USMLE Step3 Rheumatology

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. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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 urate secretion from kidney
Prednisone and cyclophosphamide


2. 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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Viral arthritis or RA


3. 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
Disseminated gonoccal infection
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
ESRD


4. Tx of lupus nephritis
Prednisone and cyclophosphamide
Primary biliary cirrhosis
Minocyclin - inhibits metalloproteases and slows joint damage
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx


5. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Dorsum of hands and the Achilies tendon
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Supplementation ca and vitamin D


6. SLE with pleural effusion
Viral arthritis or RA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
SLE - only minutes; RA; hours;
Patello femoral pain syndrome


7. schirmer test
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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.
Prednisone and cyclophosphamide


8. cylosporin used after renal transplantation
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;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Decrease urate secretion from kidney


9. 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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle


10. Tx of RA
Supplementation ca and vitamin D
Disseminated gonoccal infection
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite


11. Gait in spinal stenosis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
A for aortic regurg; s for prolapSe (MVP)
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.


12. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Measure ESR; polymyalgia rheumatica; tx prednisone
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
Hypertriglyceridamia and hypercholesterolemia


13. heberdeen nodes
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Arthritic sweling of DIP
Xray every 3m
Think about reiter (cannot see - cannot pee - cannot climb a tree)


14. Use of allopurinol after kidney transplant
Osteoarthirit (bouchard at pip - b comes first);
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Deposition of cholesterol in the periorbital skin


15. When to order MRI in LBP
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
Check pedal pulses; in claudication pulses should diminish
Symmetrical proximal weakness; increased CPK
If symptoms persist >6weeks


16. bouchard nodule
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Decrease urate secretion from kidney


17. tx pagets
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
High incidence of opportunistitc infection; reactivation of TB;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible


18. Finding of MRI in stenosis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;


19. neck mass in sjogren patient
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Check pedal pulses; in claudication pulses should diminish
Coronary atherosclerosis due to SLE


20. xanthelasma
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Deposition of cholesterol in the periorbital skin
Osteoarthirit (bouchard at pip - b comes first);
Check pedal pulses; in claudication pulses should diminish


21. Tx of gout in patient with ESRD or hx GI bleeding
Measure ESR; polymyalgia rheumatica; tx prednisone
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.
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
If person is HLA B27 positive


22. pagets in xray
Prednisone and cyclophosphamide
Measure ca and ALP; increased ALP and normal ca for dx;
Symmetrical proximal weakness; increased CPK
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications


23. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Supplementation ca and vitamin D
Specific of dx of SLE


24. gemfibrozil
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Hyper triglyceridemia
Increased serum ferritin (acute phase protein)
ESRD


25. probenecid
Osteoarthirit (bouchard at pip - b comes first);
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat


26. caplan syndrom
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Nodular lung densitieis with RA;


27. How to differentiate radicular pain with claudication
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Check pedal pulses; in claudication pulses should diminish
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis


28. 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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Abx -bedrest - exercise
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;


29. DIP joint involvement


30. management of LBP
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.
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
PPD


31. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Supplementation ca and vitamin D
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel


32. increased ALP; liver or bone origin?
Hypertriglyceridamia and hypercholesterolemia
Xray every 3m
Measure ca and ALP; increased ALP and normal ca for dx;
Order LFT - heat fractionation (bone burns and liver lives) - GGT


33. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Hypertriglyceridamia and hypercholesterolemia
PMR and giant cell arteritis; can be seen both together;
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma


34. Use of antibiotic in RA
If symptoms persist >6weeks
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Measure ca and ALP; increased ALP and normal ca for dx;
Minocyclin - inhibits metalloproteases and slows joint damage


35. morning stiffness hand joints
Viral arthritis or RA
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
SLE - only minutes; RA; hours;


36. SLE patient p/w MI - vent fibrillation
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Coronary atherosclerosis due to SLE
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`


37. pain in shoulder and pelvic girdle
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
Nodular lung densitieis with RA;
Measure ESR; polymyalgia rheumatica; tx prednisone


38. What is heliotrope sign
Measure ca and ALP; increased ALP and normal ca for dx;
Erythematous-violaceous rash on the eyelids
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If person is HLA B27 positive


39. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Hyper triglyceridemia
Pseudogout/hemochromatosis;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Prednisone and cyclophosphamide


40. mcp and PIP joint involvement
Coronary atherosclerosis due to SLE
Viral arthritis or RA
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prophylactic agent to prevent recurrent attack; not given during acute attack


41. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pseudogout/hemochromatosis;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine


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


43. criteria for AS
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.


44. How often disease activity is monitored in AS?
Malignancy - infection - vertebral fracture
Hypertriglyceridamia and hypercholesterolemia
Hyperflexion of both wrists--characteristic pain in one min
Xray every 3m


45. 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
Hyper triglyceridemia
Arthritic sweling of DIP
Prophylactic agent to prevent recurrent attack; not given during acute attack


46. MCP joint involvement
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Xray every 3m
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


47. common valvular abnormalities with AS?
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
A for aortic regurg; s for prolapSe (MVP)
Early in the course of disease; methotrexate doc; if response no adequate add other dmard


48. patient pw groin pain; on steroid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Patello femoral pain syndrome
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis


49. conjunctivitis - urethritis - and spondyloarthopathy


50. Management of HTN during acute gout
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Malignancy - infection - vertebral fracture
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.