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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. conjunctivitis - urethritis - and spondyloarthopathy

2. carpal tunnel syndrom
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
AS; sometime only symptom is uveitis;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

3. Tx of RA
Disseminated gonoccal infection
Patello femoral pain syndrome
Check pedal pulses; in claudication pulses should diminish
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

4. Rayanaud's disease vs phenomenon
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Nodular lung densitieis with RA;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

5. When to give methotrexate in SLE
Specific of dx of SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Hypertriglyceridamia and hypercholesterolemia
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

6. nicotinic acid
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hypertriglyceridamia and hypercholesterolemia
SLE - only minutes; RA; hours;
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

7. xanthelasma
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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.
Hyperflexion of both wrists--characteristic pain in one min
Deposition of cholesterol in the periorbital skin

8. patient pw groin pain; on steroid
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

9. neck mass in sjogren patient
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Coronary atherosclerosis due to SLE

10. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dorsum of hands and the Achilies tendon

11. right anterior knee pain and provoked by climbing stairs or prolong sitting
C for c ; crest syndrome
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Patello femoral pain syndrome
High incidence of opportunistitc infection; reactivation of TB;

12. allpurinol
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Prophylactic agent to prevent recurrent attack; not given during acute attack
Osteoarthirit (bouchard at pip - b comes first);
Symmetrical proximal weakness; increased CPK

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

14. morning stiffness hand joints
Decrease urate secretion from kidney
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pseudogout/hemochromatosis;
SLE - only minutes; RA; hours;

15. when SLE patient needs steroid
A for aortic regurg; s for prolapSe (MVP)
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

16. glucocorticoid therapy
Prednisone and cyclophosphamide
Prophylactic agent to prevent recurrent attack; not given during acute attack
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Measure ca and ALP; increased ALP and normal ca for dx;

17. Ca oxalate induced arthritis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
ESRD
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

18. inflammatory myositis
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
Increased serum ferritin (acute phase protein)
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

19. gemfibrozil
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Osteoarthirit (bouchard at pip - b comes first);
Hyper triglyceridemia

20. Use of antibiotic in RA
If symptoms persist >6weeks
Minocyclin - inhibits metalloproteases and slows joint damage
Dorsum of hands and the Achilies tendon
If person is HLA B27 positive

21. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
PMR and giant cell arteritis; can be seen both together;
Abx -bedrest - exercise
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

22. anti-ds DNA antibody
Specific of dx of SLE
Decrease urate secretion from kidney
If symptoms persist >6weeks
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

23. caplan syndrom
Nodular lung densitieis with RA;
Xray every 3m
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

24. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Minocyclin - inhibits metalloproteases and slows joint damage

25. probenecid
High incidence of opportunistitc infection; reactivation of TB;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Specific of dx of SLE

26. What is heliotrope sign
Symmetrical proximal weakness; increased CPK
Hypertriglyceridamia and hypercholesterolemia
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Erythematous-violaceous rash on the eyelids

27. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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.
PMR and giant cell arteritis; can be seen both together;
Malignancy - infection - vertebral fracture

28. who gets reiters syndrome after chlamydia infection
Symmetrical proximal weakness; increased CPK
If person is HLA B27 positive
Pt with significant organ involvement and have incomplete response to prednisone alone
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

29. Tx of lupus nephritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Erythematous-violaceous rash on the eyelids
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Prednisone and cyclophosphamide

30. When to stop statin if cpk elevated
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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

31. How glucocorticoid leads to bone loss
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Nodular lung densitieis with 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.

32. painless ulcer over glans penis and inflammatory arthritis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Think about reiter (cannot see - cannot pee - cannot climb a tree)

33. night back pain
Malignancy - infection - vertebral fracture
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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.

34. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Measure ca and ALP; increased ALP and normal ca for dx;
If symptoms persist >6weeks

35. patient is having pain when he moves hands above shoulder
Xray every 3m
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

36. pain in shoulder and pelvic girdle
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Measure ESR; polymyalgia rheumatica; tx prednisone

37. 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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

38. inflamed tendons in wrist - ankle - arms; sexual history
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Disseminated gonoccal infection

39. complications of anti-cytokine therapy
Pt with significant organ involvement and have incomplete response to prednisone alone
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
High incidence of opportunistitc infection; reactivation of TB;
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

40. How often disease activity is monitored in AS?
Prophylactic agent to prevent recurrent attack; not given during acute attack
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
Xray every 3m

41. DIP joint involvement

42. Finding of MRI in stenosis
Measure ESR; polymyalgia rheumatica; tx prednisone
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

43. Raynauds phenomenon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
A for aortic regurg; s for prolapSe (MVP)
PMR and giant cell arteritis; can be seen both together;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

44. Use of allopurinol after kidney transplant
AS; sometime only symptom is uveitis;
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

45. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

46. 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.
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Minocyclin - inhibits metalloproteases and slows joint damage
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

47. What should be chekcked before starting infliximab
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
ESRD
PPD
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

48. SLE patient p/w MI - vent fibrillation
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Coronary atherosclerosis due to SLE
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. Management of HTN during acute gout
Supplementation ca and vitamin D
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

50. xanthomatous nodule
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If symptoms persist >6weeks
Dorsum of hands and the Achilies tendon
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry