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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. common valvular abnormalities with AS?
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Hyperflexion of both wrists--characteristic pain in one min
A for aortic regurg; s for prolapSe (MVP)
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

2. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Erythematous-violaceous rash on the eyelids
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Measure ESR; polymyalgia rheumatica; tx prednisone

3. Tx of RA
High incidence of opportunistitc infection; reactivation of TB;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
AS; sometime only symptom is uveitis;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

4. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Xray every 3m
Pseudogout/hemochromatosis;
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

5. night back pain
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Malignancy - infection - vertebral fracture

6. 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.
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

7. allpurinol
Pt with significant organ involvement and have incomplete response to prednisone alone
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 methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Prophylactic agent to prevent recurrent attack; not given during acute attack

8. 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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

9. carpal tunnel syndrom
AS; sometime only symptom is uveitis;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

10. xanthelasma
Arthritic sweling of DIP
Deposition of cholesterol in the periorbital skin
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

11. When to give methotrexate in SLE
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Decrease urate secretion from kidney
Arthritic sweling of DIP
Pt with significant organ involvement and have incomplete response to prednisone alone

12. pain in shoulder and pelvic girdle
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Hyper triglyceridemia
Measure ESR; polymyalgia rheumatica; tx prednisone
Deposition of cholesterol in the periorbital skin

13. spondyloarthopathy
PPD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Nodular lung densitieis with RA;

14. probenecid
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Abx -bedrest - exercise

15. xanthomatous nodule
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Dorsum of hands and the Achilies tendon
Abx -bedrest - exercise
If symptoms persist >6weeks

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

17. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Measure ca and ALP; increased ALP and normal ca for dx;
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

18. management of LBP
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

19. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
Hyperflexion of both wrists--characteristic pain in one min
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

20. Use of antibiotic in RA
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.
Minocyclin - inhibits metalloproteases and slows joint damage
Decrease urate secretion from kidney
Increased serum ferritin (acute phase protein)

21. anti-mitochondrial
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
If symptoms persist >6weeks
Primary biliary cirrhosis

22. morning stiffness hand joints
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
SLE - only minutes; RA; hours;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Deposition of cholesterol in the periorbital skin

23. How to perform schober test
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Nodular lung densitieis with RA;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

24. How to differential lumbar spinal stenosis and disc herniation pain?
Symmetrical proximal weakness; increased CPK
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prophylactic agent to prevent recurrent attack; not given during acute attack
Deposition of cholesterol in the periorbital skin

25. How to prevent glucocorticoid induced bone loss
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
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

26. DIP joint involvement

27. When to stop statin if cpk elevated
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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
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

28. Raynauds phenomenon
Measure ca and ALP; increased ALP and normal ca for dx;
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

29. What should be chekcked before starting infliximab
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
PPD
Viral arthritis or RA

30. nicotinic acid
PMR and giant cell arteritis; can be seen both together;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Hypertriglyceridamia and hypercholesterolemia
If symptoms persist >6weeks

31. How often disease activity is monitored in AS?
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Xray every 3m
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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

32. pagets in xray
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Measure ca and ALP; increased ALP and normal ca for dx;
Pseudogout/hemochromatosis;

33. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Coronary atherosclerosis due to SLE
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Pseudogout/hemochromatosis;

34. Management of HTN during acute gout
If person is HLA B27 positive
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

35. PIP joint involment
Measure ca and ALP; increased ALP and normal ca for dx;
Osteoarthirit (bouchard at pip - b comes first);
Prednisone and cyclophosphamide
Patello femoral pain syndrome

36. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Pt with significant organ involvement and have incomplete response to prednisone alone
AS; sometime only symptom is uveitis;

37. 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;
SLE - only minutes; RA; hours;
If symptoms persist >6weeks

38. Finding of MRI in stenosis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Xray every 3m
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

39. neck mass in sjogren patient
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
SLE - only minutes; RA; hours;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

40. Low back pain
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;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Increased serum ferritin (acute phase protein)

41. bouchard nodule
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Decrease urate secretion from kidney
A for aortic regurg; s for prolapSe (MVP)

42. SLE with pleural effusion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Disseminated gonoccal infection
C for c ; crest syndrome
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

43. 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
PMR and giant cell arteritis; can be seen both together;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

44. What marker is used to follow up disease activity in SLE
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Specific of dx of SLE
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

45. conjunctivitis - urethritis - and spondyloarthopathy

46. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Specific of dx of SLE
Patello femoral pain syndrome
Hyperflexion of both wrists--characteristic pain in one min

47. complications of anti-cytokine therapy
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
Hyper triglyceridemia
Pt with significant organ involvement and have incomplete response to prednisone alone
High incidence of opportunistitc infection; reactivation of TB;

48. tinel sign
Arthritic sweling of DIP
High incidence of opportunistitc infection; reactivation of TB;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Supplementation ca and vitamin D

49. inflammatory myositis
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Increased serum ferritin (acute phase protein)
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

50. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Malignancy - infection - vertebral fracture