Test your basic knowledge |

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. Use of antibiotic in RA
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
Minocyclin - inhibits metalloproteases and slows joint damage
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

2. role HLA B27 in dx of ankylosing spondylitis
Measure ESR; polymyalgia rheumatica; tx prednisone
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

3. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Erythematous-violaceous rash on the eyelids
Osteoarthirit (bouchard at pip - b comes first);
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

4. Gait in spinal stenosis
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

5. Management of HTN during acute gout
Symmetrical proximal weakness; increased CPK
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
If symptoms persist >6weeks
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

6. conjunctivitis - urethritis - and spondyloarthopathy

7. probenecid
Coronary atherosclerosis due to SLE
Prophylactic agent to prevent recurrent attack; not given during acute attack
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

8. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
ESRD
Decrease urate secretion from kidney

9. tx pagets
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

10. inflammatory myositis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Increased serum ferritin (acute phase protein)
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Abx -bedrest - exercise

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
Pseudogout/hemochromatosis;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

12. schirmer test
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
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.
Measure ESR; polymyalgia rheumatica; tx prednisone
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

13. postoeriod shoulder pain
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
Minocyclin - inhibits metalloproteases and slows joint damage
If person is HLA B27 positive
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

14. How to monitor disease activity in SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Supplementation ca and vitamin D
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

15. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Hyper triglyceridemia
Prednisone and cyclophosphamide
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

16. When to order MRI in LBP
Viral arthritis or RA
If symptoms persist >6weeks
Prednisone and cyclophosphamide
Nodular lung densitieis with RA;

17. What is heliotrope sign
Pt with significant organ involvement and have incomplete response to prednisone alone
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
Erythematous-violaceous rash on the eyelids
Coronary atherosclerosis due to SLE

18. anti-mitochondrial
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Primary biliary cirrhosis
Osteoarthirit (bouchard at pip - b comes first);

19. criteria for AS
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Symmetrical proximal weakness; increased CPK

20. pain in shoulder and pelvic girdle
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Check pedal pulses; in claudication pulses should diminish
Measure ESR; polymyalgia rheumatica; tx 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

21. Tx of reiter
Abx -bedrest - exercise
Specific of dx of SLE
SLE - only minutes; RA; hours;
High incidence of opportunistitc infection; reactivation of TB;

22. phalen test
Minocyclin - inhibits metalloproteases and slows joint damage
AS; sometime only symptom is uveitis;
Hyperflexion of both wrists--characteristic pain in one min
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

23. MCP joint involvement
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Check pedal pulses; in claudication pulses should diminish
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

24. PIP joint involment
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
Osteoarthirit (bouchard at pip - b comes first);
Nodular lung densitieis with RA;
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

25. How to differentiate radicular pain with claudication
Check pedal pulses; in claudication pulses should diminish
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Osteoarthirit (bouchard at pip - b comes first);
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

26. who gets reiters syndrome after chlamydia infection
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
If person is HLA B27 positive
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
ESRD

27. mcp and PIP joint involvement
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Viral arthritis or RA
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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

28. night back pain
Malignancy - infection - vertebral fracture
Specific of dx of SLE
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

29. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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

30. Tx of gout
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
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
AS; sometime only symptom is uveitis;
Supplementation ca and vitamin D

31. allpurinol
Increased serum ferritin (acute phase protein)
Osteoarthirit (bouchard at pip - b comes first);
Prophylactic agent to prevent recurrent attack; not given during acute attack
Xray every 3m

32. xanthelasma
C for c ; crest syndrome
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
Deposition of cholesterol in the periorbital skin
Symmetrical proximal weakness; increased CPK

33. primary muscle disease
Symmetrical proximal weakness; increased CPK
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Nodular lung densitieis with RA;
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

34. How glucocorticoid leads to bone loss
Osteoarthirit (bouchard at pip - b comes first);
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

35. pagets in xray
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 ca and ALP; increased ALP and normal ca for dx;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Prophylactic agent to prevent recurrent attack; not given during acute attack

36. Ca oxalate induced arthritis
ESRD
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Viral arthritis or RA
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

37. common valvular abnormalities with AS?
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Erythematous-violaceous rash on the eyelids
A for aortic regurg; s for prolapSe (MVP)

38. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Symmetrical proximal weakness; increased CPK
C for c ; crest syndrome
Patello femoral pain syndrome

39. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Dorsum of hands and the Achilies tendon
If symptoms persist >6weeks

40. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
AS; sometime only symptom is uveitis;
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
Symmetrical proximal weakness; increased CPK

41. increased ALP; liver or bone origin?
Nodular lung densitieis with RA;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
If symptoms persist >6weeks
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

42. xanthomatous nodule
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Dorsum of hands and the Achilies tendon
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.
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

43. What marker is used to follow up disease activity in SLE
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
AS; sometime only symptom is uveitis;
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
PMR and giant cell arteritis; can be seen both together;

44. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Arthritic sweling of DIP
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

45. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Supplementation ca and vitamin D
PMR and giant cell arteritis; can be seen both together;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pt with significant organ involvement and have incomplete response to prednisone alone

46. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Increased serum ferritin (acute phase protein)
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

47. anterior shoulder pain
Nodular lung densitieis with RA;
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

48. SLE patient p/w MI - vent fibrillation
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Check pedal pulses; in claudication pulses should diminish
Coronary atherosclerosis due to SLE
PPD

49. colchicine
Check pedal pulses; in claudication pulses should diminish
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

50. cylosporin used after renal transplantation
A for aortic regurg; s for prolapSe (MVP)
Deposition of cholesterol in the periorbital skin
Erythematous-violaceous rash on the eyelids
Decrease urate secretion from kidney