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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. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
C for c ; crest syndrome
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Disseminated gonoccal infection

2. MCP joint involvement
Pseudogout/hemochromatosis;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

3. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Pseudogout/hemochromatosis;

4. When to order MRI in LBP
PPD
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If symptoms persist >6weeks

5. patient is having pain when he moves hands above shoulder
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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.

6. When to start DMARD in RA
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

7. Rayanaud's disease vs phenomenon
Viral arthritis or RA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Prophylactic agent to prevent recurrent attack; not given during acute attack

8. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Decrease urate secretion from kidney
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
C for c ; crest syndrome

9. caplan syndrom
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
Nodular lung densitieis with RA;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

10. schirmer test
Malignancy - infection - vertebral fracture
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.
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

11. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

12. heberdeen nodes
Arthritic sweling of DIP
If person is HLA B27 positive
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

13. How to prevent glucocorticoid induced bone loss
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Viral arthritis or RA

14. What is heliotrope sign
C for c ; crest syndrome
If symptoms persist >6weeks
Erythematous-violaceous rash on the eyelids
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

15. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Measure ESR; polymyalgia rheumatica; tx prednisone
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

16. morning stiffness hand joints
Symmetrical proximal weakness; increased CPK
Pt with significant organ involvement and have incomplete response to prednisone alone
Deposition of cholesterol in the periorbital skin
SLE - only minutes; RA; hours;

17. inflammatory myositis
C for c ; crest syndrome
Increased serum ferritin (acute phase protein)
Pt with significant organ involvement and have incomplete response to prednisone alone
Hyperflexion of both wrists--characteristic pain in one min

18. 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
Pseudogout/hemochromatosis;
Xray every 3m
C for c ; crest syndrome

19. xanthelasma
Viral arthritis or RA
Deposition of cholesterol in the periorbital skin
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

20. DIP joint involvement

21. increased ALP; liver or bone origin?
High incidence of opportunistitc infection; reactivation of TB;
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.
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

22. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

23. mcp and PIP joint involvement
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Erythematous-violaceous rash on the eyelids
Viral arthritis or RA
Dorsum of hands and the Achilies tendon

24. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Pt with significant organ involvement and have incomplete response to prednisone alone
Dorsum of hands and the Achilies tendon
Abx -bedrest - exercise

25. What marker is used to follow up disease activity in SLE
Increased serum ferritin (acute phase protein)
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

26. Use of allopurinol after kidney transplant
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
If person is HLA B27 positive

27. right anterior knee pain and provoked by climbing stairs or prolong sitting
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
Patello femoral pain syndrome
Dorsum of hands and the Achilies tendon
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

28. Tx of gout in patient with ESRD or hx GI bleeding
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

29. when SLE patient needs steroid
Malignancy - infection - vertebral fracture
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Measure ca and ALP; increased ALP and normal ca for dx;

30. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Disseminated gonoccal infection
PMR and giant cell arteritis; can be seen both together;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

31. pagets in xray
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
Measure ca and ALP; increased ALP and normal ca for dx;
Symmetrical proximal weakness; increased CPK
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

32. Tx of reiter
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
Abx -bedrest - exercise
Specific of dx of SLE

33. spondyloarthopathy
If symptoms persist >6weeks
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

34. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Erythematous-violaceous rash on the eyelids
AS; sometime only symptom is uveitis;

35. How to perform schober test
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Pseudogout/hemochromatosis;

36. primary muscle disease
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
AS; sometime only symptom is uveitis;
Symmetrical proximal weakness; increased CPK
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. patient pw groin pain; on steroid
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
If person is HLA B27 positive
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

38. When to give methotrexate in SLE
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Pt with significant organ involvement and have incomplete response to prednisone alone
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
High incidence of opportunistitc infection; reactivation of TB;

39. postoeriod shoulder pain
Decrease urate secretion from kidney
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Coronary atherosclerosis due to SLE
Specific of dx of SLE

40. complications of anti-cytokine therapy
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Symmetrical proximal weakness; increased CPK
High incidence of opportunistitc infection; reactivation of TB;

41. bouchard nodule
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

42. How to differentiate radicular pain with claudication
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Check pedal pulses; in claudication pulses should diminish
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

43. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
If person is HLA B27 positive
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

44. Raynauds phenomenon
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

45. How glucocorticoid leads to bone loss
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

46. How to differential lumbar spinal stenosis and disc herniation pain?
If person is HLA B27 positive
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
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. SLE patient p/w MI - vent fibrillation
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Coronary atherosclerosis due to SLE
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

48. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ca and ALP; increased ALP and normal ca for dx;
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

49. How often disease activity is monitored in AS?
Coronary atherosclerosis due to SLE
Pseudogout/hemochromatosis;
Disseminated gonoccal infection
Xray every 3m

50. who gets reiters syndrome after chlamydia infection
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Supplementation ca and vitamin D
If person is HLA B27 positive
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`