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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. colchicine
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If symptoms persist >6weeks
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ESR; polymyalgia rheumatica; tx prednisone

2. When to order MRI in LBP
If symptoms persist >6weeks
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
A for aortic regurg; s for prolapSe (MVP)
PMR and giant cell arteritis; can be seen both together;

3. 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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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

4. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pt with significant organ involvement and have incomplete response to prednisone alone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

5. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hypertriglyceridamia and hypercholesterolemia

6. How to differentiate radicular pain with claudication
ESRD
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Check pedal pulses; in claudication pulses should diminish
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

7. SLE patient p/w MI - vent fibrillation
Osteoarthirit (bouchard at pip - b comes first);
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Coronary atherosclerosis due to SLE
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

8. What should be chekcked before starting infliximab
If symptoms persist >6weeks
Arthritic sweling of DIP
Pseudogout/hemochromatosis;
PPD

9. right anterior knee pain and provoked by climbing stairs or prolong sitting
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
ESRD
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Patello femoral pain syndrome

10. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Arthritic sweling of DIP
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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

11. xanthomatous nodule
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Decrease urate secretion from kidney
Dorsum of hands and the Achilies tendon

12. patient is having pain when he moves hands above shoulder
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

13. DIP joint involvement

14. MCP joint involvement
Erythematous-violaceous rash on the eyelids
PMR and giant cell arteritis; can be seen both together;
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

15. Management of HTN during acute gout
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

16. When to give methotrexate in SLE
High incidence of opportunistitc infection; reactivation of TB;
Pt with significant organ involvement and have incomplete response to prednisone alone
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Arthritic sweling of DIP

17. postoeriod shoulder pain
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

18. neck mass in sjogren patient
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Malignancy - infection - vertebral fracture
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;

19. Use of antibiotic in RA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Minocyclin - inhibits metalloproteases and slows joint damage
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
Decrease urate secretion from kidney

20. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Disseminated gonoccal infection
Measure ca and ALP; increased ALP and normal ca for dx;
Symmetrical proximal weakness; increased CPK

21. probenecid
Prednisone and cyclophosphamide
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

22. role HLA B27 in dx of ankylosing spondylitis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Check pedal pulses; in claudication pulses should diminish

23. patient pw groin pain; on steroid
High incidence of opportunistitc infection; reactivation of TB;
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
Coronary atherosclerosis due to SLE
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

24. Ca oxalate induced arthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
ESRD
Dorsum of hands and the Achilies tendon

25. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Hypertriglyceridamia and hypercholesterolemia
Malignancy - infection - vertebral fracture
SLE - only minutes; RA; hours;

26. What is heliotrope sign
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
If person is HLA B27 positive
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.

27. common valvular abnormalities with AS?
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
SLE - only minutes; RA; hours;
Prophylactic agent to prevent recurrent attack; not given during acute attack
A for aortic regurg; s for prolapSe (MVP)

28. Tx of inflammatory myositis
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

29. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Check pedal pulses; in claudication pulses should diminish
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
AS; sometime only symptom is uveitis;
Think about reiter (cannot see - cannot pee - cannot climb a tree)

30. complications of anti-cytokine therapy
Deposition of cholesterol in the periorbital skin
High incidence of opportunistitc infection; reactivation of TB;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
If symptoms persist >6weeks

31. who gets reiters syndrome after chlamydia infection
Hyperflexion of both wrists--characteristic pain in one min
Pt with significant organ involvement and have incomplete response to prednisone alone
Osteoarthirit (bouchard at pip - b comes first);
If person is HLA B27 positive

32. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
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
Specific of dx of SLE
Prednisone and cyclophosphamide

33. increased ALP; liver or bone origin?
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Order LFT - heat fractionation (bone burns and liver lives) - GGT
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

34. Tx of lupus nephritis
Arthritic sweling of DIP
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Prednisone and cyclophosphamide

35. caplan syndrom
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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;

36. When to stop statin if cpk elevated
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

37. anti-centromere ab
High incidence of opportunistitc infection; reactivation of TB;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
C for c ; crest syndrome

38. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Deposition of cholesterol in the periorbital skin
Viral arthritis or RA

39. 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.
Supplementation ca and vitamin D
Nodular lung densitieis with RA;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

40. proximal muscle weakness; decreased tendon reflex; normal creat and ck
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.
C for c ; crest syndrome
Pt with significant organ involvement and have incomplete response to prednisone alone
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

41. Tx of gout
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
C for c ; crest syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

42. When to start DMARD in RA
Dorsum of hands and the Achilies tendon
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

43. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
SLE - only minutes; RA; hours;
Primary biliary cirrhosis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

44. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Arthritic sweling of DIP
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

45. primary muscle disease
Symmetrical proximal weakness; increased CPK
If symptoms persist >6weeks
AS; sometime only symptom is uveitis;
Xray every 3m

46. How often disease activity is monitored in AS?
Xray every 3m
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pseudogout/hemochromatosis;

47. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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
Specific of dx of SLE

48. gemfibrozil
Hyper triglyceridemia
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

49. tx pagets
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 control and physical therapy - if fails - ESR -CRP - lumbar xray;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyper triglyceridemia

50. heberdeen nodes
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Arthritic sweling of DIP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;