Usmle Step 2: Rheumatology Qbank

Front 1

progressive anterior hip pain in 40yo

Back 1

osteoarthritis!

exacerbated by walking and relieved by rest. Common presentation. morning stiffness or stiffness after porlonged resting is a consistent feature, but in contrast to RA, the morning stiffness lasts less than 30-60min.

active and passive internal and external rotationo f the hip is limited on exam!

Front 2

Charcot's joint

Back 2

complication of neuropathy! and repeated joint trauma.

affects weight bearing joints and manifests with functional limitation, deformity, and degenerative joint dz and loose bodies on joint imaging

Front 3

lateral epicondylitis

Back 3

aka tennis elbow -> manifests as pain with supination or extension of the wrist and point tenderness just distal to the lateral epicondyle.

Front 4

ankylosing spondylitis confirmation?

Back 4

plain film xray demonstrating fused SI joints and/or bamboo spine

pts often complain of morning stiffness lasting > 30min, with back pain typically improving with exercise.

decreased lumbar spinal mobility and tenderness over the SI joints are common exam findings.

involves primarily the APOPHYSEAL (facet) joints of the axial skeleton.

Front 5

hyperparathyroidism as cause of pseudogout

Back 5

elevated Ca levels and low phosphorus on exam!

with elevated calcium, look for constipation, fatigue, and excessive urination.

also causes abdominal pain, urinary stones, mental status changes, and osteoporosis (bones, groans, psychiatric moans)

pseudogout often affects the knee! (vs gout which affects first metatarsal)

Front 6

paget's disease

Back 6

osteoclast dysfunction (accelerated and disordered osteoclastic bone resorption of unclear etiology)! aka osteitis deformans!

resulting in mosaic pattern of lamellar bone, increased alkphos, characteristic xray findings like femoral bowing.

bone and joint pain, skeletal deformities and HEARING LOSS is common

OFTEN ASYMPTOMATIC, with dx made incidentally by finding an isolated elevated alk phos on routine lab testing (can also have elevated hydroxyproline -> urinary marker of bone degradation)

Front 7

tenderness to gentle percussion over spinous process

Back 7

most reliably spinal osteomyelitis, pain not relieved with rest, fever and leukocytosis are unreliable findings

esr grossly elevated.

MRI most sensitive study

very high index of suspicion for vertebral osteomyelitis should be present for pts with h/o injection drug use or recent distant site infection (eg UTI)

Front 8

cervical spondylosis

Back 8

h/o chronic neck pain

limited neck rotation and lateral bending due to osteoarthritis and secondary muscle spasm.

typical radiographic findings include bony spurs and sclerotic facet joints, but specificity of these findings is low

Front 9

reactive arthritis vs gonococcal arthritis

Back 9

Reactive arthritis: seronegative spondyloarthropathy resulting from enteric or genitourinary infection. Findings in reactive arthritis may include urethritis, conjunctivitis, mucocutaneous lesions, enthesitis, and asymmetric oligoarthritis.

NSAIDs first line therapy


gonococcal: look for fever

Front 10

dermatomyositis at risk for what?

Back 10

internal malignancy (over 10%), most commonly ovarian CA

Front 11

polymyalgia rheumatica

Back 11

look for elevated ESR, sx improvement with steroids, age >50

Front 12

viral arthritis

Back 12

can p/w symmetric small joint inflammatory arthritis.

distinguished from other causes of symmetric inflammatory arthritis by the fact that it tends to resolve within two mo. Positive inflammatory markers such as ANA and RF may occur.

can be swollen, but doesn't have to be

Tx involves NSAIDs for resolution of sx.

Antiviral therapy unnecessary since this is self-limited

Front 13

compression fx

Back 13

intense, focal vertebral pain w/o neuro sx

almost alway soccur when VERTEBRAL BODY DEMINERALIZATION is present, which occurs in osteomalacia, where inadequate serum vitD, Ca, and phos results in demineralized osteoid.

also occurs in osteoporosis, a condition where bone mineral density is decreased and the bone's microarchitecture is disrupted. Pathologic fx can occur in either condition.

systemic sx also include pulmonary dz! result from fusion of the costovertebral joints resulting in CHEST WALL MOTION RESTRICTION and a restrictive pattern on pulm function testing

Front 14

anklyosing spondylitis

Back 14

most often in adults 20-30

most prominent extraarticular manifestation of AS is anterior uveitis!! (occurs in 25-40%)

strong a/w HLA-B27

definitively diagnosed in a pt with sx of AS and bilateral sacroiliitis on plain film.

increased risk of VERTEBRAL FX due to decreased bone mineral density -> may occur with minimal trauma; therefore, clinical suspicion should be high!

