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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. What marker is used to follow up disease activity in SLE
Arthritic sweling of DIP
Hyperflexion of both wrists--characteristic pain in one min
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

2. MCP joint involvement
Arthritic sweling of DIP
Specific of dx of SLE
SLE - only minutes; RA; hours;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

3. colchicine
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Primary biliary cirrhosis

4. anti-centromere ab
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
C for c ; crest syndrome
Deposition of cholesterol in the periorbital skin
Osteoarthirit (bouchard at pip - b comes first);

5. How to monitor disease activity in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Increased serum ferritin (acute phase protein)
Hyperflexion of both wrists--characteristic pain in one min
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

6. carpal tunnel
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
Osteoarthirit (bouchard at pip - b comes first);
Patello femoral pain syndrome

7. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Primary biliary cirrhosis
Order LFT - heat fractionation (bone burns and liver lives) - GGT

8. Ca oxalate induced arthritis
Decrease urate secretion from kidney
Primary biliary cirrhosis
SLE - only minutes; RA; hours;
ESRD

9. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
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
PMR and giant cell arteritis; can be seen both together;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
High incidence of opportunistitc infection; reactivation of TB;

10. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Dorsum of hands and the Achilies tendon

11. who gets reiters syndrome after chlamydia infection
Erythematous-violaceous rash on the eyelids
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
If person is HLA B27 positive
Deposition of cholesterol in the periorbital skin

12. pain in shoulder and pelvic girdle
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Measure ESR; polymyalgia rheumatica; tx prednisone
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Check pedal pulses; in claudication pulses should diminish

13. patient pw groin pain; on steroid
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Patello femoral pain syndrome
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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.

14. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Coronary atherosclerosis due to SLE
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.

15. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
AS; sometime only symptom is uveitis;
Erythematous-violaceous rash on the eyelids
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

16. Tx of reiter
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Abx -bedrest - exercise
Check pedal pulses; in claudication pulses should diminish
Symmetrical proximal weakness; increased CPK

17. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Osteoarthirit (bouchard at pip - b comes first);
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
AS; sometime only symptom is uveitis;

18. Low back pain
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Osteoarthirit (bouchard at pip - b comes first);

19. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Disseminated gonoccal infection
Erythematous-violaceous rash on the eyelids
Hypertriglyceridamia and hypercholesterolemia

20. glucocorticoid therapy
Minocyclin - inhibits metalloproteases and slows joint damage
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
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

21. schirmer test
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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.

22. Tx of gout in patient with ESRD or hx GI bleeding
PPD
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
Pt with significant organ involvement and have incomplete response to prednisone alone

23. primary muscle disease
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
Prednisone and cyclophosphamide
Symmetrical proximal weakness; increased CPK
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

24. What is heliotrope sign
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Erythematous-violaceous rash on the eyelids
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Nodular lung densitieis with RA;

25. phalen test
Hyperflexion of both wrists--characteristic pain in one min
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

26. allpurinol
Pt with significant organ involvement and have incomplete response to prednisone alone
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Prophylactic agent to prevent recurrent attack; not given during acute attack
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

27. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
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

28. morning stiffness hand joints
Minocyclin - inhibits metalloproteases and slows joint damage
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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.
SLE - only minutes; RA; hours;

29. Management of HTN during acute gout
Supplementation ca and vitamin D
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pt with significant organ involvement and have incomplete response to prednisone alone
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

30. proximal muscle weakness; decreased tendon reflex; normal creat and ck
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

31. mcp and PIP joint involvement
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Hyper triglyceridemia
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Viral arthritis or RA

32. carpal tunnel syndrom
SLE - only minutes; RA; hours;
Disseminated gonoccal infection
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

33. gemfibrozil
Hyper triglyceridemia
Abx -bedrest - exercise
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
AS; sometime only symptom is uveitis;

34. Tx of lupus nephritis
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;
Prednisone and cyclophosphamide
PMR and giant cell arteritis; can be seen both together;

35. How to perform schober test
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If symptoms persist >6weeks
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
AS; sometime only symptom is uveitis;

36. increased ALP; liver or bone origin?
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ESR; polymyalgia rheumatica; tx prednisone
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. How to differentiate radicular pain with claudication
C for c ; crest syndrome
Check pedal pulses; in claudication pulses should diminish
Increased serum ferritin (acute phase protein)
Abx -bedrest - exercise

38. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
PMR and giant cell arteritis; can be seen both together;
Dorsum of hands and the Achilies tendon
Pseudogout/hemochromatosis;

39. anti-mitochondrial
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Primary biliary cirrhosis
Pseudogout/hemochromatosis;

40. conjunctivitis - urethritis - and spondyloarthopathy

41. When to give methotrexate in SLE
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pt with significant organ involvement and have incomplete response to prednisone alone
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

42. SLE with pleural effusion
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Measure ESR; polymyalgia rheumatica; tx prednisone
Arthritic sweling of DIP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

43. caplan syndrom
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Nodular lung densitieis with RA;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

44. complications of anti-cytokine therapy
Prednisone and cyclophosphamide
High incidence of opportunistitc infection; reactivation of TB;
If symptoms persist >6weeks
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

45. DIP joint involvement

46. When to start DMARD in RA
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pt with significant organ involvement and have incomplete response to prednisone alone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

47. management of LBP
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

48. PIP joint involment
Deposition of cholesterol in the periorbital skin
Hyper triglyceridemia
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

49. role HLA B27 in dx of ankylosing spondylitis
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
Arthritic sweling of DIP
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

50. inflammatory myositis
Abx -bedrest - exercise
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Increased serum ferritin (acute phase protein)