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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. complications of anti-cytokine therapy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
High incidence of opportunistitc infection; reactivation of TB;

2. common valvular abnormalities with AS?
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
A for aortic regurg; s for prolapSe (MVP)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

3. patient pw groin pain; on steroid
Increased serum ferritin (acute phase protein)
Supplementation ca and vitamin D
Deposition of cholesterol in the periorbital skin
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

4. When to give methotrexate in SLE
A for aortic regurg; s for prolapSe (MVP)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pt with significant organ involvement and have incomplete response to prednisone alone
ESRD

5. 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.
Prednisone and cyclophosphamide
Hyper triglyceridemia
Abx -bedrest - exercise

6. Use of antibiotic in RA
Coronary atherosclerosis due to SLE
Deposition of cholesterol in the periorbital skin
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Minocyclin - inhibits metalloproteases and slows joint damage

7. How to perform schober test
Prophylactic agent to prevent recurrent attack; not given during acute attack
PPD
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

8. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
AS; sometime only symptom is uveitis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

9. postoeriod shoulder pain
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hyper triglyceridemia
Patello femoral pain syndrome

10. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Abx -bedrest - exercise
AS; sometime only symptom is uveitis;
Decrease urate secretion from kidney

11. What is heliotrope sign
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Erythematous-violaceous rash on the eyelids
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

12. tinel sign
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
SLE - only minutes; RA; hours;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Disseminated gonoccal infection

13. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pseudogout/hemochromatosis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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. How often disease activity is monitored in AS?
Viral arthritis or RA
Xray every 3m
Increased serum ferritin (acute phase protein)
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

15. Rayanaud's disease vs phenomenon
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
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

16. PIP joint involment
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);
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

17. criteria for AS
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Erythematous-violaceous rash on the eyelids
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

18. Tx of lupus nephritis
Prednisone and cyclophosphamide
Arthritic sweling of DIP
Measure ca and ALP; increased ALP and normal ca for dx;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

19. when SLE patient needs steroid
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

20. Management of HTN during acute gout
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Prednisone and cyclophosphamide
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Decrease urate secretion from kidney

21. probenecid
Malignancy - infection - vertebral fracture
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Nodular lung densitieis with RA;
ESRD

22. glucocorticoid therapy
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

23. anterior shoulder pain
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Specific of dx of SLE

24. schirmer test
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
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.
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

25. tx pagets
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Symmetrical proximal weakness; increased CPK

26. Finding of MRI in stenosis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Dorsum of hands and the Achilies tendon
Disseminated gonoccal infection
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

27. How to monitor disease activity in SLE
Erythematous-violaceous rash on the eyelids
Prednisone and cyclophosphamide
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
High incidence of opportunistitc infection; reactivation of TB;

28. Low back pain
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

29. Tx of inflammatory myositis
PPD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Erythematous-violaceous rash on the eyelids
Dorsum of hands and the Achilies tendon

30. DIP joint involvement

31. xanthelasma
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Deposition of cholesterol in the periorbital skin
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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.

32. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Minocyclin - inhibits metalloproteases and slows joint damage

33. phalen test
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Hyperflexion of both wrists--characteristic pain in one min
AS; sometime only symptom is uveitis;
C for c ; crest syndrome

34. allpurinol
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Prophylactic agent to prevent recurrent attack; not given during acute attack
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

35. How glucocorticoid leads to bone loss
Measure ESR; polymyalgia rheumatica; tx prednisone
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Primary biliary cirrhosis

36. caplan syndrom
Symmetrical proximal weakness; increased CPK
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Nodular lung densitieis with RA;
Disseminated gonoccal infection

37. When to start DMARD in RA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Increased serum ferritin (acute phase protein)

38. carpal tunnel
Malignancy - infection - vertebral fracture
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
Arthritic sweling of DIP
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

39. Raynauds phenomenon
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Coronary atherosclerosis due to SLE
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

40. neck mass in sjogren patient
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Increased serum ferritin (acute phase protein)
Disseminated gonoccal infection
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

41. morning stiffness hand joints
Coronary atherosclerosis due to SLE
SLE - only minutes; RA; hours;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Erythematous-violaceous rash on the eyelids

42. 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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Measure ca and ALP; increased ALP and normal ca for dx;
Deposition of cholesterol in the periorbital skin

43. inflammatory myositis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Increased serum ferritin (acute phase protein)

44. pagets in xray
Hypertriglyceridamia and hypercholesterolemia
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Measure ca and ALP; increased ALP and normal ca for dx;

45. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Deposition of cholesterol in the periorbital skin
Nodular lung densitieis with RA;
Hyperflexion of both wrists--characteristic pain in one min

46. anti-ds DNA antibody
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Specific of dx of SLE

47. bouchard nodule
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hyperflexion of both wrists--characteristic pain in one min
PMR and giant cell arteritis; can be seen both together;

48. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Abx -bedrest - exercise
A for aortic regurg; s for prolapSe (MVP)
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
PMR and giant cell arteritis; can be seen both together;

49. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Coronary atherosclerosis due to SLE
Nodular lung densitieis with RA;

50. role HLA B27 in dx of ankylosing spondylitis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Decrease urate secretion from kidney
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;