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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. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prednisone and cyclophosphamide

2. How often disease activity is monitored in AS?
Arthritic sweling of DIP
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Xray every 3m

3. when SLE patient needs steroid
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
PPD
Patello femoral pain syndrome
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

4. PIP joint involment
SLE - only minutes; RA; hours;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Osteoarthirit (bouchard at pip - b comes first);
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

5. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Erythematous-violaceous rash on the eyelids
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Supplementation ca and vitamin D

6. Low back pain
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
A for aortic regurg; s for prolapSe (MVP)
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Osteoarthirit (bouchard at pip - b comes first);

7. allpurinol
Patello femoral pain syndrome
Viral arthritis or RA
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Prophylactic agent to prevent recurrent attack; not given during acute attack

8. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Minocyclin - inhibits metalloproteases and slows joint damage
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

9. 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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

10. phalen test
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
Hyperflexion of both wrists--characteristic pain in one min
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

11. How glucocorticoid leads to bone loss
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
PMR and giant cell arteritis; can be seen both together;
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

12. DIP joint involvement

13. management of LBP
Nodular lung densitieis with RA;
Viral arthritis or RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Erythematous-violaceous rash on the eyelids

14. 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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Minocyclin - inhibits metalloproteases and slows joint damage
If person is HLA B27 positive

15. pagets in xray
A for aortic regurg; s for prolapSe (MVP)
Measure ESR; polymyalgia rheumatica; tx prednisone
Measure ca and ALP; increased ALP and normal ca for dx;
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.

16. Rayanaud's disease vs phenomenon
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Increased serum ferritin (acute phase protein)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

17. heberdeen nodes
Supplementation ca and vitamin D
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Arthritic sweling of DIP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

18. cylosporin used after renal transplantation
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Decrease urate secretion from kidney

19. patient is having pain when he moves hands above shoulder
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

20. increased ALP; liver or bone origin?
Increased serum ferritin (acute phase protein)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Decrease urate secretion from kidney

21. carpal tunnel
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
Decrease urate secretion from kidney
Viral arthritis or RA
Measure ESR; polymyalgia rheumatica; tx prednisone

22. inflammatory myositis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
A for aortic regurg; s for prolapSe (MVP)
Increased serum ferritin (acute phase protein)

23. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Primary biliary cirrhosis
Deposition of cholesterol in the periorbital skin

24. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Disseminated gonoccal infection
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Dorsum of hands and the Achilies tendon

25. carpal tunnel syndrom
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Osteoarthirit (bouchard at pip - b comes first);
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

26. Use of allopurinol after kidney transplant
Patello femoral pain syndrome
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Xray every 3m

27. xanthomatous nodule
Pseudogout/hemochromatosis;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Dorsum of hands and the Achilies tendon

28. inflamed tendons in wrist - ankle - arms; sexual history
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Disseminated gonoccal infection
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Abx -bedrest - exercise

29. xanthelasma
Deposition of cholesterol in the periorbital skin
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Symmetrical proximal weakness; increased CPK

30. When to start DMARD in RA
Patello femoral pain syndrome
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pseudogout/hemochromatosis;

31. 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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

32. Tx of reiter
Abx -bedrest - exercise
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

33. When to order MRI in LBP
If symptoms persist >6weeks
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Arthritic sweling of DIP
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

34. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Coronary atherosclerosis due to SLE
Supplementation ca and vitamin D
High incidence of opportunistitc infection; reactivation of TB;

35. Ca oxalate induced arthritis
ESRD
Hyper triglyceridemia
Viral arthritis or RA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

36. anti-mitochondrial
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Primary biliary cirrhosis

37. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
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

38. How to prevent glucocorticoid induced bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pt with significant organ involvement and have incomplete response to prednisone alone
Supplementation ca and vitamin D
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

39. anti-ds DNA antibody
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Specific of dx of SLE
Dorsum of hands and the Achilies tendon

40. What is heliotrope sign
High incidence of opportunistitc infection; reactivation of TB;
Nodular lung densitieis with RA;
Erythematous-violaceous rash on the eyelids
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

41. colchicine
High incidence of opportunistitc infection; reactivation of TB;
Coronary atherosclerosis due to SLE
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Hyper triglyceridemia

42. morning stiffness hand joints
PPD
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Hyper triglyceridemia
SLE - only minutes; RA; hours;

43. tinel sign
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

44. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Disseminated gonoccal infection
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

45. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

46. SLE with pleural effusion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Disseminated gonoccal infection
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

47. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Patello femoral pain syndrome
A for aortic regurg; s for prolapSe (MVP)
Hyperflexion of both wrists--characteristic pain in one min

48. When to give methotrexate in SLE
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Disseminated gonoccal infection
Pt with significant organ involvement and have incomplete response to prednisone alone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

49. Management of HTN during acute gout
If person is HLA B27 positive
Hyperflexion of both wrists--characteristic pain in one min
Osteoarthirit (bouchard at pip - b comes first);
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

50. MCP joint involvement
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Coronary atherosclerosis due to SLE
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia