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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. who gets reiters syndrome after chlamydia infection
Order LFT - heat fractionation (bone burns and liver lives) - GGT
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
If person is HLA B27 positive
Malignancy - infection - vertebral fracture

2. morning stiffness hand joints
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
SLE - only minutes; RA; hours;
AS; sometime only symptom is uveitis;

3. xanthelasma
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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.
Deposition of cholesterol in the periorbital skin
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

4. Raynauds phenomenon
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Osteoarthirit (bouchard at pip - b comes first);
C for c ; crest syndrome

5. primary muscle disease
Pt with significant organ involvement and have incomplete response to prednisone alone
Primary biliary cirrhosis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Symmetrical proximal weakness; increased CPK

6. management of LBP
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Specific of dx of SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
A for aortic regurg; s for prolapSe (MVP)

7. tx pagets
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

8. MCP joint involvement
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Increased serum ferritin (acute phase protein)
Xray every 3m

9. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

10. spondyloarthopathy
Hyper triglyceridemia
Dorsum of hands and the Achilies tendon
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

11. Use of allopurinol after kidney transplant
Viral arthritis or RA
Minocyclin - inhibits metalloproteases and slows joint damage
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Abx -bedrest - exercise

12. carpal tunnel syndrom
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Symmetrical proximal weakness; increased CPK
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Malignancy - infection - vertebral fracture

13. common valvular abnormalities with AS?
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
A for aortic regurg; s for prolapSe (MVP)
Hyperflexion of both wrists--characteristic pain in one min
Think about reiter (cannot see - cannot pee - cannot climb a tree)

14. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Nodular lung densitieis with RA;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

15. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Nodular lung densitieis with RA;
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. Tx of gout in patient with ESRD or hx GI bleeding
Symmetrical proximal weakness; increased CPK
Pseudogout/hemochromatosis;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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

17. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
PMR and giant cell arteritis; can be seen both together;
Erythematous-violaceous rash on the eyelids

18. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Hyper triglyceridemia
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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

19. bouchard nodule
Pseudogout/hemochromatosis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Prednisone and cyclophosphamide
Specific of dx of SLE

20. nicotinic acid
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
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
PMR and giant cell arteritis; can be seen both together;
Hypertriglyceridamia and hypercholesterolemia

21. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

22. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Disseminated gonoccal infection
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

23. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Abx -bedrest - exercise
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

24. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
A for aortic regurg; s for prolapSe (MVP)
Pseudogout/hemochromatosis;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Increased serum ferritin (acute phase protein)

25. How to differential lumbar spinal stenosis and disc herniation pain?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
If person is HLA B27 positive
Symmetrical proximal weakness; increased CPK
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

26. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Disseminated gonoccal infection
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

27. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Prednisone and cyclophosphamide
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

28. 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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Specific of dx of SLE
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

29. tinel sign
Abx -bedrest - exercise
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
If person is HLA B27 positive
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

30. Ca oxalate induced arthritis
Abx -bedrest - exercise
Increased serum ferritin (acute phase protein)
ESRD
Xray every 3m

31. When to order MRI in LBP
Osteoarthirit (bouchard at pip - b comes first);
If symptoms persist >6weeks
Patello femoral pain syndrome
Pseudogout/hemochromatosis;

32. cylosporin used after renal transplantation
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
AS; sometime only symptom is uveitis;
Decrease urate secretion from kidney

33. How to perform schober test
Primary biliary cirrhosis
Decrease urate secretion from kidney
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

34. glucocorticoid therapy
Viral arthritis or RA
Arthritic sweling of DIP
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Patello femoral pain syndrome

35. When to stop statin if cpk elevated
Osteoarthirit (bouchard at pip - b comes first);
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Prednisone and cyclophosphamide

36. Management of HTN during acute gout
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

37. How often disease activity is monitored in AS?
Supplementation ca and vitamin D
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Symmetrical proximal weakness; increased CPK
Xray every 3m

38. neck mass in sjogren patient
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

39. SLE patient p/w MI - vent fibrillation
Increased serum ferritin (acute phase protein)
Coronary atherosclerosis due to SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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

40. patient is having pain when he moves hands above shoulder
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
AS; sometime only symptom is uveitis;

41. Tx of reiter
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Viral arthritis or RA
Abx -bedrest - exercise
Prophylactic agent to prevent recurrent attack; not given during acute attack

42. 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
Hyper triglyceridemia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Decrease urate secretion from kidney

43. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
AS; sometime only symptom is uveitis;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

44. postoeriod shoulder pain
Erythematous-violaceous rash on the eyelids
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

45. What is heliotrope sign
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Erythematous-violaceous rash on the eyelids
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

46. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Symmetrical proximal weakness; increased CPK
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Prednisone and cyclophosphamide

47. patient pw groin pain; on steroid
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Specific of dx of SLE
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

48. heberdeen nodes
Measure ESR; polymyalgia rheumatica; tx prednisone
Arthritic sweling of DIP
Viral arthritis or RA
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

49. Finding of MRI in stenosis
Supplementation ca and vitamin D
Prednisone and cyclophosphamide
Xray every 3m
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

50. Tx of RA
Pseudogout/hemochromatosis;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
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