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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. Tx of reiter
Pt with significant organ involvement and have incomplete response to prednisone alone
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Abx -bedrest - exercise
Patello femoral pain syndrome

2. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Arthritic sweling of DIP
Measure ca and ALP; increased ALP and normal ca for dx;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

3. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Measure ca and ALP; increased ALP and normal ca for dx;
Decrease urate secretion from kidney

4. criteria for AS
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hypertriglyceridamia and hypercholesterolemia
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

5. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

6. neck mass in sjogren patient
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

7. gemfibrozil
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hyper triglyceridemia
If person is HLA B27 positive
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

8. glucocorticoid therapy
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Measure ca and ALP; increased ALP and normal ca for dx;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

9. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
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
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

10. Tx of lupus nephritis
Prednisone and cyclophosphamide
PPD
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
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

11. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Decrease urate secretion from kidney
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

12. DIP joint involvement

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13. 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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Measure ESR; polymyalgia rheumatica; tx prednisone
Decrease urate secretion from kidney

14. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
If symptoms persist >6weeks

15. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Osteoarthirit (bouchard at pip - b comes first);
High incidence of opportunistitc infection; reactivation of TB;

16. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Nodular lung densitieis with RA;

17. cylosporin used after renal transplantation
Prednisone and cyclophosphamide
High incidence of opportunistitc infection; reactivation of TB;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Decrease urate secretion from kidney

18. nicotinic acid
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hypertriglyceridamia and hypercholesterolemia

19. schirmer 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.
Specific of dx of SLE
C for c ; crest syndrome
Coronary atherosclerosis due to SLE

20. anterior shoulder pain
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

21. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Minocyclin - inhibits metalloproteases and slows joint damage
Pseudogout/hemochromatosis;

22. anti-ds DNA antibody
Pt with significant organ involvement and have incomplete response to prednisone alone
Specific of dx of SLE
Hypertriglyceridamia and hypercholesterolemia
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

23. What should be chekcked before starting infliximab
PPD
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Osteoarthirit (bouchard at pip - b comes first);
Increased serum ferritin (acute phase protein)

24. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

25. How to perform schober test
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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

26. carpal tunnel
Coronary atherosclerosis due to SLE
AS; sometime only symptom is uveitis;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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

27. How to differentiate radicular pain with claudication
Increased serum ferritin (acute phase protein)
Xray every 3m
Check pedal pulses; in claudication pulses should diminish
High incidence of opportunistitc infection; reactivation of TB;

28. How to prevent glucocorticoid induced bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Supplementation ca and vitamin D
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

29. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Deposition of cholesterol in the periorbital skin

30. patient pw groin pain; on steroid
Xray every 3m
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Osteoarthirit (bouchard at pip - b comes first);
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

31. PIP joint involment
Symmetrical proximal weakness; increased CPK
Osteoarthirit (bouchard at pip - b comes first);
PPD
A for aortic regurg; s for prolapSe (MVP)

32. probenecid
Supplementation ca and vitamin D
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

33. inflamed tendons in wrist - ankle - arms; sexual history
Xray every 3m
Dorsum of hands and the Achilies tendon
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Disseminated gonoccal infection

34. bouchard nodule
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
Supplementation ca and vitamin D
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Patello femoral pain syndrome

35. postoeriod shoulder pain
Hyperflexion of both wrists--characteristic pain in one min
Patello femoral pain syndrome
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hyper triglyceridemia

36. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Nodular lung densitieis with RA;
Deposition of cholesterol in the periorbital skin

37. inflammatory myositis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Increased serum ferritin (acute phase protein)
Measure ca and ALP; increased ALP and normal ca for dx;

38. Use of antibiotic in RA
Minocyclin - inhibits metalloproteases and slows joint damage
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

39. Ca oxalate induced arthritis
ESRD
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Pt with significant organ involvement and have incomplete response to prednisone alone
Hyperflexion of both wrists--characteristic pain in one min

40. phalen test
Coronary atherosclerosis due to SLE
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Hyperflexion of both wrists--characteristic pain in one min
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

41. Low back pain
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

42. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Viral arthritis or RA
Deposition of cholesterol in the periorbital skin
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

43. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Primary biliary cirrhosis
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

44. painless ulcer over glans penis and inflammatory arthritis
Pseudogout/hemochromatosis;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Disseminated gonoccal infection

45. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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.
Coronary atherosclerosis due to SLE

46. night back pain
Malignancy - infection - vertebral fracture
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
A for aortic regurg; s for prolapSe (MVP)
Hypertriglyceridamia and hypercholesterolemia

47. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
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;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

48. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Primary biliary cirrhosis
A for aortic regurg; s for prolapSe (MVP)

49. increased ALP; liver or bone origin?
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.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Order LFT - heat fractionation (bone burns and liver lives) - GGT

50. anti-centromere ab
Nodular lung densitieis with RA;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
C for c ; crest syndrome
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry