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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. Management of HTN during acute gout
Viral arthritis or RA
A for aortic regurg; s for prolapSe (MVP)
Check pedal pulses; in claudication pulses should diminish
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

2. Use of antibiotic in 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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Erythematous-violaceous rash on the eyelids
Minocyclin - inhibits metalloproteases and slows joint damage

3. SLE patient p/w MI - vent fibrillation
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
Xray every 3m
Check pedal pulses; in claudication pulses should diminish

4. How often disease activity is monitored in AS?
Coronary atherosclerosis due to SLE
Abx -bedrest - exercise
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

5. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Patello femoral pain syndrome
Coronary atherosclerosis due to SLE

6. Tx of gout in patient with ESRD or hx GI bleeding
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
Hyperflexion of both wrists--characteristic pain in one min
A for aortic regurg; s for prolapSe (MVP)
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

7. cylosporin used after renal transplantation
Check pedal pulses; in claudication pulses should diminish
Decrease urate secretion from kidney
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

8. Low back pain
PMR and giant cell arteritis; can be seen both together;
Minocyclin - inhibits metalloproteases and slows joint damage
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;

9. tx pagets
If symptoms persist >6weeks
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

10. inflammatory myositis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Increased serum ferritin (acute phase protein)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

11. pagets in xray
If person is HLA B27 positive
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Measure ca and ALP; increased ALP and normal ca for dx;
Coronary atherosclerosis due to SLE

12. management of LBP
If person is HLA B27 positive
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

13. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Symmetrical proximal weakness; increased CPK
Pseudogout/hemochromatosis;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

14. morning stiffness hand joints
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hyperflexion of both wrists--characteristic pain in one min
Minocyclin - inhibits metalloproteases and slows joint damage
SLE - only minutes; RA; hours;

15. schirmer test
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Osteoarthirit (bouchard at pip - b comes first);
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.
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

16. anti-mitochondrial
Primary biliary cirrhosis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Hyper triglyceridemia
Malignancy - infection - vertebral fracture

17. Gait in spinal stenosis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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;

18. gemfibrozil
Hyper triglyceridemia
Erythematous-violaceous rash on the eyelids
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Osteoarthirit (bouchard at pip - b comes first);

19. What marker is used to follow up disease activity in SLE
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
If person is HLA B27 positive

20. patient pw groin pain; on steroid
Pseudogout/hemochromatosis;
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Coronary atherosclerosis due to SLE

21. pain in shoulder and pelvic girdle
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Measure ESR; polymyalgia rheumatica; tx prednisone
A for aortic regurg; s for prolapSe (MVP)

22. bouchard nodule
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

23. How to prevent glucocorticoid induced bone loss
Hyper triglyceridemia
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
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Supplementation ca and vitamin D

24. caplan syndrom
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Nodular lung densitieis with RA;
If symptoms persist >6weeks
Abx -bedrest - exercise

25. spondyloarthopathy
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

26. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Erythematous-violaceous rash on the eyelids
Disseminated gonoccal infection
Specific of dx of SLE

27. Ca oxalate induced arthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
SLE - only minutes; RA; hours;
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
ESRD

28. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
C for c ; crest syndrome
Arthritic sweling of DIP
Pseudogout/hemochromatosis;

29. anti-ds DNA antibody
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;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Specific of dx of SLE

30. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Supplementation ca and vitamin D
Coronary atherosclerosis due to SLE
Malignancy - infection - vertebral fracture

31. Tx of lupus nephritis
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
High incidence of opportunistitc infection; reactivation of TB;

32. How glucocorticoid leads to bone loss
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

33. Tx of gout
Disseminated gonoccal infection
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Decrease urate secretion from kidney
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

34. What should be chekcked before starting infliximab
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
PPD
Viral arthritis or RA
Deposition of cholesterol in the periorbital skin

35. mcp and PIP joint involvement
Supplementation ca and vitamin D
Minocyclin - inhibits metalloproteases and slows joint damage
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Viral arthritis or RA

36. right anterior knee pain and provoked by climbing stairs or prolong sitting
Decrease urate secretion from kidney
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Patello femoral pain syndrome
Disseminated gonoccal infection

37. role HLA B27 in dx of ankylosing spondylitis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

38. inflamed tendons in wrist - ankle - arms; sexual history
Increased serum ferritin (acute phase protein)
Arthritic sweling of DIP
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Disseminated gonoccal infection

39. When to order MRI in LBP
If symptoms persist >6weeks
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

40. common valvular abnormalities with AS?
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Check pedal pulses; in claudication pulses should diminish
A for aortic regurg; s for prolapSe (MVP)
Deposition of cholesterol in the periorbital skin

41. Use of allopurinol after kidney transplant
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Supplementation ca and vitamin D
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

42. anterior shoulder pain
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
Deposition of cholesterol in the periorbital skin
Primary biliary cirrhosis
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

43. carpal tunnel syndrom
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Think about reiter (cannot see - cannot pee - cannot climb a tree)
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Osteoarthirit (bouchard at pip - b comes first);

44. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Supplementation ca and vitamin D
AS; sometime only symptom is uveitis;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Viral arthritis or RA

45. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Check pedal pulses; in claudication pulses should diminish
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
Supplementation ca and vitamin D

46. anti-centromere ab
AS; sometime only symptom is uveitis;
Decrease urate secretion from kidney
C for c ; crest syndrome
High incidence of opportunistitc infection; reactivation of TB;

47. Finding of MRI in stenosis
Patello femoral pain syndrome
Xray every 3m
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hypertriglyceridamia and hypercholesterolemia

48. nicotinic acid
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Hypertriglyceridamia and hypercholesterolemia

49. When to start DMARD in RA
Dorsum of hands and the Achilies tendon
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
PPD
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

50. tinel sign
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Pseudogout/hemochromatosis;
If person is HLA B27 positive
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel