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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.
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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. How to monitor disease activity in SLE
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;
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

2. allpurinol
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Patello femoral pain syndrome
C for c ; crest syndrome
Prophylactic agent to prevent recurrent attack; not given during acute attack

3. What marker is used to follow up disease activity in SLE
PMR and giant cell arteritis; can be seen both together;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Specific of dx of SLE
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

4. painless ulcer over glans penis and inflammatory arthritis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Primary biliary cirrhosis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

5. night back pain
Malignancy - infection - vertebral fracture
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Arthritic sweling of DIP
Pseudogout/hemochromatosis;

6. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Pseudogout/hemochromatosis;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hypertriglyceridamia and hypercholesterolemia

7. PIP joint involment
C for c ; crest syndrome
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Prophylactic agent to prevent recurrent attack; not given during acute attack
Osteoarthirit (bouchard at pip - b comes first);

8. How glucocorticoid leads to bone loss
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;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

9. increased ALP; liver or bone origin?
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
C for c ; crest syndrome
Order LFT - heat fractionation (bone burns and liver lives) - GGT

10. Tx of reiter
Abx -bedrest - exercise
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Viral arthritis or RA
Specific of dx of SLE

11. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Increased serum ferritin (acute phase protein)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Xray every 3m

12. heberdeen nodes
High incidence of opportunistitc infection; reactivation of TB;
Arthritic sweling of DIP
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

13. patient pw groin pain; on steroid
Hyperflexion of both wrists--characteristic pain in one min
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hypertriglyceridamia and hypercholesterolemia

14. primary muscle disease
Nodular lung densitieis with RA;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Symmetrical proximal weakness; increased CPK

15. management of LBP
Primary biliary cirrhosis
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
A for aortic regurg; s for prolapSe (MVP)
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

16. tx pagets
Xray every 3m
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Arthritic sweling of DIP

17. cylosporin used after renal transplantation
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Deposition of cholesterol in the periorbital skin
Abx -bedrest - exercise
Decrease urate secretion from kidney

18. When to order MRI in LBP
If symptoms persist >6weeks
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Measure ca and ALP; increased ALP and normal ca for dx;
SLE - only minutes; RA; hours;

19. Tx of lupus nephritis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Prednisone and cyclophosphamide
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

20. morning stiffness hand joints
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
SLE - only minutes; RA; hours;
Increased serum ferritin (acute phase protein)

21. MCP joint involvement
Arthritic sweling of DIP
Coronary atherosclerosis due to SLE
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

22. postoeriod shoulder pain
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
ESRD
Nodular lung densitieis with RA;

23. Tx of gout in patient with ESRD or hx GI bleeding
Xray every 3m
Erythematous-violaceous rash on the eyelids
Abx -bedrest - exercise
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

24. pain in shoulder and pelvic girdle
Supplementation ca and vitamin D
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Nodular lung densitieis with RA;
Measure ESR; polymyalgia rheumatica; tx prednisone

25. phalen test
Dorsum of hands and the Achilies tendon
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
Hyperflexion of both wrists--characteristic pain in one min

26. right anterior knee pain and provoked by climbing stairs or prolong sitting
Malignancy - infection - vertebral fracture
Patello femoral pain syndrome
Coronary atherosclerosis due to SLE
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

27. How often disease activity is monitored in AS?
Patello femoral pain syndrome
If symptoms persist >6weeks
Malignancy - infection - vertebral fracture
Xray every 3m

28. Raynauds phenomenon
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If person is HLA B27 positive
SLE - only minutes; RA; hours;

29. How to differential lumbar spinal stenosis and disc herniation pain?
Coronary atherosclerosis due to SLE
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

30. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Osteoarthirit (bouchard at pip - b comes first);
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pseudogout/hemochromatosis;

31. schirmer test
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.
Hyperflexion of both wrists--characteristic pain in one min
PPD
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

32. anti-mitochondrial
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
Primary biliary cirrhosis
C for c ; crest syndrome
Viral arthritis or RA

33. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Prednisone and cyclophosphamide
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Patello femoral pain syndrome
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

34. Tx of RA
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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

35. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Hypertriglyceridamia and hypercholesterolemia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

36. colchicine
Increased serum ferritin (acute phase protein)
Supplementation ca and vitamin D
Symmetrical proximal weakness; increased CPK
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

37. when SLE patient needs steroid
Check pedal pulses; in claudication pulses should diminish
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
Disseminated gonoccal infection

38. anterior shoulder pain
C for c ; crest syndrome
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Nodular lung densitieis with RA;

39. DIP joint involvement

40. Use of allopurinol after kidney transplant
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

41. Tx of inflammatory myositis
Hyper triglyceridemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Primary biliary cirrhosis

42. When to start DMARD in RA
Increased serum ferritin (acute phase protein)
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

43. 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
Xray every 3m
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

44. criteria for AS
Measure ca and ALP; increased ALP and normal ca for dx;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Coronary atherosclerosis due to SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

45. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Decrease urate secretion from kidney
Hypertriglyceridamia and hypercholesterolemia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

46. complications of anti-cytokine therapy
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Primary biliary cirrhosis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
High incidence of opportunistitc infection; reactivation of TB;

47. Low back pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
SLE - only minutes; RA; hours;

48. When to give methotrexate in SLE
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
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

49. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Prednisone and cyclophosphamide
Erythematous-violaceous rash on the eyelids
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

50. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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