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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. What should be chekcked before starting infliximab
Check pedal pulses; in claudication pulses should diminish
Supplementation ca and vitamin D
Pt with significant organ involvement and have incomplete response to prednisone alone
PPD

2. primary muscle disease
Measure ca and ALP; increased ALP and normal ca for dx;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hyper triglyceridemia
Symmetrical proximal weakness; increased CPK

3. patient pw groin pain; on steroid
If symptoms persist >6weeks
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
Supplementation ca and vitamin D
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

4. painless ulcer over glans penis and inflammatory arthritis
Check pedal pulses; in claudication pulses should diminish
A for aortic regurg; s for prolapSe (MVP)
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Patello femoral pain syndrome

5. inflamed tendons in wrist - ankle - arms; sexual history
Hyperflexion of both wrists--characteristic pain in one min
Patello femoral pain syndrome
Disseminated gonoccal infection
Prophylactic agent to prevent recurrent attack; not given during acute attack

6. night back pain
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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;
Malignancy - infection - vertebral fracture

7. complications of anti-cytokine therapy
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
High incidence of opportunistitc infection; reactivation of TB;

8. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
C for c ; crest syndrome
Nodular lung densitieis with RA;
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

9. PIP joint involment
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Osteoarthirit (bouchard at pip - b comes first);
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Prophylactic agent to prevent recurrent attack; not given during acute attack

10. 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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

11. Ca oxalate induced arthritis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Erythematous-violaceous rash on the eyelids
ESRD
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

12. carpal tunnel
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Dorsum of hands and the Achilies tendon
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
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

13. xanthelasma
Deposition of cholesterol in the periorbital skin
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

14. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
A for aortic regurg; s for prolapSe (MVP)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
PMR and giant cell arteritis; can be seen both together;

15. When to stop statin if cpk elevated
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)
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

16. xanthomatous nodule
Disseminated gonoccal infection
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Dorsum of hands and the Achilies tendon

17. heberdeen nodes
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Arthritic sweling of DIP
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
C for c ; crest syndrome

18. What is heliotrope sign
Supplementation ca and vitamin D
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Erythematous-violaceous rash on the eyelids
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

19. morning stiffness hand joints
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Xray every 3m
SLE - only minutes; RA; hours;

20. caplan syndrom
Xray every 3m
Nodular lung densitieis with RA;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Abx -bedrest - exercise

21. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Primary biliary cirrhosis

22. Tx of gout
Check pedal pulses; in claudication pulses should diminish
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
Measure ESR; polymyalgia rheumatica; tx prednisone

23. increased ALP; liver or bone origin?
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pseudogout/hemochromatosis;
Prophylactic agent to prevent recurrent attack; not given during acute attack

24. pain in shoulder and pelvic girdle
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Measure ESR; polymyalgia rheumatica; tx prednisone
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

25. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
AS; sometime only symptom is uveitis;

26. nicotinic acid
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Coronary atherosclerosis due to SLE
Hypertriglyceridamia and hypercholesterolemia

27. MCP joint involvement
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

28. anti-centromere ab
Think about reiter (cannot see - cannot pee - cannot climb a tree)
C for c ; crest syndrome
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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

29. What marker is used to follow up disease activity in 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
Pseudogout/hemochromatosis;
Symmetrical proximal weakness; increased CPK
Dorsum of hands and the Achilies tendon

30. Raynauds phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
Arthritic sweling of DIP

31. mcp and PIP joint involvement
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Viral arthritis or RA

32. glucocorticoid therapy
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Patello femoral pain syndrome

33. tinel sign
PMR and giant cell arteritis; can be seen both together;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Symmetrical proximal weakness; increased CPK
Prednisone and cyclophosphamide

34. Tx of inflammatory myositis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

35. Low back pain
Prophylactic agent to prevent recurrent attack; not given during acute attack
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

36. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Hypertriglyceridamia and hypercholesterolemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
PMR and giant cell arteritis; can be seen both together;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

37. DIP joint involvement

38. How glucocorticoid leads to bone loss
Patello femoral pain syndrome
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
Arthritic sweling of DIP
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

39. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Viral arthritis or RA
Hyper triglyceridemia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

40. 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.
Symmetrical proximal weakness; increased CPK
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Coronary atherosclerosis due to SLE

41. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Osteoarthirit (bouchard at pip - b comes first);

42. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Specific of dx of SLE

43. colchicine
Disseminated gonoccal infection
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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;

44. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

45. when SLE patient needs steroid
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

46. common valvular abnormalities with AS?
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
A for aortic regurg; s for prolapSe (MVP)
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Specific of dx of SLE

47. neck mass in sjogren patient
PMR and giant cell arteritis; can be seen both together;
Hyper triglyceridemia
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Symmetrical proximal weakness; increased CPK

48. management of LBP
Malignancy - infection - vertebral fracture
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
PPD

49. right anterior knee pain and provoked by climbing stairs or prolong sitting
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Patello femoral pain syndrome
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

50. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Prednisone and cyclophosphamide