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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. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Viral arthritis or RA
AS; sometime only symptom is uveitis;
Supplementation ca and vitamin D
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

2. postoeriod shoulder pain
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Increased serum ferritin (acute phase protein)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

3. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Measure ESR; polymyalgia rheumatica; tx prednisone

4. Use of allopurinol after kidney transplant
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
A for aortic regurg; s for prolapSe (MVP)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

5. common valvular abnormalities with AS?
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Specific of dx of SLE
A for aortic regurg; s for prolapSe (MVP)
Think about reiter (cannot see - cannot pee - cannot climb a tree)

6. What is heliotrope sign
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pt with significant organ involvement and have incomplete response to prednisone alone
Erythematous-violaceous rash on the eyelids

7. tinel sign
Arthritic sweling of DIP
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
PMR and giant cell arteritis; can be seen both together;

8. SLE patient p/w MI - vent fibrillation
Osteoarthirit (bouchard at pip - b comes first);
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Coronary atherosclerosis due to SLE
If person is HLA B27 positive

9. right anterior knee pain and provoked by climbing stairs or prolong sitting
Malignancy - infection - vertebral fracture
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Patello femoral pain syndrome

10. role HLA B27 in dx of ankylosing spondylitis
Dorsum of hands and the Achilies tendon
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

11. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Hypertriglyceridamia and hypercholesterolemia
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
Pt with significant organ involvement and have incomplete response to prednisone alone

12. xanthomatous nodule
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Dorsum of hands and the Achilies tendon
Disseminated gonoccal infection

13. Low back pain
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;
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;

14. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Xray every 3m

15. anti-centromere ab
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
C for c ; crest syndrome
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

16. painless ulcer over glans penis and inflammatory arthritis
SLE - only minutes; RA; hours;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Think about reiter (cannot see - cannot pee - cannot climb a tree)

17. primary muscle disease
Minocyclin - inhibits metalloproteases and slows joint damage
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Symmetrical proximal weakness; increased CPK
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

18. conjunctivitis - urethritis - and spondyloarthopathy

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19. cylosporin used after renal transplantation
A for aortic regurg; s for prolapSe (MVP)
Decrease urate secretion from kidney
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

20. night back pain
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Minocyclin - inhibits metalloproteases and slows joint damage
Specific of dx of SLE
Malignancy - infection - vertebral fracture

21. morning stiffness hand joints
SLE - only minutes; RA; hours;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
High incidence of opportunistitc infection; reactivation of TB;
If person is HLA B27 positive

22. Tx of gout
Increased serum ferritin (acute phase protein)
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
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

23. Use of antibiotic in RA
Osteoarthirit (bouchard at pip - b comes first);
Minocyclin - inhibits metalloproteases and slows joint damage
ESRD
A for aortic regurg; s for prolapSe (MVP)

24. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
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
Disseminated gonoccal infection
Specific of dx of SLE

25. glucocorticoid therapy
Measure ESR; polymyalgia rheumatica; tx prednisone
Xray every 3m
If symptoms persist >6weeks
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

26. patient is having pain when he moves hands above shoulder
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Deposition of cholesterol in the periorbital skin
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

27. Gait in spinal stenosis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

28. inflammatory myositis
Increased serum ferritin (acute phase protein)
If symptoms persist >6weeks
Check pedal pulses; in claudication pulses should diminish
A for aortic regurg; s for prolapSe (MVP)

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

30. nicotinic acid
Hyperflexion of both wrists--characteristic pain in one min
Hypertriglyceridamia and hypercholesterolemia
Supplementation ca and vitamin D
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

31. anti-ds DNA antibody
C for c ; crest syndrome
Hyperflexion of both wrists--characteristic pain in one min
Specific of dx of SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT

32. When to stop statin if cpk elevated
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Decrease urate secretion from kidney

33. anti-mitochondrial
Hyper triglyceridemia
Supplementation ca and vitamin D
Primary biliary cirrhosis
Xray every 3m

34. schirmer test
Specific of dx of SLE
Viral arthritis or RA
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.

35. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Patello femoral pain syndrome

36. When to give methotrexate in SLE
C for c ; crest syndrome
Hypertriglyceridamia and hypercholesterolemia
Pt with significant organ involvement and have incomplete response to prednisone alone
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

37. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Malignancy - infection - vertebral fracture

38. management of LBP
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

39. who gets reiters syndrome after chlamydia infection
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If person is HLA B27 positive

40. SLE with pleural effusion
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.
Hypertriglyceridamia and hypercholesterolemia
C for c ; crest syndrome

41. What marker is used to follow up disease activity in SLE
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

42. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PPD
PMR and giant cell arteritis; can be seen both together;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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

43. Raynauds phenomenon
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
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

44. Management of HTN during acute gout
Coronary atherosclerosis due to SLE
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

45. probenecid
PPD
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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.
SLE - only minutes; RA; hours;

46. gemfibrozil
Hyper triglyceridemia
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.
Hyperflexion of both wrists--characteristic pain in one min
Specific of dx of SLE

47. allpurinol
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
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

48. colchicine
Viral arthritis or RA
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

49. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
C for c ; crest syndrome
Hyper triglyceridemia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

50. phalen test
Disseminated gonoccal infection
Minocyclin - inhibits metalloproteases and slows joint damage
Hyperflexion of both wrists--characteristic pain in one min
Specific of dx of SLE