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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.
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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. postoeriod shoulder pain
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

2. anti-ds DNA antibody
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Specific of dx of SLE
Malignancy - infection - vertebral fracture
Supplementation ca and vitamin D

3. glucocorticoid therapy
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Erythematous-violaceous rash on the eyelids

4. Finding of MRI in stenosis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Hyperflexion of both wrists--characteristic pain in one min

5. How often disease activity is monitored in AS?
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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
Xray every 3m
Erythematous-violaceous rash on the eyelids

6. When to stop statin if cpk elevated
Increased serum ferritin (acute phase protein)
Decrease urate secretion from kidney
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
Prophylactic agent to prevent recurrent attack; not given during acute attack

7. patient is having pain when he moves hands above shoulder
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

8. pagets in xray
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Measure ca and ALP; increased ALP and normal ca for dx;
A for aortic regurg; s for prolapSe (MVP)

9. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Minocyclin - inhibits metalloproteases and slows joint damage
Prednisone and cyclophosphamide
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

10. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
AS; sometime only symptom is uveitis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pseudogout/hemochromatosis;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

11. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

12. SLE with pleural effusion
Abx -bedrest - exercise
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pseudogout/hemochromatosis;
ESRD

13. Tx of RA
Prednisone and cyclophosphamide
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
If symptoms persist >6weeks
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

14. Tx of reiter
Prednisone and cyclophosphamide
Abx -bedrest - exercise
Viral arthritis or RA
Patello femoral pain syndrome

15. morning stiffness hand joints
PPD
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
SLE - only minutes; RA; hours;
Minocyclin - inhibits metalloproteases and slows joint damage

16. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Supplementation ca and vitamin D
Pt with significant organ involvement and have incomplete response to prednisone alone
AS; sometime only symptom is uveitis;

17. carpal tunnel syndrom
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

18. Rayanaud's disease vs phenomenon
Decrease urate secretion from kidney
Prednisone and cyclophosphamide
Check pedal pulses; in claudication pulses should diminish
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

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

20. anterior shoulder pain
Pseudogout/hemochromatosis;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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

21. common valvular abnormalities with AS?
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
A for aortic regurg; s for prolapSe (MVP)
Arthritic sweling of DIP
Abx -bedrest - exercise

22. carpal tunnel
Hyperflexion of both wrists--characteristic pain in one min
Malignancy - infection - vertebral fracture
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

23. When to give methotrexate in SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Coronary atherosclerosis due to SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Patello femoral pain syndrome

24. Management of HTN during acute gout
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
C for c ; crest syndrome
Deposition of cholesterol in the periorbital skin
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

25. proximal muscle weakness; decreased tendon reflex; normal creat and ck
PMR and giant cell arteritis; can be seen both together;
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

26. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Xray every 3m
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

27. How to differential lumbar spinal stenosis and disc herniation pain?
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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

28. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Measure ESR; polymyalgia rheumatica; tx prednisone
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

29. What should be chekcked before starting infliximab
PPD
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Symmetrical proximal weakness; increased CPK

30. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

31. phalen test
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
Hyperflexion of both wrists--characteristic pain in one min
A for aortic regurg; s for prolapSe (MVP)
Abx -bedrest - exercise

32. colchicine
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Malignancy - infection - vertebral fracture
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
If symptoms persist >6weeks

33. pain in shoulder and pelvic girdle
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ESR; polymyalgia rheumatica; tx prednisone

34. increased ALP; liver or bone origin?
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
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

35. right anterior knee pain and provoked by climbing stairs or prolong sitting
Abx -bedrest - exercise
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
Patello femoral pain syndrome

36. patient pw groin pain; on steroid
Coronary atherosclerosis due to SLE
PMR and giant cell arteritis; can be seen both together;
AS; sometime only symptom is uveitis;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

37. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Arthritic sweling of DIP

38. spondyloarthopathy
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

39. What marker is used to follow up disease activity in SLE
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
PPD

40. Tx of gout
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

41. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

42. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Minocyclin - inhibits metalloproteases and slows joint damage
Dorsum of hands and the Achilies tendon
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

43. PIP joint involment
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Osteoarthirit (bouchard at pip - b comes first);
Pseudogout/hemochromatosis;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

44. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
If symptoms persist >6weeks
Order LFT - heat fractionation (bone burns and liver lives) - GGT
AS; sometime only symptom is uveitis;

45. anti-centromere ab
High incidence of opportunistitc infection; reactivation of TB;
C for c ; crest syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Xray every 3m

46. bouchard nodule
Measure ESR; polymyalgia rheumatica; tx prednisone
Coronary atherosclerosis due to SLE
Viral arthritis or RA
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

47. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Xray every 3m

48. When to start DMARD in RA
A for aortic regurg; s for prolapSe (MVP)
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;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

49. conjunctivitis - urethritis - and spondyloarthopathy

50. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
If symptoms persist >6weeks
AS; sometime only symptom is uveitis;
Erythematous-violaceous rash on the eyelids
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine