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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. glucocorticoid therapy
If person is HLA B27 positive
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Malignancy - infection - vertebral fracture

2. probenecid
PPD
PMR and giant cell arteritis; can be seen both together;
Abx -bedrest - exercise
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

3. tinel sign
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Prophylactic agent to prevent recurrent attack; not given during acute attack

4. morning stiffness hand joints
SLE - only minutes; RA; hours;
Pseudogout/hemochromatosis;
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.

5. DIP joint involvement

6. PIP joint involment
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
ESRD
Osteoarthirit (bouchard at pip - b comes first);
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

7. anti-mitochondrial
ESRD
C for c ; crest syndrome
PMR and giant cell arteritis; can be seen both together;
Primary biliary cirrhosis

8. anti-ds DNA antibody
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Specific of dx of SLE

9. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Check pedal pulses; in claudication pulses should diminish
Patello femoral pain syndrome
Supplementation ca and vitamin D
AS; sometime only symptom is uveitis;

10. mcp and PIP joint involvement
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Viral arthritis or RA
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
PMR and giant cell arteritis; can be seen both together;

11. who gets reiters syndrome after chlamydia infection
Patello femoral pain syndrome
If symptoms persist >6weeks
If person is HLA B27 positive
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

12. Rayanaud's disease vs phenomenon
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

13. increased ALP; liver or bone origin?
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Order LFT - heat fractionation (bone burns and liver lives) - GGT
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

14. When to order MRI in LBP
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
AS; sometime only symptom is uveitis;
If symptoms persist >6weeks

15. inflammatory myositis
Pt with significant organ involvement and have incomplete response to prednisone alone
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Primary biliary cirrhosis
Increased serum ferritin (acute phase protein)

16. caplan syndrom
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
Check pedal pulses; in claudication pulses should diminish
Nodular lung densitieis with RA;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

17. criteria for AS
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Arthritic sweling of DIP
Check pedal pulses; in claudication pulses should diminish
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

18. xanthomatous nodule
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)
Hyper triglyceridemia
Dorsum of hands and the Achilies tendon

19. What marker is used to follow up disease activity in SLE
Increased serum ferritin (acute phase protein)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pseudogout/hemochromatosis;
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

20. Tx of reiter
Coronary atherosclerosis due to SLE
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Abx -bedrest - exercise

21. conjunctivitis - urethritis - and spondyloarthopathy

22. Low back pain
Pt with significant organ involvement and have incomplete response to prednisone alone
Arthritic sweling of DIP
Supplementation ca and vitamin D
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

23. How to differential lumbar spinal stenosis and disc herniation pain?
Erythematous-violaceous rash on the eyelids
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Nodular lung densitieis with RA;

24. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Deposition of cholesterol in the periorbital skin
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

25. What should be chekcked before starting infliximab
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
If person is HLA B27 positive
PPD
Increased serum ferritin (acute phase protein)

26. heberdeen nodes
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
A for aortic regurg; s for prolapSe (MVP)
Hyper triglyceridemia
Arthritic sweling of DIP

27. night back pain
Increased serum ferritin (acute phase protein)
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
Malignancy - infection - vertebral fracture
Symmetrical proximal weakness; increased CPK

28. primary muscle disease
C for c ; crest 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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Symmetrical proximal weakness; increased CPK

29. painless ulcer over glans penis and inflammatory arthritis
Malignancy - infection - vertebral fracture
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Viral arthritis or RA
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

30. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pseudogout/hemochromatosis;
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;

31. carpal tunnel
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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
If person is HLA B27 positive

32. pagets in xray
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
Measure ca and ALP; increased ALP and normal ca for dx;
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
Viral arthritis or RA

33. neck mass in sjogren patient
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Increased serum ferritin (acute phase protein)

34. MCP joint involvement
Patello femoral pain syndrome
Decrease urate secretion from kidney
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

35. role HLA B27 in dx of ankylosing spondylitis
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
A for aortic regurg; s for prolapSe (MVP)
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

36. anti-centromere ab
AS; sometime only symptom is uveitis;
C for c ; crest syndrome
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Nodular lung densitieis with RA;

37. schirmer test
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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.
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

38. How often disease activity is monitored in AS?
Hyper triglyceridemia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Xray every 3m

39. right anterior knee pain and provoked by climbing stairs or prolong sitting
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Patello femoral pain syndrome
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
A for aortic regurg; s for prolapSe (MVP)

40. tx pagets
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
ESRD
Erythematous-violaceous rash on the eyelids
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

41. Use of antibiotic in RA
Viral arthritis or RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Minocyclin - inhibits metalloproteases and slows joint damage
If person is HLA B27 positive

42. allpurinol
If person is HLA B27 positive
Increased serum ferritin (acute phase protein)
Prophylactic agent to prevent recurrent attack; not given during acute attack
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

43. Gait in spinal stenosis
C for c ; crest syndrome
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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

44. management of LBP
Measure ca and ALP; increased ALP and normal ca for dx;
Pseudogout/hemochromatosis;
Pt with significant organ involvement and have incomplete response to prednisone alone
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

45. bouchard nodule
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

46. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Supplementation ca and vitamin D
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

47. xanthelasma
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
Deposition of cholesterol in the periorbital skin

48. proximal muscle weakness; decreased tendon reflex; normal creat and ck
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
Prednisone and cyclophosphamide
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

49. phalen test
Erythematous-violaceous rash on the eyelids
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyperflexion of both wrists--characteristic pain in one min
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

50. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
AS; sometime only symptom is uveitis;
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