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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. primary muscle disease
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
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

2. Finding of MRI in stenosis
Coronary atherosclerosis due to SLE
PMR and giant cell arteritis; can be seen both together;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
SLE - only minutes; RA; hours;

3. complications of anti-cytokine therapy
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
High incidence of opportunistitc infection; reactivation of TB;
Hyper triglyceridemia
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

4. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
PMR and giant cell arteritis; can be seen both together;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Abx -bedrest - exercise

5. xanthelasma
Deposition of cholesterol in the periorbital skin
If person is HLA B27 positive
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

6. Ca oxalate induced arthritis
High incidence of opportunistitc infection; reactivation of TB;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
ESRD

7. Tx of reiter
Abx -bedrest - exercise
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

8. Low back pain
Measure ca and ALP; increased ALP and normal ca for dx;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

9. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Prophylactic agent to prevent recurrent attack; not given during acute attack
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

10. management of LBP
Hyper triglyceridemia
Supplementation ca and vitamin D
Primary biliary cirrhosis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

11. How to perform schober test
PMR and giant cell arteritis; can be seen both together;
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

12. colchicine
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
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 symptoms persist >6weeks
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

13. glucocorticoid therapy
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

14. night back pain
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
Malignancy - infection - vertebral fracture
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.
Pseudogout/hemochromatosis;

15. SLE with pleural effusion
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
High incidence of opportunistitc infection; reactivation of TB;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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. Use of antibiotic in RA
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.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Minocyclin - inhibits metalloproteases and slows joint damage

17. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Pseudogout/hemochromatosis;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Disseminated gonoccal infection

18. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Symmetrical proximal weakness; increased CPK
Prophylactic agent to prevent recurrent attack; not given during acute attack

19. What should be chekcked before starting infliximab
PPD
Xray every 3m
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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

20. When to order MRI in LBP
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Disseminated gonoccal infection
If symptoms persist >6weeks
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

21. DIP joint involvement

22. Tx of gout
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
Hypertriglyceridamia and hypercholesterolemia
Minocyclin - inhibits metalloproteases and slows joint damage
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

23. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Prednisone and cyclophosphamide

24. painless ulcer over glans penis and inflammatory arthritis
PPD
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina 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
Think about reiter (cannot see - cannot pee - cannot climb a tree)

25. Rayanaud's disease vs phenomenon
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Arthritic sweling of DIP

26. Tx of inflammatory myositis
Specific of dx of SLE
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Deposition of cholesterol in the periorbital skin
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

27. Raynauds phenomenon
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
C for c ; crest syndrome

28. gemfibrozil
Primary biliary cirrhosis
Hyper triglyceridemia
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Disseminated gonoccal infection

29. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
If symptoms persist >6weeks
Coronary atherosclerosis due to SLE

30. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

31. Tx of lupus nephritis
Symmetrical proximal weakness; increased CPK
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Prednisone and cyclophosphamide
Think about reiter (cannot see - cannot pee - cannot climb a tree)

32. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Osteoarthirit (bouchard at pip - b comes first);
Xray every 3m
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

33. What is heliotrope sign
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Erythematous-violaceous rash on the eyelids
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

34. inflammatory myositis
Abx -bedrest - exercise
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Osteoarthirit (bouchard at pip - b comes first);
Increased serum ferritin (acute phase protein)

35. When to start DMARD in RA
Measure ESR; polymyalgia rheumatica; tx prednisone
Increased serum ferritin (acute phase protein)
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pseudogout/hemochromatosis;

36. patient pw groin pain; on steroid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Patello femoral pain syndrome
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

37. conjunctivitis - urethritis - and spondyloarthopathy

38. anti-centromere ab
C for c ; crest syndrome
Hyperflexion of both wrists--characteristic pain in one min
Hyper triglyceridemia
ESRD

39. Tx of gout in patient with ESRD or hx GI bleeding
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ca and ALP; increased ALP and normal ca for dx;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

40. when SLE patient needs steroid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
PPD
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

41. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
PPD
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Prednisone and cyclophosphamide

42. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
High incidence of opportunistitc infection; reactivation of TB;

43. How often disease activity is monitored in AS?
Xray every 3m
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
Specific of dx of SLE

44. inflamed tendons in wrist - ankle - arms; sexual history
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Disseminated gonoccal infection
Decrease urate secretion from kidney
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

45. What marker is used to follow up disease activity in SLE
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Increased serum ferritin (acute phase protein)
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

46. heberdeen nodes
Symmetrical proximal weakness; increased CPK
Arthritic sweling of DIP
Pseudogout/hemochromatosis;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

47. allpurinol
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.
Prophylactic agent to prevent recurrent attack; not given during acute attack
A for aortic regurg; s for prolapSe (MVP)
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

48. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Minocyclin - inhibits metalloproteases and slows joint damage

49. bouchard nodule
Pt with significant organ involvement and have incomplete response to prednisone alone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Erythematous-violaceous rash on the eyelids

50. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
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
Pseudogout/hemochromatosis;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard