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USMLE Step3 Rheumatology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
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. when SLE patient needs steroid
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

2. spondyloarthopathy
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

3. complications of anti-cytokine therapy
High incidence of opportunistitc infection; reactivation of TB;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
C for c ; crest syndrome
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

4. cylosporin used after renal transplantation
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Symmetrical proximal weakness; increased CPK
Decrease urate secretion from kidney
Abx -bedrest - exercise

5. who gets reiters syndrome after chlamydia infection
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
If person is HLA B27 positive

6. What marker is used to follow up disease activity in SLE
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Symmetrical proximal weakness; increased CPK
PPD

7. Management of HTN during acute gout
Osteoarthirit (bouchard at pip - b comes first);
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

8. Raynauds phenomenon
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Disseminated gonoccal infection

9. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

10. Tx of reiter
Abx -bedrest - exercise
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Prophylactic agent to prevent recurrent attack; not given during acute attack
If symptoms persist >6weeks

11. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Symmetrical proximal weakness; increased CPK
Nodular lung densitieis with RA;
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

12. Tx of RA
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
Malignancy - infection - vertebral fracture

13. How to perform schober test
C for c ; crest syndrome
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
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

14. anti-ds DNA antibody
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Specific of dx of SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

15. primary muscle disease
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
C for c ; crest syndrome
Symmetrical proximal weakness; increased CPK

16. inflammatory myositis
If person is HLA B27 positive
Increased serum ferritin (acute phase protein)
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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

17. PIP joint involment
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
Malignancy - infection - vertebral fracture
Osteoarthirit (bouchard at pip - b comes first);

18. postoeriod shoulder pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Arthritic sweling of DIP
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Symmetrical proximal weakness; increased CPK

19. probenecid
Pseudogout/hemochromatosis;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

20. xanthelasma
A for aortic regurg; s for prolapSe (MVP)
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Deposition of cholesterol in the periorbital skin
Increased serum ferritin (acute phase protein)

21. night back pain
Malignancy - infection - vertebral fracture
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
PPD

22. conjunctivitis - urethritis - and spondyloarthopathy

23. anti-mitochondrial
Xray every 3m
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
Primary biliary cirrhosis
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

24. mcp and PIP joint involvement
Viral arthritis or RA
Patello femoral pain syndrome
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

25. 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.
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

26. management of LBP
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Disseminated gonoccal infection
Decrease urate secretion from kidney

27. caplan syndrom
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Coronary atherosclerosis due to SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Nodular lung densitieis with RA;

28. What is heliotrope sign
Coronary atherosclerosis due to SLE
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Erythematous-violaceous rash on the eyelids
Disseminated gonoccal infection

29. painless ulcer over glans penis and inflammatory arthritis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Osteoarthirit (bouchard at pip - b comes first);

30. pain in shoulder and pelvic girdle
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
Measure ESR; polymyalgia rheumatica; tx prednisone
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

31. 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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Arthritic sweling of DIP
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

32. criteria for AS
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

33. When to give methotrexate in SLE
Deposition of cholesterol in the periorbital skin
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Pt with significant organ involvement and have incomplete response to prednisone alone
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

34. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Erythematous-violaceous rash on the eyelids
Decrease urate secretion from kidney

35. How glucocorticoid leads to bone loss
If person is HLA B27 positive
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Hyperflexion of both wrists--characteristic pain in one min
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

36. anti-centromere ab
C for c ; crest syndrome
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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

37. role HLA B27 in dx of ankylosing spondylitis
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Prednisone and cyclophosphamide
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

38. Tx of 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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Abx -bedrest - exercise
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

39. bouchard nodule
Measure ca and ALP; increased ALP and normal ca for dx;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hyperflexion of both wrists--characteristic pain in one min
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. Finding of MRI in stenosis
Symmetrical proximal weakness; increased CPK
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

41. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
High incidence of opportunistitc infection; reactivation of TB;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Supplementation ca and vitamin D

42. 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.
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
Xray every 3m
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

43. Rayanaud's disease vs phenomenon
Nodular lung densitieis with RA;
Viral arthritis or RA
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

44. glucocorticoid therapy
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Deposition of cholesterol in the periorbital skin
Hypertriglyceridamia and hypercholesterolemia
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

45. allpurinol
Measure ca and ALP; increased ALP and normal ca for dx;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Coronary atherosclerosis due to SLE
Prophylactic agent to prevent recurrent attack; not given during acute attack

46. patient is having pain when he moves hands above shoulder
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
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

47. When to start DMARD in RA
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Measure ESR; polymyalgia rheumatica; tx prednisone
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

48. Use of allopurinol after kidney transplant
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Hyperflexion of both wrists--characteristic pain in one min

49. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Malignancy - infection - vertebral fracture
PMR and giant cell arteritis; can be seen both together;

50. nicotinic acid
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
Hypertriglyceridamia and hypercholesterolemia
Xray every 3m
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA