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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. SLE patient p/w MI - vent fibrillation
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Pseudogout/hemochromatosis;
Coronary atherosclerosis due to SLE
Hyperflexion of both wrists--characteristic pain in one min

2. heberdeen nodes
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Arthritic sweling of DIP

3. How to differential lumbar spinal stenosis and disc herniation pain?
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Disseminated gonoccal infection
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
AS; sometime only symptom is uveitis;

4. xanthelasma
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Deposition of cholesterol in the periorbital skin
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Symmetrical proximal weakness; increased CPK

5. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
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
ESRD
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

6. What marker is used to follow up disease activity in SLE
If person is HLA B27 positive
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hypertriglyceridamia and hypercholesterolemia
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

7. When to start DMARD in RA
Osteoarthirit (bouchard at pip - b comes first);
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

8. increased ALP; liver or bone origin?
Malignancy - infection - vertebral fracture
Order LFT - heat fractionation (bone burns and liver lives) - GGT
If symptoms persist >6weeks
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

9. Tx of reiter
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Hypertriglyceridamia and hypercholesterolemia
Hyper triglyceridemia
Abx -bedrest - exercise

10. 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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Arthritic sweling of DIP

11. Tx of gout
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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
Supplementation ca and vitamin D
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. Management of HTN during acute gout
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pt with significant organ involvement and have incomplete response to prednisone alone

13. gemfibrozil
Hyper triglyceridemia
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Dorsum of hands and the Achilies tendon

14. allpurinol
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Deposition of cholesterol in the periorbital skin
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Prophylactic agent to prevent recurrent attack; not given during acute attack

15. primary muscle disease
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
If person is HLA B27 positive
Symmetrical proximal weakness; increased CPK

16. Ca oxalate induced arthritis
ESRD
Specific of dx of SLE
Viral arthritis or RA
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

17. morning stiffness hand joints
C for c ; crest syndrome
SLE - only minutes; RA; hours;
ESRD
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.

18. management of LBP
Erythematous-violaceous rash on the eyelids
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Symmetrical proximal weakness; increased CPK
Supplementation ca and vitamin D

19. How to perform schober test
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
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
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

20. role HLA B27 in dx of ankylosing spondylitis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Check pedal pulses; in claudication pulses should diminish
Hypertriglyceridamia and hypercholesterolemia

21. xanthomatous nodule
Measure ca and ALP; increased ALP and normal ca for dx;
Pseudogout/hemochromatosis;
Dorsum of hands and the Achilies tendon
Specific of dx of SLE

22. conjunctivitis - urethritis - and spondyloarthopathy

23. PIP joint involment
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Osteoarthirit (bouchard at pip - b comes first);
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

24. Rayanaud's disease vs phenomenon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

25. proximal muscle weakness; decreased tendon reflex; normal creat and ck
AS; sometime only symptom is uveitis;
Hypertriglyceridamia and hypercholesterolemia
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Malignancy - infection - vertebral fracture

26. right anterior knee pain and provoked by climbing stairs or prolong sitting
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.
C for c ; crest syndrome
Xray every 3m
Patello femoral pain syndrome

27. Gait in spinal stenosis
PPD
Osteoarthirit (bouchard at pip - b comes first);
Xray every 3m
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

28. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Osteoarthirit (bouchard at pip - b comes first);
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
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

29. How often disease activity is monitored in AS?
Coronary atherosclerosis due to SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Xray every 3m
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

30. nicotinic acid
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Prophylactic agent to prevent recurrent attack; not given during acute attack
Hypertriglyceridamia and hypercholesterolemia
Decrease urate secretion from kidney

31. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Pseudogout/hemochromatosis;
High incidence of opportunistitc infection; reactivation of TB;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

32. Finding of MRI in stenosis
Nodular lung densitieis with RA;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
PMR and giant cell arteritis; can be seen both together;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

33. 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.
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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

34. How to prevent glucocorticoid induced bone loss
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
Supplementation ca and vitamin D

35. patient pw groin pain; on steroid
SLE - only minutes; RA; hours;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

36. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Deposition of cholesterol in the periorbital skin
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

37. criteria for AS
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
High incidence of opportunistitc infection; reactivation of TB;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

38. Use of allopurinol after kidney transplant
Nodular lung densitieis with RA;
Osteoarthirit (bouchard at pip - b comes first);
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

39. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
If person is HLA B27 positive
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Deposition of cholesterol in the periorbital skin

40. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Measure ESR; polymyalgia rheumatica; tx prednisone
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

41. anterior shoulder pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Specific of dx of SLE
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

42. pain in shoulder and pelvic girdle
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Symmetrical proximal weakness; increased CPK
Measure ESR; polymyalgia rheumatica; tx prednisone

43. colchicine
Xray every 3m
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
Arthritic sweling of DIP

44. Low back pain
Deposition of cholesterol in the periorbital skin
Hypertriglyceridamia and hypercholesterolemia
Symmetrical proximal weakness; increased CPK
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

45. inflammatory myositis
Prophylactic agent to prevent recurrent attack; not given during acute attack
Increased serum ferritin (acute phase protein)
Hyper triglyceridemia
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

46. How glucocorticoid leads to bone loss
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

47. common valvular abnormalities with AS?
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
A for aortic regurg; s for prolapSe (MVP)
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

48. anti-centromere ab
Specific of dx of SLE
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.
C for c ; crest syndrome
A for aortic regurg; s for prolapSe (MVP)

49. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

50. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Increased serum ferritin (acute phase protein)
C for c ; crest syndrome
AS; sometime only symptom is uveitis;
Pseudogout/hemochromatosis;