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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. When to stop statin if cpk elevated
Nodular lung densitieis with RA;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Hypertriglyceridamia and hypercholesterolemia

2. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Viral arthritis or RA
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

3. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Disseminated gonoccal infection
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Prednisone and cyclophosphamide
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

4. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Order LFT - heat fractionation (bone burns and liver lives) - GGT

5. who gets reiters syndrome after chlamydia infection
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
If person is HLA B27 positive
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

6. morning stiffness hand joints
Measure ca and ALP; increased ALP and normal ca for dx;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
SLE - only minutes; RA; hours;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

7. How glucocorticoid leads to bone loss
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
If person is HLA B27 positive
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

8. Tx of inflammatory myositis
If person is HLA B27 positive
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

9. What should be chekcked before starting infliximab
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
If symptoms persist >6weeks
PPD
Patello femoral pain syndrome

10. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
AS; sometime only symptom is uveitis;
A for aortic regurg; s for prolapSe (MVP)

11. Finding of MRI in stenosis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
A for aortic regurg; s for prolapSe (MVP)
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

12. night back pain
Measure ca and ALP; increased ALP and normal ca for dx;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Malignancy - infection - vertebral fracture
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

13. PIP joint involment
Pseudogout/hemochromatosis;
Osteoarthirit (bouchard at pip - b comes first);
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

14. pagets in xray
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pt with significant organ involvement and have incomplete response to prednisone alone
Measure ca and ALP; increased ALP and normal ca for dx;
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

15. pain in shoulder and pelvic girdle
Primary biliary cirrhosis
Patello femoral pain syndrome
Nodular lung densitieis with RA;
Measure ESR; polymyalgia rheumatica; tx prednisone

16. Use of allopurinol after kidney transplant
Hyper triglyceridemia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

17. What marker is used to follow up disease activity in SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
AS; sometime only symptom is uveitis;

18. DIP joint involvement

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19. How often disease activity is monitored in AS?
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Xray every 3m
Pseudogout/hemochromatosis;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

20. Tx of gout
Check pedal pulses; in claudication pulses should diminish
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Malignancy - infection - vertebral fracture

21. SLE patient p/w MI - vent fibrillation
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
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
Coronary atherosclerosis due to SLE

22. How to perform schober 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.
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
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

23. Ca oxalate induced arthritis
Minocyclin - inhibits metalloproteases and slows joint damage
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
ESRD

24. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Decrease urate secretion from kidney
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

25. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
PPD

26. When to start DMARD in RA
Coronary atherosclerosis due to SLE
AS; sometime only symptom is uveitis;
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

27. conjunctivitis - urethritis - and spondyloarthopathy

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28. inflamed tendons in wrist - ankle - arms; sexual history
Measure ca and ALP; increased ALP and normal ca for dx;
Disseminated gonoccal infection
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
AS; sometime only symptom is uveitis;

29. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Patello femoral pain syndrome
Decrease urate secretion from kidney
Primary biliary cirrhosis

30. Tx of lupus nephritis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Prednisone and cyclophosphamide
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

31. nicotinic acid
If person is HLA B27 positive
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hypertriglyceridamia and hypercholesterolemia

32. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Supplementation ca and vitamin D
Deposition of cholesterol in the periorbital skin
AS; sometime only symptom is uveitis;

33. allpurinol
PPD
Prophylactic agent to prevent recurrent attack; not given during acute attack
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia

34. cylosporin used after renal transplantation
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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
Supplementation ca and vitamin D

35. When to give methotrexate in SLE
If symptoms persist >6weeks
ESRD
Pt with significant organ involvement and have incomplete response to prednisone alone
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

36. anti-ds DNA antibody
Specific of dx of SLE
ESRD
Prednisone and cyclophosphamide
Pseudogout/hemochromatosis;

37. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Coronary atherosclerosis due to SLE
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
Specific of dx of SLE

38. patient pw groin pain; on steroid
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

39. primary muscle disease
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Increased serum ferritin (acute phase protein)
Symmetrical proximal weakness; increased CPK
Prophylactic agent to prevent recurrent attack; not given during acute attack

40. criteria for AS
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
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

41. How to differentiate radicular pain with claudication
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Check pedal pulses; in claudication pulses should diminish

42. inflammatory myositis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
PMR and giant cell arteritis; can be seen both together;
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
Increased serum ferritin (acute phase protein)

43. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Primary biliary cirrhosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

44. Rayanaud's disease vs phenomenon
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

45. heberdeen nodes
Arthritic sweling of DIP
Coronary atherosclerosis due to SLE
Measure ca and ALP; increased ALP and normal ca for dx;
Pt with significant organ involvement and have incomplete response to prednisone alone

46. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
A for aortic regurg; s for prolapSe (MVP)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
If person is HLA B27 positive

47. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
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
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

48. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
Supplementation ca and vitamin D

49. Tx of gout in patient with ESRD or hx GI bleeding
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
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.
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

50. How to prevent glucocorticoid induced bone loss
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Viral arthritis or RA
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Supplementation ca and vitamin D