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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. anti-mitochondrial
PMR and giant cell arteritis; can be seen both together;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Primary biliary cirrhosis

2. schirmer test
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
Osteoarthirit (bouchard at pip - b comes first);
Disseminated gonoccal infection
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.

3. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
SLE - only minutes; RA; hours;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

4. Rayanaud's disease vs phenomenon
PPD
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Measure ESR; polymyalgia rheumatica; tx prednisone

5. DIP joint involvement

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6. tinel sign
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
SLE - only minutes; RA; hours;

7. common valvular abnormalities with AS?
Hyper triglyceridemia
PMR and giant cell arteritis; can be seen both together;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
A for aortic regurg; s for prolapSe (MVP)

8. Finding of MRI in stenosis
Specific of dx of SLE
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

9. Ca oxalate induced arthritis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Specific of dx of SLE
ESRD
AS; sometime only symptom is uveitis;

10. who gets reiters syndrome after chlamydia infection
Hyper triglyceridemia
Measure ca and ALP; increased ALP and normal ca for dx;
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
If person is HLA B27 positive

11. 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
Osteoarthirit (bouchard at pip - b comes first);
C for c ; crest syndrome
Pseudogout/hemochromatosis;

12. anti-ds DNA antibody
High incidence of opportunistitc infection; reactivation of TB;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Specific of dx of SLE

13. Tx of inflammatory myositis
If symptoms persist >6weeks
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

14. carpal tunnel
Coronary atherosclerosis due to SLE
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

15. When to start DMARD in RA
Increased serum ferritin (acute phase protein)
If person is HLA B27 positive
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

16. What is heliotrope sign
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Erythematous-violaceous rash on the eyelids
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Measure ESR; polymyalgia rheumatica; tx prednisone

17. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Hypertriglyceridamia and hypercholesterolemia
Patello femoral pain syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

18. Low back pain
Xray every 3m
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Abx -bedrest - exercise
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

19. What should be chekcked before starting infliximab
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
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
PPD
Check pedal pulses; in claudication pulses should diminish

20. 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.
Decrease urate secretion from kidney
Minocyclin - inhibits metalloproteases and slows joint damage
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

21. Use of allopurinol after kidney transplant
Malignancy - infection - vertebral fracture
If person is HLA B27 positive
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

22. How to differentiate radicular pain with claudication
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Malignancy - infection - vertebral fracture
Check pedal pulses; in claudication pulses should diminish
Deposition of cholesterol in the periorbital skin

23. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
If person is HLA B27 positive
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Hyperflexion of both wrists--characteristic pain in one min

24. pagets in xray
Patello femoral pain syndrome
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ca and ALP; increased ALP and normal ca for dx;

25. nicotinic acid
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
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Hypertriglyceridamia and hypercholesterolemia

26. gemfibrozil
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Hyperflexion of both wrists--characteristic pain in one min
Hyper triglyceridemia

27. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
C for c ; crest syndrome
Order LFT - heat fractionation (bone burns and liver lives) - GGT
AS; sometime only symptom is uveitis;

28. inflamed tendons in wrist - ankle - arms; sexual history
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Disseminated gonoccal infection
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

29. Management of HTN during acute gout
Hypertriglyceridamia and hypercholesterolemia
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

30. bouchard nodule
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
Decrease urate secretion from kidney
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

31. Tx of gout in patient with ESRD or hx GI bleeding
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
Malignancy - infection - vertebral fracture
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Xray every 3m

32. right anterior knee pain and provoked by climbing stairs or prolong sitting
AS; sometime only symptom is uveitis;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Patello femoral pain syndrome

33. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
ESRD
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

34. Tx of reiter
Malignancy - infection - vertebral fracture
Xray every 3m
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
Abx -bedrest - exercise

35. mcp and PIP joint involvement
Measure ESR; polymyalgia rheumatica; tx prednisone
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

36. patient is having pain when he moves hands above shoulder
Abx -bedrest - exercise
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Nodular lung densitieis with RA;

37. PIP joint involment
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Arthritic sweling of DIP
Osteoarthirit (bouchard at pip - b comes first);

38. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Nodular lung densitieis with RA;
Disseminated gonoccal infection
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pseudogout/hemochromatosis;

39. Tx of RA
PMR and giant cell arteritis; can be seen both together;
SLE - only minutes; RA; hours;
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

40. How often disease activity is monitored in AS?
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Hyper triglyceridemia
Xray every 3m
Coronary atherosclerosis due to SLE

41. inflammatory myositis
Increased serum ferritin (acute phase protein)
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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

42. probenecid
Coronary atherosclerosis due to SLE
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

43. When to order MRI in LBP
Minocyclin - inhibits metalloproteases and slows joint damage
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If symptoms persist >6weeks
Supplementation ca and vitamin D

44. Use of antibiotic in RA
Hyper triglyceridemia
Minocyclin - inhibits metalloproteases and slows joint damage
C for c ; crest syndrome
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

45. Tx of lupus nephritis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
If person is HLA B27 positive
Prednisone and cyclophosphamide
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

46. heberdeen nodes
Xray every 3m
Arthritic sweling of DIP
Pt with significant organ involvement and have incomplete response to prednisone alone
Hyperflexion of both wrists--characteristic pain in one min

47. xanthelasma
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.
Pt with significant organ involvement and have incomplete response to prednisone alone
Deposition of cholesterol in the periorbital skin
If symptoms persist >6weeks

48. complications of anti-cytokine therapy
Symmetrical proximal weakness; increased CPK
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
High incidence of opportunistitc infection; reactivation of TB;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

49. SLE patient p/w MI - vent fibrillation
Nodular lung densitieis with RA;
Coronary atherosclerosis due to SLE
Check pedal pulses; in claudication pulses should diminish
Viral arthritis or RA

50. spondyloarthopathy
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine