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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. What marker is used to follow up disease activity in SLE
Abx -bedrest - exercise
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Measure ca and ALP; increased ALP and normal ca for dx;

2. increased ALP; liver or bone origin?
Measure ESR; polymyalgia rheumatica; tx prednisone
SLE - only minutes; RA; hours;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Prednisone and cyclophosphamide

3. management of LBP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Pseudogout/hemochromatosis;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

4. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Disseminated gonoccal infection
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pseudogout/hemochromatosis;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

5. SLE patient p/w MI - vent fibrillation
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
Coronary atherosclerosis due to SLE
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

6. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Nodular lung densitieis with RA;
SLE - only minutes; RA; hours;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

7. conjunctivitis - urethritis - and spondyloarthopathy

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8. anti-ds DNA antibody
Symmetrical proximal weakness; increased CPK
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Specific of dx of SLE
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

9. schirmer test
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.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

10. How to differentiate radicular pain with claudication
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Measure ESR; polymyalgia rheumatica; tx prednisone
Check pedal pulses; in claudication pulses should diminish

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

12. caplan syndrom
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Prophylactic agent to prevent recurrent attack; not given during acute attack
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Nodular lung densitieis with RA;

13. Use of antibiotic in RA
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Nodular lung densitieis with RA;
Minocyclin - inhibits metalloproteases and slows joint damage
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

14. inflammatory myositis
Hyperflexion of both wrists--characteristic pain in one min
Dorsum of hands and the Achilies tendon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Increased serum ferritin (acute phase protein)

15. anti-mitochondrial
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Primary biliary cirrhosis
AS; sometime only symptom is uveitis;
PMR and giant cell arteritis; can be seen both together;

16. How glucocorticoid leads to bone loss
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
PMR and giant cell arteritis; can be seen both together;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hyper triglyceridemia

17. Low back pain
Viral arthritis or RA
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hyperflexion of both wrists--characteristic pain in one min
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

18. role HLA B27 in dx of ankylosing spondylitis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Increased serum ferritin (acute phase protein)
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

19. anti-centromere ab
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Increased serum ferritin (acute phase protein)
C for c ; crest syndrome
Malignancy - infection - vertebral fracture

20. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
AS; sometime only symptom is uveitis;

21. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
PMR and giant cell arteritis; can be seen both together;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
AS; sometime only symptom is uveitis;

22. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Prophylactic agent to prevent recurrent attack; not given during acute attack
C for c ; crest syndrome
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

23. pain in shoulder and pelvic girdle
Increased serum ferritin (acute phase protein)
Measure ESR; polymyalgia rheumatica; tx prednisone
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

24. gemfibrozil
If symptoms persist >6weeks
Pt with significant organ involvement and have incomplete response to prednisone alone
Hyper triglyceridemia
PPD

25. tx pagets
C for c ; crest syndrome
AS; sometime only symptom is uveitis;
SLE - only minutes; RA; hours;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

26. Tx of reiter
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Abx -bedrest - exercise
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

27. neck mass in sjogren patient
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.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

28. right anterior knee pain and provoked by climbing stairs or prolong sitting
Pseudogout/hemochromatosis;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Patello femoral pain syndrome
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

29. When to stop statin if cpk elevated
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
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
SLE - only minutes; RA; hours;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

30. patient is having pain when he moves hands above shoulder
Specific of dx of SLE
Patello femoral pain syndrome
Malignancy - infection - vertebral fracture
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

31. who gets reiters syndrome after chlamydia infection
Supplementation ca and vitamin D
If person is HLA B27 positive
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

32. common valvular abnormalities with AS?
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
A for aortic regurg; s for prolapSe (MVP)
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

33. inflamed tendons in wrist - ankle - arms; sexual history
Nodular lung densitieis with RA;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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

34. How to monitor disease activity in SLE
Hypertriglyceridamia and hypercholesterolemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
A for aortic regurg; s for prolapSe (MVP)
Order LFT - heat fractionation (bone burns and liver lives) - GGT

35. Management of HTN during acute gout
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

36. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
If symptoms persist >6weeks
Prophylactic agent to prevent recurrent attack; not given during acute attack

37. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Osteoarthirit (bouchard at pip - b comes first);
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

38. heberdeen nodes
Pt with significant organ involvement and have incomplete response to prednisone alone
Abx -bedrest - exercise
Arthritic sweling of DIP
Hyperflexion of both wrists--characteristic pain in one min

39. carpal tunnel
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Nodular lung densitieis with RA;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

40. When to give methotrexate in SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pt with significant organ involvement and have incomplete response to prednisone alone
Prednisone and cyclophosphamide
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

41. mcp and PIP joint involvement
AS; sometime only symptom is uveitis;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Viral arthritis or RA
Hyperflexion of both wrists--characteristic pain in one min

42. PIP joint involment
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Osteoarthirit (bouchard at pip - b comes first);
Prednisone and cyclophosphamide
Order LFT - heat fractionation (bone burns and liver lives) - GGT

43. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Erythematous-violaceous rash on the eyelids
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

44. How to differential lumbar spinal stenosis and disc herniation pain?
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

45. bouchard nodule
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

46. probenecid
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Viral arthritis or RA
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

47. anterior shoulder pain
Supplementation ca and vitamin D
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

48. Ca oxalate induced arthritis
ESRD
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

49. Tx of gout in patient with ESRD or hx GI bleeding
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
If symptoms persist >6weeks
Order LFT - heat fractionation (bone burns and liver lives) - GGT

50. Tx of inflammatory myositis
Pseudogout/hemochromatosis;
Hypertriglyceridamia and hypercholesterolemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.