Front 15

lumbar spinal stenosis vs lumbar disk herniation

Back 15

lumbar spinal stenosis is characterized by back pain radiating to the buttocks and thighs that interferes with walking and lumbar extension

spinal canal narrowed, resulting in compression of one or more spinal roots -> enlarging osteophytes at facet joints and hypertrophy of ligamentum flavum

sx typically worse during walking and lymbar extension, while lumbar flexion alleviates the sx

lumbar disk herniation: acute onset of back pain with or without radiation down one leg. pts usually recall an inciting event. lumbar flexion and sitting will make pain WORSE

Front 16

de quervain tenosynovitis

Back 16

classically affects new mothers who hold their infants with the thumb outstretched (abducted/extended). The abductor pollicus longus and extensor pollicis brevis tendons are affected; passive stretch of these tendons elicits pain.

Front 17

patients with RA at most risk for developing ___

Back 17

osteopenia, osteoporosis, and bone fx

mgmt includes adequate physical activity, optimization of ca and vitd intake, minimization of corticosteroid therapy, and consideration for bisphosphonate tx

Front 18

avascular necrosis more common in what conditions

Back 18

systemic corticosteroid therapy, heavy alcohol use, SLE, and sickle cell

Front 19

lumbosacral strain

Back 19

acute onset of back pain after physical exertion, absence of radiation, presence of paravertebral tenderness, negative straight leg raising test, and nl neuro exam

Front 20

fibromyalgia tx

Back 20

amitryptiline, pregabalin, duloxetine, and milnacipran

but first try exercise program with aerobic conditioning!!!

Front 21

prevention of tumor lysis syndrome

Back 21

allopurinol AND probenecid, rasburicase, adequate hydration

Front 22

Osgood-schlatter disease

Back 22

typically preadolescent/adolescent with recent growth spurt, episodic pain, tenderness at tibial tubercle

Front 23

polymyositis

Back 23

can be isolated SLOWLY progressive proximal weakness of lower extremities characterized by difficulty ascending and descending stairs or rising froma seated position. usually progresses over hte course of years; acute presentation atypical

Front 24

most appropriate next step in mgmt with new onset SLE p/w elevated creatinine

Back 24

kidney bx, since mgmt relies on the class of lupus nephritis

immunosuppressive therapy may be given once lupus nephritis is classified

Front 25

QID 3322

Back 25

answer!

Front 26

bone deformities in OA, RA, and SLE, and psoriatic arthritis

Back 26

OA: osteophytes, cartilate degradation

RA: subluxaiton of the cervical vertebrae and tendon damage in hands

SLE: NO permanent deformity

psoriatic arthritis: bone resorption (leading to classic pencil in cup deformity)

Front 27

typical SLE

Back 27

african american woman aged 20-40

systemic manifestations: fatigue, fever, weight loss, nondeforming arthritis, oral ulcers!!, serositis, hematologic abnl, proteinuria, and rash

greater than 90% have arthritis, most commonly affecting the MCP and PIP joints of the hands

Front 28

sarcoidosis

Back 28

typically AA during third and fourth decades of life. lungs most commonly affected organ system.

when symptomatic, cough, erythema nodosum, anterior uveitis, adn arthritis may be seen. Hilar adenopathy and reticular opacities on Cxr are classic findings

Front 29

well known complication of giant cell or temporal arteritis

Back 29

aortic aneurysms

Front 30

six classic criteria used to establish the dx of OA

Back 30

age > 50, minimal or no morning stiffness, bony tenderness, bony enlargement, crepitus on active motion and no warmth of joint

Front 31

calcinosis cutis

Back 31

CREST syndrome

refers to localized dystrophic deposition of Ca in the skin and manifests as subcutaneous pink-to white nodules typically on the upper extremities

Front 32

pain on palpation of vertebrae

Back 32

suggestive of spinal infection or possibly lytic lesion in the spine

initial test of choice is plain films. if not diagnostic, then MRI or CT scan to evaluate for possible disc disease, CA, and spinal infections.

