wrist - ankle - arms; sexual history
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Decrease urate secretion from kidney
Disseminated gonoccal infection

23. How to differentiate radicular pain with claudication
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Check pedal pulses; in claudication pulses should diminish

24. How often disease activity is monitored in AS?
Hyperflexion of both wrists--characteristic pain in one min
Patello femoral pain syndrome
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Xray every 3m

25. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
PMR and giant cell arteritis; can be seen both together;
Pseudogout/hemochromatosis;

26. Tx of inflammatory myositis
PMR and giant cell arteritis; can be seen both together;
Pseudogout/hemochromatosis;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

27. SLE patient p/w MI - vent fibrillation
Patello femoral pain syndrome
Coronary atherosclerosis due to SLE
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

28. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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)

29. Tx of gout in patient with ESRD or hx GI bleeding
Measure ca and ALP; increased ALP and normal ca for dx;
Abx -bedrest - exercise
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
Viral arthritis or RA

30. DIP joint involvement

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31. 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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
If person is HLA B27 positive

32. schirmer test
Decrease urate secretion from kidney
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

33. How to perform schober test
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Erythematous-violaceous rash on the eyelids
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

34. gemfibrozil
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
Abx -bedrest - exercise
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyper triglyceridemia

35. MCP joint involvement
If person is HLA B27 positive
Malignancy - infection - vertebral fracture
Viral arthritis or RA
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

36. night back pain
Malignancy - infection - vertebral fracture
Osteoarthirit (bouchard at pip - b comes first);
Nodular lung densitieis with RA;
Decrease urate secretion from kidney

37. Tx of gout
Nodular lung densitieis with 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
Specific of dx of SLE
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

38. who gets reiters syndrome after chlamydia infection
Osteoarthirit (bouchard at pip - b comes first);
Specific of dx of SLE
Patello femoral pain syndrome
If person is HLA B27 positive

39. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
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
Nodular lung densitieis with 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

40. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Disseminated gonoccal infection
Specific of dx of SLE

41. Rayanaud's disease vs phenomenon
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Symmetrical proximal weakness; increased CPK
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

42. patient pw groin pain; on steroid
PMR and giant cell arteritis; can be seen both together;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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.

43. allpurinol
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Prophylactic agent to prevent recurrent attack; not given during acute attack
Prednisone and cyclophosphamide
Hypertriglyceridamia and hypercholesterolemia

44. criteria for AS
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
Minocyclin - inhibits metalloproteases and slows joint damage
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

45. when SLE patient needs steroid
Prednisone and cyclophosphamide
PPD
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

46. anti-ds DNA antibody
Specific of dx of SLE
Supplementation ca and vitamin D
Hypertriglyceridamia and hypercholesterolemia
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.

47. Use of antibiotic in RA
Erythematous-violaceous rash on the eyelids
If symptoms persist >6weeks
Measure ESR; polymyalgia rheumatica; tx prednisone
Minocyclin - inhibits metalloproteases and slows joint damage

48. primary muscle disease
Symmetrical proximal weakness; increased CPK
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Prednisone and cyclophosphamide
Disseminated gonoccal infection

49. When to give methotrexate in SLE
Hyper triglyceridemia
Pt with significant organ involvement and have incomplete response to prednisone alone
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

50. Finding of MRI in stenosis
Minocyclin - inhibits metalloproteases and slows joint damage
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;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard