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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. pain in shoulder and pelvic girdle
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Measure ESR; polymyalgia rheumatica; tx prednisone
ESRD

2. right anterior knee pain and provoked by climbing stairs or prolong sitting
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Coronary atherosclerosis due to SLE
Patello femoral pain syndrome

3. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
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
SLE - only minutes; RA; hours;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

4. anti-ds DNA antibody
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
Specific of dx of SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

5. How to differentiate radicular pain with claudication
Arthritic sweling of DIP
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Check pedal pulses; in claudication pulses should diminish
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

6. schirmer test
Symmetrical proximal weakness; increased CPK
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.
Xray every 3m
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

7. heberdeen nodes
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Arthritic sweling of DIP
Patello femoral pain syndrome

8. Management of HTN during acute gout
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

9. glucocorticoid therapy
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

10. Use of allopurinol after kidney transplant
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Nodular lung densitieis with RA;
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

11. When to order MRI in LBP
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
If symptoms persist >6weeks

12. morning stiffness hand joints
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
SLE - only minutes; RA; hours;

13. 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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Supplementation ca and vitamin D

14. role HLA B27 in dx of ankylosing spondylitis
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
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

15. patient pw groin pain; on steroid
Specific of dx of SLE
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

16. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Increased serum ferritin (acute phase protein)
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pseudogout/hemochromatosis;

17. conjunctivitis - urethritis - and spondyloarthopathy

18. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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)
Order LFT - heat fractionation (bone burns and liver lives) - GGT

19. phalen test
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
Hyperflexion of both wrists--characteristic pain in one min
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
AS; sometime only symptom is uveitis;

20. painless ulcer over glans penis and inflammatory arthritis
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Malignancy - infection - vertebral fracture
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

21. allpurinol
Deposition of cholesterol in the periorbital skin
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Xray every 3m
Prophylactic agent to prevent recurrent attack; not given during acute attack

22. How to prevent glucocorticoid induced bone loss
If person is HLA B27 positive
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Supplementation ca and vitamin D

23. patient is having pain when he moves hands above shoulder
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Malignancy - infection - vertebral fracture
SLE - only minutes; RA; hours;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

24. common valvular abnormalities with AS?
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Pseudogout/hemochromatosis;
A for aortic regurg; s for prolapSe (MVP)

25. mcp and PIP joint involvement
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Viral arthritis or RA
Disseminated gonoccal infection
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

26. PIP joint involment
Hyper triglyceridemia
Disseminated gonoccal infection
Osteoarthirit (bouchard at pip - b comes first);
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

27. gemfibrozil
Hyper triglyceridemia
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;
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.

28. What is heliotrope sign
Prednisone and cyclophosphamide
Nodular lung densitieis with RA;
Erythematous-violaceous rash on the eyelids
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

29. xanthelasma
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hyperflexion of both wrists--characteristic pain in one min
Primary biliary cirrhosis
Deposition of cholesterol in the periorbital skin

30. 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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hypertriglyceridamia and hypercholesterolemia
Arthritic sweling of DIP

31. Gait in spinal stenosis
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Erythematous-violaceous rash on the eyelids

32. SLE patient p/w MI - vent fibrillation
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Symmetrical proximal weakness; increased CPK
Coronary atherosclerosis due to SLE
Hyperflexion of both wrists--characteristic pain in one min

33. complications of anti-cytokine therapy
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
High incidence of opportunistitc infection; reactivation of TB;
Decrease urate secretion from kidney
Prophylactic agent to prevent recurrent attack; not given during acute attack

34. when SLE patient needs steroid
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
PMR and giant cell arteritis; can be seen both together;
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

35. How often disease activity is monitored in AS?
Xray every 3m
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
If symptoms persist >6weeks
Supplementation ca and vitamin D

36. bouchard nodule
Symmetrical proximal weakness; increased CPK
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

37. neck mass in sjogren patient
Abx -bedrest - exercise
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Disseminated gonoccal infection
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

38. postoeriod shoulder pain
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Increased serum ferritin (acute phase protein)

39. Tx of gout
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pt with significant organ involvement and have incomplete response to prednisone alone
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--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

40. Tx of inflammatory myositis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

41. Tx of lupus nephritis
Prednisone and cyclophosphamide
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Malignancy - infection - vertebral fracture
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

42. spondyloarthopathy
Hypertriglyceridamia and hypercholesterolemia
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
If symptoms persist >6weeks

43. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
ESRD
Hyperflexion of both wrists--characteristic pain in one min

44. anterior shoulder pain
Xray every 3m
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

45. cylosporin used after renal transplantation
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
ESRD
Decrease urate secretion from kidney

46. xanthomatous nodule
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
Dorsum of hands and the Achilies tendon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

47. When to stop statin if cpk elevated
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

48. Raynauds phenomenon
Osteoarthirit (bouchard at pip - b comes first);
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Increased serum ferritin (acute phase protein)
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

49. SLE with pleural effusion
Measure ESR; polymyalgia rheumatica; tx prednisone
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Abx -bedrest - exercise
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

50. tx pagets
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyperflexion of both wrists--characteristic pain in one min
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis