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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. anti-centromere ab
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
C for c ; crest syndrome
Xray every 3m
Pt with significant organ involvement and have incomplete response to prednisone alone

2. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hypertriglyceridamia and hypercholesterolemia
Pseudogout/hemochromatosis;

3. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Disseminated gonoccal infection
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Check pedal pulses; in claudication pulses should diminish

4. MCP joint involvement
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
C for c ; crest syndrome

5. anti-ds DNA antibody
PMR and giant cell arteritis; can be seen both together;
If person is HLA B27 positive
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Specific of dx of SLE

6. management of LBP
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
Dorsum of hands and the Achilies tendon
Erythematous-violaceous rash on the eyelids

7. DIP joint involvement

8. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hyperflexion of both wrists--characteristic pain in one min
Osteoarthirit (bouchard at pip - b comes first);
SLE - only minutes; RA; hours;

9. inflamed tendons in wrist - ankle - arms; sexual history
Osteoarthirit (bouchard at pip - b comes first);
Supplementation ca and vitamin D
Malignancy - infection - vertebral fracture
Disseminated gonoccal infection

10. tinel sign
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
If symptoms persist >6weeks
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

11. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
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.

12. bouchard nodule
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Nodular lung densitieis with RA;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

13. role HLA B27 in dx of ankylosing spondylitis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
AS; sometime only symptom is uveitis;

14. caplan syndrom
High incidence of opportunistitc infection; reactivation of TB;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hyperflexion of both wrists--characteristic pain in one min
Nodular lung densitieis with RA;

15. tx pagets
PPD
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Specific of dx of SLE
A for aortic regurg; s for prolapSe (MVP)

16. How to differentiate radicular pain with claudication
Supplementation ca and vitamin D
Pt with significant organ involvement and have incomplete response to prednisone alone
Check pedal pulses; in claudication pulses should diminish
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

17. Tx of lupus nephritis
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
Prednisone and cyclophosphamide
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Symmetrical proximal weakness; increased CPK

18. pain in shoulder and pelvic girdle
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.
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
If person is HLA B27 positive
Measure ESR; polymyalgia rheumatica; tx prednisone

19. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Xray every 3m
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Primary biliary cirrhosis

20. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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

21. Tx of RA
Specific of dx of SLE
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

22. anterior shoulder pain
Dorsum of hands and the Achilies tendon
Pseudogout/hemochromatosis;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

23. morning stiffness hand joints
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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;
Hypertriglyceridamia and hypercholesterolemia

24. Low back pain
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hypertriglyceridamia and hypercholesterolemia
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

25. Ca oxalate induced 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
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
ESRD

26. When to order MRI in LBP
If symptoms persist >6weeks
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

27. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
PMR and giant cell arteritis; can be seen both together;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

28. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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;
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

29. when SLE patient needs steroid
Pseudogout/hemochromatosis;
Hyper triglyceridemia
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

30. How to differential lumbar spinal stenosis and disc herniation pain?
Check pedal pulses; in claudication pulses should diminish
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)

31. 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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Abx -bedrest - exercise

32. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Measure ca and ALP; increased ALP and normal ca for dx;
Primary biliary cirrhosis

33. allpurinol
Specific of dx of SLE
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Prophylactic agent to prevent recurrent attack; not given during acute attack
Pseudogout/hemochromatosis;

34. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Hyperflexion of both wrists--characteristic pain in one min

35. neck mass in sjogren patient
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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.
Symmetrical proximal weakness; increased CPK

36. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
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
Decrease urate secretion from kidney
Xray every 3m

37. inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Hyper triglyceridemia
Increased serum ferritin (acute phase protein)
Hyperflexion of both wrists--characteristic pain in one min

38. How to prevent glucocorticoid induced bone loss
Osteoarthirit (bouchard at pip - b comes first);
Supplementation ca and vitamin D
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

39. PIP joint involment
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Patello femoral pain syndrome
Hyperflexion of both wrists--characteristic pain in one min
Osteoarthirit (bouchard at pip - b comes first);

40. Tx of gout in patient with ESRD or hx GI bleeding
Dorsum of hands and the Achilies tendon
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

41. conjunctivitis - urethritis - and spondyloarthopathy

42. How to monitor disease activity in SLE
Prednisone and cyclophosphamide
Prophylactic agent to prevent recurrent attack; not given during acute attack
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

43. What marker is used to follow up disease activity in SLE
Disseminated gonoccal infection
Coronary atherosclerosis due to SLE
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;

44. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
If symptoms persist >6weeks

45. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Primary biliary cirrhosis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

46. gemfibrozil
Hyper triglyceridemia
Abx -bedrest - exercise
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
Primary biliary cirrhosis

47. SLE with pleural effusion
Supplementation ca and vitamin D
PMR and giant cell arteritis; can be seen both together;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
A for aortic regurg; s for prolapSe (MVP)

48. Use of allopurinol after kidney transplant
Minocyclin - inhibits metalloproteases and slows joint damage
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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

49. 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.
Think about reiter (cannot see - cannot pee - cannot climb a tree)
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Coronary atherosclerosis due to SLE

50. painless ulcer over glans penis and inflammatory arthritis
Disseminated gonoccal infection
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Think about reiter (cannot see - cannot pee - cannot climb a tree)