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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. glucocorticoid therapy
Check pedal pulses; in claudication pulses should diminish
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

2. inflamed tendons in wrist - ankle - arms; sexual history
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Order LFT - heat fractionation (bone burns and liver lives) - GGT
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Disseminated gonoccal infection

3. patient pw groin pain; on steroid
Hyperflexion of both wrists--characteristic pain in one min
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Disseminated gonoccal infection
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

4. postoeriod shoulder pain
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
C for c ; crest syndrome
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

5. Ca oxalate induced arthritis
ESRD
Dorsum of hands and the Achilies tendon
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

6. common valvular abnormalities with AS?
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Abx -bedrest - exercise
A for aortic regurg; s for prolapSe (MVP)
PMR and giant cell arteritis; can be seen both together;

7. How to differentiate radicular pain with claudication
Increased serum ferritin (acute phase protein)
Erythematous-violaceous rash on the eyelids
Check pedal pulses; in claudication pulses should diminish
Order LFT - heat fractionation (bone burns and liver lives) - GGT

8. mcp and PIP joint involvement
C for c ; crest syndrome
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Deposition of cholesterol in the periorbital skin
Viral arthritis or RA

9. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
If person is HLA B27 positive
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.
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

10. carpal tunnel syndrom
AS; sometime only symptom is uveitis;
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.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

11. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
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
Prophylactic agent to prevent recurrent attack; not given during acute attack
PMR and giant cell arteritis; can be seen both together;

12. PIP joint involment
SLE - only minutes; RA; hours;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Increased serum ferritin (acute phase protein)
Osteoarthirit (bouchard at pip - b comes first);

13. Tx of gout in patient with ESRD or hx GI bleeding
Nodular lung densitieis with RA;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Coronary atherosclerosis due to SLE

14. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
AS; sometime only symptom is uveitis;

15. caplan syndrom
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Disseminated gonoccal infection
Nodular lung densitieis with RA;
Decrease urate secretion from kidney

16. DIP joint involvement

17. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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

18. schirmer test
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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.
Check pedal pulses; in claudication pulses should diminish

19. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hyperflexion of both wrists--characteristic pain in one min
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
If symptoms persist >6weeks

20. pain in shoulder and pelvic girdle
Minocyclin - inhibits metalloproteases and slows joint damage
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
Decrease urate secretion from kidney

21. heberdeen nodes
Pt with significant organ involvement and have incomplete response to prednisone alone
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Arthritic sweling of DIP
Malignancy - infection - vertebral fracture

22. How to prevent glucocorticoid induced bone loss
Deposition of cholesterol in the periorbital skin
Supplementation ca and vitamin D
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
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

23. tinel sign
Symmetrical proximal weakness; increased CPK
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
Hyper triglyceridemia
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

24. Raynauds phenomenon
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If symptoms persist >6weeks
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

25. role HLA B27 in dx of ankylosing spondylitis
Prednisone and cyclophosphamide
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
Patello femoral pain syndrome

26. conjunctivitis - urethritis - and spondyloarthopathy

27. pagets in xray
If person is HLA B27 positive
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Measure ca and ALP; increased ALP and normal ca for dx;
Malignancy - infection - vertebral fracture

28. anti-centromere ab
C for c ; crest syndrome
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Specific of dx of SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

29. Use of allopurinol after kidney transplant
Symmetrical proximal weakness; increased CPK
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

30. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Supplementation ca and vitamin D

31. How glucocorticoid leads to bone loss
C for c ; crest syndrome
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

32. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
PMR and giant cell arteritis; can be seen both together;
Decrease urate secretion from kidney
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

33. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Measure ca and ALP; increased ALP and normal ca for dx;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Prednisone and cyclophosphamide

34. SLE with pleural effusion
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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

35. primary muscle disease
Symmetrical proximal weakness; increased CPK
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Nodular lung densitieis with RA;
AS; sometime only symptom is uveitis;

36. What marker is used to follow up disease activity in SLE
High incidence of opportunistitc infection; reactivation of TB;
Coronary atherosclerosis due to SLE
Measure ESR; polymyalgia rheumatica; tx prednisone
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

37. What should be chekcked before starting infliximab
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
PPD
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

38. When to stop statin if cpk elevated
ESRD
Osteoarthirit (bouchard at pip - b comes first);
Primary biliary cirrhosis
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

39. 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
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Hyper triglyceridemia

40. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Coronary atherosclerosis due to SLE
AS; sometime only symptom is uveitis;
Arthritic sweling of DIP

41. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
PMR and giant cell arteritis; can be seen both together;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hypertriglyceridamia and hypercholesterolemia

42. anterior shoulder pain
Hyper triglyceridemia
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Abx -bedrest - exercise

43. morning stiffness hand joints
Primary biliary cirrhosis
SLE - only minutes; RA; hours;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

44. How to perform schober test
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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

45. anti-mitochondrial
Primary biliary cirrhosis
PMR and giant cell arteritis; can be seen both together;
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

46. Tx of gout
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

47. MCP joint involvement
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Erythematous-violaceous rash on the eyelids
Specific of dx of SLE

48. How often disease activity is monitored in AS?
C for c ; crest syndrome
Xray every 3m
Dorsum of hands and the Achilies tendon
Primary biliary cirrhosis

49. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Coronary atherosclerosis due to SLE
Decrease urate secretion from kidney
Disseminated gonoccal infection

50. bouchard nodule
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Nodular lung densitieis with RA;
Measure ESR; polymyalgia rheumatica; tx prednisone