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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. carpal tunnel
Dorsum of hands and the Achilies tendon
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hyperflexion of both wrists--characteristic pain in one min

2. inflamed tendons in wrist - ankle - arms; sexual history
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Disseminated gonoccal infection
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

3. How to differential lumbar spinal stenosis and disc herniation pain?
Deposition of cholesterol in the periorbital skin
ESRD
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

4. inflammatory myositis
Measure ESR; polymyalgia rheumatica; tx prednisone
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Increased serum ferritin (acute phase protein)
Arthritic sweling of DIP

5. anterior shoulder pain
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Pt with significant organ involvement and have incomplete response to prednisone alone
Measure ca and ALP; increased ALP and normal ca for dx;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

6. spondyloarthopathy
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
A for aortic regurg; s for prolapSe (MVP)
Erythematous-violaceous rash on the eyelids
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

7. who gets reiters syndrome after chlamydia infection
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
If person is HLA B27 positive

8. Tx of reiter
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Symmetrical proximal weakness; increased CPK
Abx -bedrest - exercise

9. patient is having pain when he moves hands above shoulder
Deposition of cholesterol in the periorbital skin
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

10. Gait in spinal stenosis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

11. anti-centromere ab
Prophylactic agent to prevent recurrent attack; not given during acute attack
C for c ; crest syndrome
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

12. tinel sign
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Prophylactic agent to prevent recurrent attack; not given during acute attack

13. bouchard nodule
PPD
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
PMR and giant cell arteritis; can be seen both together;
Prednisone and cyclophosphamide

14. PIP joint involment
Symmetrical proximal weakness; increased CPK
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Osteoarthirit (bouchard at pip - b comes first);
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

15. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Hyper triglyceridemia
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

16. How to perform schober test
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

17. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
If symptoms persist >6weeks
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

18. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Viral arthritis or RA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
SLE - only minutes; RA; hours;

19. What marker is used to follow up disease activity in 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
Coronary atherosclerosis due to SLE
Patello femoral pain syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

20. What is heliotrope sign
Specific of dx of SLE
Erythematous-violaceous rash on the eyelids
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

21. carpal tunnel syndrom
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Dorsum of hands and the Achilies tendon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

22. Tx of RA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

23. anti-ds DNA antibody
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Specific of dx of SLE

24. SLE with pleural effusion
Hyper triglyceridemia
Supplementation ca and vitamin D
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

25. colchicine
SLE - only minutes; RA; hours;
If person is HLA B27 positive
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

26. morning stiffness hand joints
Viral arthritis or RA
SLE - only minutes; RA; hours;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Symmetrical proximal weakness; increased CPK

27. management of LBP
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Hypertriglyceridamia and hypercholesterolemia
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

28. Use of antibiotic in RA
ESRD
Minocyclin - inhibits metalloproteases and slows joint damage
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

29. conjunctivitis - urethritis - and spondyloarthopathy

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30. xanthelasma
High incidence of opportunistitc infection; reactivation of TB;
Deposition of cholesterol in the periorbital skin
Pt with significant organ involvement and have incomplete response to prednisone alone
PPD

31. role HLA B27 in dx of ankylosing spondylitis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Erythematous-violaceous rash on the eyelids
C for c ; crest syndrome

32. night back pain
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Malignancy - infection - vertebral fracture
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Coronary atherosclerosis due to SLE

33. anti-mitochondrial
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Primary biliary cirrhosis
A for aortic regurg; s for prolapSe (MVP)

34. Tx of gout
If symptoms persist >6weeks
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
Minocyclin - inhibits metalloproteases and slows joint damage

35. When to give methotrexate in SLE
Viral arthritis or RA
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Pt with significant organ involvement and have incomplete response to prednisone alone
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

36. cylosporin used after renal transplantation
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
Decrease urate secretion from kidney
A for aortic regurg; s for prolapSe (MVP)
Pt with significant organ involvement and have incomplete response to prednisone alone

37. Management of HTN during acute gout
Minocyclin - inhibits metalloproteases and slows joint damage
Supplementation ca and vitamin D
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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.

38. nicotinic acid
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hypertriglyceridamia and hypercholesterolemia
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
SLE - only minutes; RA; hours;

39. How to differentiate radicular pain with claudication
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Measure ca and ALP; increased ALP and normal ca for dx;
Check pedal pulses; in claudication pulses should diminish

40. caplan syndrom
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Nodular lung densitieis with RA;

41. when SLE patient needs steroid
Arthritic sweling of DIP
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Supplementation ca and vitamin D

42. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Supplementation ca and vitamin D
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

43. glucocorticoid therapy
Minocyclin - inhibits metalloproteases and slows joint damage
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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

44. When to order MRI in LBP
Xray every 3m
Disseminated gonoccal infection
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

45. How to monitor disease activity in SLE
High incidence of opportunistitc infection; reactivation of TB;
C for c ; crest syndrome
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

46. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
PMR and giant cell arteritis; can be seen both together;
If symptoms persist >6weeks
Prophylactic agent to prevent recurrent attack; not given during acute attack

47. patient pw groin pain; on steroid
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
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

48. complications of anti-cytokine therapy
Pseudogout/hemochromatosis;
Xray every 3m
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
High incidence of opportunistitc infection; reactivation of TB;

49. Raynauds phenomenon
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Deposition of cholesterol in the periorbital skin

50. tx pagets
Patello femoral pain syndrome
PPD
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat