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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. Use of allopurinol after kidney transplant
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

2. How to prevent glucocorticoid induced bone loss
Specific of dx of SLE
Deposition of cholesterol in the periorbital skin
Supplementation ca and vitamin D
Hyper triglyceridemia

3. tx pagets
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
ESRD
Hyperflexion of both wrists--characteristic pain in one min

4. What should be chekcked before starting infliximab
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
PPD
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

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.
Supplementation ca and vitamin D
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pt with significant organ involvement and have incomplete response to prednisone alone

6. cylosporin used after renal transplantation
Prednisone and cyclophosphamide
Malignancy - infection - vertebral fracture
Decrease urate secretion from kidney
Patello femoral pain syndrome

7. management of LBP
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

8. neck mass in sjogren patient
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Decrease urate secretion from kidney
Symmetrical proximal weakness; increased CPK
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

9. Tx of RA
Check pedal pulses; in claudication pulses should diminish
Prophylactic agent to prevent recurrent attack; not given during acute attack
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

10. mcp and PIP joint involvement
Viral arthritis or RA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ESRD
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

11. glucocorticoid therapy
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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

12. Tx of reiter
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.
Measure ca and ALP; increased ALP and normal ca for dx;
Abx -bedrest - exercise
Pt with significant organ involvement and have incomplete response to prednisone alone

13. conjunctivitis - urethritis - and spondyloarthopathy

14. proximal muscle weakness; decreased tendon reflex; normal creat and ck
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.
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
Increased serum ferritin (acute phase protein)

15. role HLA B27 in dx of ankylosing spondylitis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
If symptoms persist >6weeks
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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

16. phalen test
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Hyperflexion of both wrists--characteristic pain in one min

17. How to monitor disease activity in SLE
Pseudogout/hemochromatosis;
Patello femoral pain syndrome
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pt with significant organ involvement and have incomplete response to prednisone alone

18. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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

19. patient pw groin pain; on steroid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Nodular lung densitieis with RA;
If symptoms persist >6weeks
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

20. xanthelasma
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Deposition of cholesterol in the periorbital skin
If symptoms persist >6weeks
Think about reiter (cannot see - cannot pee - cannot climb a tree)

21. who gets reiters syndrome after chlamydia infection
Disseminated gonoccal infection
Dorsum of hands and the Achilies tendon
If person is HLA B27 positive
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

22. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Primary biliary cirrhosis
Symmetrical proximal weakness; increased CPK

23. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hypertriglyceridamia and hypercholesterolemia
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

24. criteria for AS
PPD
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

25. Finding of MRI in stenosis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pseudogout/hemochromatosis;

26. 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
Specific of dx of SLE
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
If symptoms persist >6weeks

27. PIP joint involment
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Osteoarthirit (bouchard at pip - b comes first);
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

28. carpal tunnel syndrom
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Abx -bedrest - exercise
Minocyclin - inhibits metalloproteases and slows joint damage
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

29. How to differential lumbar spinal stenosis and disc herniation pain?
AS; sometime only symptom is uveitis;
Osteoarthirit (bouchard at pip - b comes first);
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Abx -bedrest - exercise

30. right anterior knee pain and provoked by climbing stairs or prolong sitting
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Patello femoral pain syndrome
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
C for c ; crest syndrome

31. What marker is used to follow up disease activity in SLE
Hypertriglyceridamia and hypercholesterolemia
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
Arthritic sweling of DIP

32. Tx of lupus nephritis
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Hyper triglyceridemia
Prednisone and cyclophosphamide
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

33. Tx of gout in patient with ESRD or hx GI bleeding
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Viral arthritis or RA

34. night back pain
Primary biliary cirrhosis
High incidence of opportunistitc infection; reactivation of TB;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Malignancy - infection - vertebral fracture

35. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

36. When to order MRI in LBP
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Prophylactic agent to prevent recurrent attack; not given during acute attack
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
If symptoms persist >6weeks

37. increased ALP; liver or bone origin?
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Check pedal pulses; in claudication pulses should diminish

38. carpal tunnel
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
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
Measure ca and ALP; increased ALP and normal ca for dx;

39. Rayanaud's disease vs phenomenon
Measure ca and ALP; increased ALP and normal ca for dx;
Arthritic sweling of DIP
Disseminated gonoccal infection
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

40. DIP joint involvement

41. When to give methotrexate in SLE
Hypertriglyceridamia and hypercholesterolemia
Abx -bedrest - exercise
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pt with significant organ involvement and have incomplete response to prednisone alone

42. probenecid
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Coronary atherosclerosis due to SLE
PPD
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

43. Raynauds phenomenon
Pseudogout/hemochromatosis;
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT

44. SLE with pleural effusion
Malignancy - infection - vertebral fracture
Measure ESR; polymyalgia rheumatica; tx prednisone
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

45. gemfibrozil
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Hyperflexion of both wrists--characteristic pain in one min
C for c ; crest syndrome
Hyper triglyceridemia

46. schirmer test
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
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.
High incidence of opportunistitc infection; reactivation of TB;
Decrease urate secretion from kidney

47. Ca oxalate induced arthritis
ESRD
Measure ca and ALP; increased ALP and normal ca for dx;
Pseudogout/hemochromatosis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

48. colchicine
Decrease urate secretion from kidney
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Nodular lung densitieis with RA;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

49. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
PMR and giant cell arteritis; can be seen both together;
Deposition of cholesterol in the periorbital skin
ESRD

50. morning stiffness hand joints
Viral arthritis or RA
Hyperflexion of both wrists--characteristic pain in one min
SLE - only minutes; RA; hours;
Primary biliary cirrhosis