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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. 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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Arthritic sweling of DIP
Measure ESR; polymyalgia rheumatica; tx prednisone

2. phalen test
Pseudogout/hemochromatosis;
Hyperflexion of both wrists--characteristic pain in one min
SLE - only minutes; RA; hours;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

3. night back pain
Nodular lung densitieis with RA;
PMR and giant cell arteritis; can be seen both together;
Malignancy - infection - vertebral fracture
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

4. complications of anti-cytokine therapy
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 person is HLA B27 positive
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
High incidence of opportunistitc infection; reactivation of TB;

5. conjunctivitis - urethritis - and spondyloarthopathy

6. pagets in xray
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Viral arthritis or RA
Measure ca and ALP; increased ALP and normal ca for dx;
Pt with significant organ involvement and have incomplete response to prednisone alone

7. who gets reiters syndrome after chlamydia infection
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
If person is HLA B27 positive
Deposition of cholesterol in the periorbital skin
Xray every 3m

8. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Xray every 3m
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

9. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
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
Minocyclin - inhibits metalloproteases and slows joint damage
PPD

10. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ca and ALP; increased ALP and normal ca for dx;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

11. How often disease activity is monitored in AS?
Xray every 3m
Viral arthritis or RA
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

12. Tx of inflammatory myositis
Erythematous-violaceous rash on the eyelids
PMR and giant cell arteritis; can be seen both together;
Supplementation ca and vitamin D
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

13. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

14. inflammatory myositis
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
Decrease urate secretion from kidney
Coronary atherosclerosis due to SLE
Increased serum ferritin (acute phase protein)

15. probenecid
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Minocyclin - inhibits metalloproteases and slows joint damage
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

16. 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.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Hyperflexion of both wrists--characteristic pain in one min

17. anti-ds DNA antibody
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Coronary atherosclerosis due to SLE
Specific of dx of SLE

18. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Decrease urate secretion from kidney

19. postoeriod shoulder pain
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Arthritic sweling of DIP
AS; sometime only symptom is uveitis;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

20. Finding of MRI in stenosis
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Arthritic sweling of DIP

21. Use of antibiotic in RA
Minocyclin - inhibits metalloproteases and slows joint damage
Measure ESR; polymyalgia rheumatica; tx prednisone
If symptoms persist >6weeks
Nodular lung densitieis with RA;

22. Tx of lupus nephritis
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Prednisone and cyclophosphamide
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

23. allpurinol
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prophylactic agent to prevent recurrent attack; not given during acute attack
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

24. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Decrease urate secretion from kidney
AS; sometime only symptom is uveitis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
PMR and giant cell arteritis; can be seen both together;

25. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Xray every 3m
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

26. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
A for aortic regurg; s for prolapSe (MVP)
Abx -bedrest - exercise

27. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Primary biliary cirrhosis
Pseudogout/hemochromatosis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

28. What should be chekcked before starting infliximab
PPD
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Deposition of cholesterol in the periorbital skin

29. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

30. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
High incidence of opportunistitc infection; reactivation of TB;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

31. morning stiffness hand joints
SLE - only minutes; RA; hours;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Patello femoral pain syndrome
Pseudogout/hemochromatosis;

32. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Prednisone and cyclophosphamide
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

33. Raynauds phenomenon
High incidence of opportunistitc infection; reactivation of TB;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pseudogout/hemochromatosis;
SLE - only minutes; RA; hours;

34. patient pw groin pain; on steroid
Pt with significant organ involvement and have incomplete response to prednisone alone
Erythematous-violaceous rash on the eyelids
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
High incidence of opportunistitc infection; reactivation of TB;

35. painless ulcer over glans penis and inflammatory arthritis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
High incidence of opportunistitc infection; reactivation of TB;
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

36. How to differential lumbar spinal stenosis and disc herniation pain?
Pseudogout/hemochromatosis;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hyper triglyceridemia

37. 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.
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

38. How to prevent glucocorticoid induced bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Measure ca and ALP; increased ALP and normal ca for dx;
Supplementation ca and vitamin D
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

39. schirmer test
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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.
Symmetrical proximal weakness; increased CPK
Specific of dx of SLE

40. criteria for AS
Hypertriglyceridamia and hypercholesterolemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Arthritic sweling of DIP
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

41. carpal tunnel
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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

42. Ca oxalate induced arthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
C for c ; crest syndrome
ESRD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

43. pain in shoulder and pelvic girdle
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ESR; polymyalgia rheumatica; tx prednisone
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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.

44. Tx of reiter
Measure ESR; polymyalgia rheumatica; tx prednisone
Disseminated gonoccal infection
Abx -bedrest - exercise
Xray every 3m

45. 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
Hypertriglyceridamia and hypercholesterolemia
Coronary atherosclerosis due to SLE
Dorsum of hands and the Achilies tendon

46. Tx of gout in patient with ESRD or hx GI bleeding
Measure ca and ALP; increased ALP and normal ca for dx;
Pseudogout/hemochromatosis;
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
Viral arthritis or RA

47. anti-centromere ab
C for c ; crest syndrome
Decrease urate secretion from kidney
Coronary atherosclerosis due to SLE
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

48. proximal muscle weakness; decreased tendon reflex; normal creat and ck
If person is HLA B27 positive
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

49. primary muscle disease
SLE - only minutes; RA; hours;
Symmetrical proximal weakness; increased CPK
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

50. carpal tunnel syndrom
Pseudogout/hemochromatosis;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Supplementation ca and vitamin D
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