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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. who gets reiters syndrome after chlamydia infection
PMR and giant cell arteritis; can be seen both together;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
If person is HLA B27 positive
Abx -bedrest - exercise

2. complications of anti-cytokine therapy
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If person is HLA B27 positive
Prophylactic agent to prevent recurrent attack; not given during acute attack
High incidence of opportunistitc infection; reactivation of TB;

3. role HLA B27 in dx of ankylosing spondylitis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Measure ca and ALP; increased ALP and normal ca for dx;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hyper triglyceridemia

4. night back pain
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Malignancy - infection - vertebral fracture
Abx -bedrest - exercise
Coronary atherosclerosis due to SLE

5. gemfibrozil
Hyper triglyceridemia
Hyperflexion of both wrists--characteristic pain in one min
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
Hypertriglyceridamia and hypercholesterolemia

6. Finding of MRI in stenosis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hypertriglyceridamia and hypercholesterolemia

7. postoeriod shoulder pain
Prophylactic agent to prevent recurrent attack; not given during acute attack
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

8. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
ESRD

9. inflamed tendons in wrist - ankle - arms; sexual history
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Order LFT - heat fractionation (bone burns and liver lives) - GGT
PMR and giant cell arteritis; can be seen both together;
Disseminated gonoccal infection

10. Use of allopurinol after kidney transplant
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

11. What marker is used to follow up disease activity in SLE
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

12. Raynauds phenomenon
Primary biliary cirrhosis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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.

13. 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.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
PPD
Patello femoral pain syndrome

14. MCP joint involvement
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Prednisone and cyclophosphamide

15. Use of antibiotic in RA
If person is HLA B27 positive
Disseminated gonoccal infection
Minocyclin - inhibits metalloproteases and slows joint damage
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

16. bouchard nodule
PMR and giant cell arteritis; can be seen both together;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and 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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

17. painless ulcer over glans penis and inflammatory arthritis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Hypertriglyceridamia and hypercholesterolemia
Think about reiter (cannot see - cannot pee - cannot climb a tree)

18. Rayanaud's disease vs phenomenon
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ESRD
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Decrease urate secretion from kidney

19. right anterior knee pain and provoked by climbing stairs or prolong sitting
Arthritic sweling of DIP
Patello femoral pain syndrome
If person is HLA B27 positive
Symmetrical proximal weakness; increased CPK

20. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Coronary atherosclerosis due to SLE
Decrease urate secretion from kidney
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

21. What should be chekcked before starting infliximab
Pseudogout/hemochromatosis;
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
PPD

22. How often disease activity is monitored in AS?
Erythematous-violaceous rash on the eyelids
Xray every 3m
Arthritic sweling of DIP
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

23. increased ALP; liver or bone origin?
Check pedal pulses; in claudication pulses should diminish
Prednisone and cyclophosphamide
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Specific of dx of SLE

24. anti-ds DNA antibody
Specific of dx of SLE
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

25. pagets in xray
Abx -bedrest - exercise
PMR and giant cell arteritis; can be seen both together;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Measure ca and ALP; increased ALP and normal ca for dx;

26. How to monitor disease activity in SLE
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
If person is HLA B27 positive
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Decrease urate secretion from kidney

27. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Measure ca and ALP; increased ALP and normal ca for dx;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

28. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Patello femoral pain syndrome
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

29. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
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

30. SLE patient p/w MI - vent fibrillation
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Coronary atherosclerosis due to SLE
Think about reiter (cannot see - cannot pee - cannot climb a tree)

31. When to give methotrexate in SLE
SLE - only minutes; RA; hours;
Pt with significant organ involvement and have incomplete response to prednisone alone
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

32. 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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

33. mcp and PIP joint involvement
ESRD
Viral arthritis or RA
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

34. schirmer test
Nodular lung densitieis with RA;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
PPD
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.

35. proximal muscle weakness; decreased tendon reflex; normal creat and ck
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.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Arthritic sweling of DIP
Measure ca and ALP; increased ALP and normal ca for dx;

36. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pseudogout/hemochromatosis;
C for c ; crest syndrome
Abx -bedrest - exercise

37. Gait in spinal stenosis
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Erythematous-violaceous rash on the eyelids
Xray every 3m

38. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Specific of dx of SLE
Patello femoral pain syndrome
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

39. probenecid
SLE - only minutes; RA; hours;
Primary biliary cirrhosis
Osteoarthirit (bouchard at pip - b comes first);
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

40. heberdeen nodes
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Arthritic sweling of DIP

41. anti-mitochondrial
Primary biliary cirrhosis
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 incidence of opportunistitc infection; reactivation of TB;
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

42. carpal tunnel
AS; sometime only symptom is uveitis;
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
PMR and giant cell arteritis; can be seen both together;
Osteoarthirit (bouchard at pip - b comes first);

43. When to order MRI in LBP
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
If symptoms persist >6weeks
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Decrease urate secretion from kidney

44. tx pagets
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
Disseminated gonoccal infection

45. cylosporin used after renal transplantation
Minocyclin - inhibits metalloproteases and slows joint damage
Decrease urate secretion from kidney
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.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

46. PIP joint involment
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.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hypertriglyceridamia and hypercholesterolemia
Osteoarthirit (bouchard at pip - b comes first);

47. conjunctivitis - urethritis - and spondyloarthopathy

48. Tx of gout in patient with ESRD or hx GI bleeding
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Erythematous-violaceous rash on the eyelids
Patello femoral pain syndrome

49. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

50. xanthelasma
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Deposition of cholesterol in the periorbital skin
Supplementation ca and vitamin D