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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. inflammatory myositis
Hypertriglyceridamia and hypercholesterolemia
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
Increased serum ferritin (acute phase protein)
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

2. 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
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

3. probenecid
SLE - only minutes; RA; hours;
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

4. complications of anti-cytokine therapy
Hypertriglyceridamia and hypercholesterolemia
High incidence of opportunistitc infection; reactivation of TB;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
If person is HLA B27 positive

5. tinel sign
Increased serum ferritin (acute phase protein)
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
C for c ; crest syndrome
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

6. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dorsum of hands and the Achilies tendon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
C for c ; crest syndrome

7. When to order MRI in LBP
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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 symptoms persist >6weeks
AS; sometime only symptom is uveitis;

8. Tx of lupus nephritis
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
Prednisone and cyclophosphamide
Dorsum of hands and the Achilies tendon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

9. glucocorticoid therapy
Supplementation ca and vitamin D
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Osteoarthirit (bouchard at pip - b comes first);

10. who gets reiters syndrome after chlamydia infection
Disseminated gonoccal infection
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If person is HLA B27 positive

11. gemfibrozil
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Hyper triglyceridemia
Increased serum ferritin (acute phase protein)
PPD

12. primary muscle disease
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Symmetrical proximal weakness; increased CPK
Measure ca and ALP; increased ALP and normal ca for dx;
Disseminated gonoccal infection

13. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
If symptoms persist >6weeks
Nodular lung densitieis with RA;

14. PIP joint involment
Supplementation ca and vitamin D
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
C for c ; crest syndrome
Osteoarthirit (bouchard at pip - b comes first);

15. How glucocorticoid leads to bone loss
Disseminated gonoccal infection
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;
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

16. Management of HTN during acute gout
Supplementation ca and vitamin D
Dorsum of hands and the Achilies tendon
High incidence of opportunistitc infection; reactivation of TB;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

17. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
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
Symmetrical proximal weakness; increased CPK
Primary biliary cirrhosis

18. Low back pain
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.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Prophylactic agent to prevent recurrent attack; not given during acute attack
SLE - only minutes; RA; hours;

19. neck mass in sjogren patient
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
AS; sometime only symptom is uveitis;
A for aortic regurg; s for prolapSe (MVP)

20. How to perform schober test
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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;

21. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Dorsum of hands and the Achilies tendon
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

22. anti-centromere ab
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Measure ca and ALP; increased ALP and normal ca for dx;
C for c ; crest syndrome
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

23. Finding of MRI in stenosis
Pt with significant organ involvement and have incomplete response to prednisone alone
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

24. heberdeen nodes
Arthritic sweling of DIP
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

25. inflamed tendons in wrist - ankle - arms; sexual history
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
Disseminated gonoccal infection
Malignancy - infection - vertebral fracture

26. What should be chekcked before starting infliximab
PPD
Dorsum of hands and the Achilies tendon
Prophylactic agent to prevent recurrent attack; not given during acute attack
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

27. right anterior knee pain and provoked by climbing stairs or prolong sitting
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Pt with significant organ involvement and have incomplete response to prednisone alone
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Patello femoral pain syndrome

28. role HLA B27 in dx of ankylosing spondylitis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pt with significant organ involvement and have incomplete response to prednisone alone
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

29. Ca oxalate induced arthritis
Hyperflexion of both wrists--characteristic pain in one min
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
If person is HLA B27 positive
ESRD

30. cylosporin used after renal transplantation
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
Decrease urate secretion from kidney
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

31. carpal tunnel
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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

32. carpal tunnel syndrom
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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

33. postoeriod shoulder pain
ESRD
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

34. xanthelasma
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Increased serum ferritin (acute phase protein)
Measure ESR; polymyalgia rheumatica; tx prednisone
Deposition of cholesterol in the periorbital skin

35. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Dorsum of hands and the Achilies tendon
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

36. SLE with pleural effusion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pt with significant organ involvement and have incomplete response to prednisone alone
Pseudogout/hemochromatosis;

37. anterior shoulder pain
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

38. Use of antibiotic in RA
If symptoms persist >6weeks
If person is HLA B27 positive
Viral arthritis or RA
Minocyclin - inhibits metalloproteases and slows joint damage

39. