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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. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Symmetrical proximal weakness; increased CPK
Osteoarthirit (bouchard at pip - b comes first);
C for c ; crest syndrome

2. Tx of gout in patient with ESRD or hx GI bleeding
Dorsum of hands and the Achilies tendon
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Malignancy - infection - vertebral fracture

3. SLE with pleural effusion
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Primary biliary cirrhosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

4. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Nodular lung densitieis with RA;

5. How to prevent glucocorticoid induced bone loss
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Osteoarthirit (bouchard at pip - b comes first);
Pt with significant organ involvement and have incomplete response to prednisone alone
Supplementation ca and vitamin D

6. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hyper triglyceridemia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Supplementation ca and vitamin D

7. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

8. 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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Disseminated gonoccal infection
AS; sometime only symptom is uveitis;

9. xanthomatous nodule
Prednisone and cyclophosphamide
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Check pedal pulses; in claudication pulses should diminish
Dorsum of hands and the Achilies tendon

10. anterior shoulder pain
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Dorsum of hands and the Achilies tendon
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

11. caplan syndrom
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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.
Nodular lung densitieis with RA;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

12. 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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Arthritic sweling of DIP
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

13. carpal tunnel
Pseudogout/hemochromatosis;
Arthritic sweling of DIP
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

14. tx pagets
Hypertriglyceridamia and hypercholesterolemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Symmetrical proximal weakness; increased CPK

15. when SLE patient needs steroid
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Supplementation ca and vitamin D

16. pagets in xray
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Measure ca and ALP; increased ALP and normal ca for dx;
Prophylactic agent to prevent recurrent attack; not given during acute attack
PPD

17. Management of HTN during acute gout
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Symmetrical proximal weakness; increased CPK

18. gemfibrozil
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Hyper triglyceridemia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

19. probenecid
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Dorsum of hands and the Achilies tendon
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

20. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Specific of dx of SLE
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

21. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

22. common valvular abnormalities with AS?
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
A for aortic regurg; s for prolapSe (MVP)

23. night back pain
If person is HLA B27 positive
Malignancy - infection - vertebral fracture
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

24. complications of anti-cytokine therapy
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
Osteoarthirit (bouchard at pip - b comes first);
ESRD
High incidence of opportunistitc infection; reactivation of TB;

25. anti-centromere ab
Hyperflexion of both wrists--characteristic pain in one min
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
C for c ; crest syndrome
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

26. Gait in spinal stenosis
C for c ; crest syndrome
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

27. primary muscle disease
Symmetrical proximal weakness; increased CPK
Osteoarthirit (bouchard at pip - b comes first);
Primary biliary cirrhosis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

28. patient is having pain when he moves hands above shoulder
Measure ca and ALP; increased ALP and normal ca for dx;
SLE - only minutes; RA; hours;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Malignancy - infection - vertebral fracture

29. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

30. What is heliotrope sign
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Dorsum of hands and the Achilies tendon
Viral arthritis or RA
Erythematous-violaceous rash on the eyelids

31. DIP joint involvement

32. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Arthritic sweling of DIP
Measure ESR; polymyalgia rheumatica; tx prednisone
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

33. pain in shoulder and pelvic girdle
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
Measure ESR; polymyalgia rheumatica; tx prednisone
SLE - only minutes; RA; hours;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

34. criteria for AS
Erythematous-violaceous rash on the eyelids
PMR and giant cell arteritis; can be seen both together;
Pseudogout/hemochromatosis;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

35. nicotinic acid
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Hypertriglyceridamia and hypercholesterolemia
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

36. schirmer test
PPD
Malignancy - infection - vertebral fracture
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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.

37. role HLA B27 in dx of ankylosing spondylitis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Patello femoral pain syndrome
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

38. increased ALP; liver or bone origin?
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

39. Use of antibiotic in RA
Minocyclin - inhibits metalloproteases and slows joint damage
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)
Viral arthritis or RA

40. How to perform schober test
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
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
Minocyclin - inhibits metalloproteases and slows joint damage

41. PIP joint involment
Coronary atherosclerosis due to SLE
ESRD
Osteoarthirit (bouchard at pip - b comes first);
High incidence of opportunistitc infection; reactivation of TB;

42. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

43. heberdeen nodes
Arthritic sweling of DIP
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
PMR and giant cell arteritis; can be seen both together;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

44. mcp and PIP joint involvement
Patello femoral pain syndrome
Hyper triglyceridemia
Viral arthritis or RA
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

45. patient pw groin pain; on steroid
Minocyclin - inhibits metalloproteases and slows joint damage
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

46. Finding of MRI in stenosis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Minocyclin - inhibits metalloproteases and slows joint damage
Osteoarthirit (bouchard at pip - b comes first);
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

47. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pseudogout/hemochromatosis;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

48. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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;
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

49. painless ulcer over glans penis and inflammatory arthritis
Osteoarthirit (bouchard at pip - b comes first);
Deposition of cholesterol in the periorbital skin
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

50. What should be chekcked before starting infliximab
PPD
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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