Front 33

which part of the spine most commonly affected in RA?

Back 33

cervical spine -> spinal subluxation and spinal cord compression

Front 34

know difference between negative and positive birefringence

Back 34

negative: gout

positive: pseudogout

Front 35

adhesive capsulitis vs rotator cuff impingement

Back 35

adhesive capsulitis (aka frozen shoulde) -> idiopathic condition characterized by pain and contracture -> p/w inability to lift arm above the head. even after injection of lidocaine, the arm still cannot be lifted above the head d/t fibrosis of the shoulder capsule

rotator cuff impingement -> pain and limition of motion resolved with lidocaine

Front 36

features of low back pain that suggest an inflammatory cause

Back 36

gradual onset of pain, onset at age < 40, pain at night that does not improve with rest, and improvement in pain with activity or exercise

this includes anklyosing spondylitis, psoriatic arthritis, reactive arthritis, or arthritis a/w inflammatory bowel dz

Front 37

imaging findings of gouty arthritis, RA, infectious arthritis, and pseudogout, and OA

Back 37

gouty arthritis: punched out erostions with a rim of cortical bone

RA: periarticular osteopenia and joint margin erosions

infectious arthritis; normal joint space with soft tissue swelling

pseudogout: calcification of cartilaginous structures

OA: joint space narrowing and osteophytes

Front 38

disseminated gonococcal arthritis

Back 38

high fever, chills, tenosynovitis, migratory polyarthralgias and a small number of pustular lesions on the extremities

routine blood and pustule cx are typically neg due to the growth requirements of the organism

Front 39

behcet's

Back 39

multi-systemic inflammatory condition characterized by recurrent oral and genital ulcers, skin lesions; seen most commonly in the turkish, asian, and middle eastern population

Front 40

subacromial bursitis

Back 40

result of repetitive overhead motions. Patients c/o pain with active ROM of the shoulder, and passive internal rotation and forward flexion at the shoulder also elicits tenderness.

Front 41

common side effects of MTX in setting of RA

Back 41

GI sx, oral ulcers or stomatitis, rash, alopecia, hepatotoxicity, pulmonary toxicity, and bone marrow suppression

Front 42

pathogenesis of carpal tunnel syndrome

Back 42

deposition of mucopolysaccharide protein complexes within the perineurium and endoneurium of the median nerve is thought to be primarily responsible for its pathogenesis

Front 43

crystal induced vs gonococcal arthritis

Back 43

crystal: wbc 10-50k

gonococcal: young, sexually active, wbc greater than 50k

can present in one of two ways: as an asymmetric polyarthritis a/w tenosynovitis and skin rash) or as an isolated purulent arthritis afffecting one or a few joints.

Front 44

enthesitis

Back 44

inflammation and pain occuring at the site of tendon and ligament attachment to bone -> common finding in ankylosing spondylitis.

typical sites include the heels, tibial tuberosities and iliac crests

Front 45

first treatment for OA

Back 45

tylenol! (remember that it is a noninflammatory arthritis, so NSAIDs don't necessarily provide greater benefit)

Front 46

baker cyst

Back 46

develop as a result of excessive fluid production by an INFLAMED SYNOVIUM, as occurs in cases of RA, OA, and cartilage tears

excess fluid accumulates in the popliteal bursa which expands, creating a tender mass in the popliteal fossa. Baker cysts occasionally burst and release their contents into the calf, resulting in an appearance similar to a DVT.

Front 47

RA pt with prednisone developing hip pain. next step?

Back 47

corticosteroid induced avascular necrosis of the femoral head usually presents as progressive hip or groin pain w/o restricton of motion range and nl radiograph on early stages

MRI gold standard for dx

Front 48

side effect of cyclophosphamide

Back 48

acute hemorrhagic cystitis and bladder carcinoma

Front 49

disseminated gonococcal infxn

Back 49

triad of polyarthralgias, tenosynovitis, and vesiculopustular lesions.