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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. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Xray every 3m
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pseudogout/hemochromatosis;
Erythematous-violaceous rash on the eyelids

2. pagets in xray
A for aortic regurg; s for prolapSe (MVP)
Measure ca and ALP; increased ALP and normal ca for dx;
High incidence of opportunistitc infection; reactivation of TB;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

3. Tx of gout in patient with ESRD or hx GI bleeding
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
Primary biliary cirrhosis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Measure ESR; polymyalgia rheumatica; tx prednisone

4. anti-ds DNA antibody
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Patello femoral pain syndrome
Prednisone and cyclophosphamide
Specific of dx of SLE

5. when SLE patient needs steroid
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

6. heberdeen nodes
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritic sweling of DIP
If person is HLA B27 positive

7. increased ALP; liver or bone origin?
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyper triglyceridemia

8. Tx of lupus nephritis
Primary biliary cirrhosis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Prednisone and cyclophosphamide

9. What should be chekcked before starting infliximab
SLE - only minutes; RA; hours;
PPD
Measure ESR; polymyalgia rheumatica; tx prednisone
Malignancy - infection - vertebral fracture

10. How often disease activity is monitored in AS?
Abx -bedrest - exercise
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Nodular lung densitieis with RA;
Xray every 3m

11. Tx of gout
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
SLE - only minutes; RA; hours;
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

12. Tx of inflammatory myositis
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Deposition of cholesterol in the periorbital skin
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

13. neck mass in sjogren patient
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
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

14. management of LBP
Prednisone and cyclophosphamide
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
C for c ; crest syndrome
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

15. mcp and PIP joint involvement
If person is HLA B27 positive
PMR and giant cell arteritis; can be seen both together;
Viral arthritis or RA
Prednisone and cyclophosphamide

16. morning stiffness hand joints
SLE - only minutes; RA; hours;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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
Measure ESR; polymyalgia rheumatica; tx prednisone

17. Tx of RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

18. probenecid
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Supplementation ca and vitamin D
Prednisone and cyclophosphamide

19. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
AS; sometime only symptom is uveitis;
Arthritic sweling of DIP

20. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Pseudogout/hemochromatosis;
PMR and giant cell arteritis; can be seen both together;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Specific of dx of SLE

21. nicotinic acid
SLE - only minutes; RA; hours;
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Hypertriglyceridamia and hypercholesterolemia

22. Low back pain
PPD
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
SLE - only minutes; RA; hours;

23. When to order MRI in LBP
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hypertriglyceridamia and hypercholesterolemia
Specific of dx of SLE
If symptoms persist >6weeks

24. night back pain
Malignancy - infection - vertebral fracture
Measure ESR; polymyalgia rheumatica; tx prednisone
Viral arthritis or RA
Deposition of cholesterol in the periorbital skin

25. Ca oxalate induced arthritis
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
ESRD
If person is HLA B27 positive
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

26. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

27. bouchard nodule
AS; sometime only symptom is uveitis;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

28. who gets reiters syndrome after chlamydia infection
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

29. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Xray every 3m
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

30. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Hyper triglyceridemia
Viral arthritis or RA
Check pedal pulses; in claudication pulses should diminish

31. SLE patient p/w MI - vent fibrillation
Pseudogout/hemochromatosis;
Coronary atherosclerosis due to SLE
C for c ; crest syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

32. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
PMR and giant cell arteritis; can be seen both together;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

33. gemfibrozil
Deposition of cholesterol in the periorbital skin
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hyper triglyceridemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

34. tx pagets
Osteoarthirit (bouchard at pip - b comes first);
PPD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

35. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Supplementation ca and vitamin D
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Check pedal pulses; in claudication pulses should diminish

36. criteria for AS
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
ESRD
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Check pedal pulses; in claudication pulses should diminish

37. SLE with pleural effusion
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Symmetrical proximal weakness; increased CPK
Disseminated gonoccal infection
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

38. inflamed tendons in wrist - ankle - arms; sexual history
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Disseminated gonoccal infection
Pseudogout/hemochromatosis;
Viral arthritis or RA

39. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Osteoarthirit (bouchard at pip - b comes first);
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
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

40. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
Coronary atherosclerosis due to SLE
Increased serum ferritin (acute phase protein)
Malignancy - infection - vertebral fracture

41. colchicine
Disseminated gonoccal infection
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Think about reiter (cannot see - cannot pee - cannot climb a tree)

42. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

43. 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.
Malignancy - infection - vertebral fracture
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

44. Management of HTN during acute gout
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ESR; polymyalgia rheumatica; tx prednisone
If person is HLA B27 positive

45. Tx of reiter
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Abx -bedrest - exercise
Think about reiter (cannot see - cannot pee - cannot climb a tree)
C for c ; crest syndrome

46. role HLA B27 in dx of ankylosing spondylitis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

47. patient pw groin pain; on steroid
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Symmetrical proximal weakness; increased CPK
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

48. DIP joint involvement

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49. 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
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Viral arthritis or RA

50. How to perform schober test
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
PPD
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
A for aortic regurg; s for prolapSe (MVP)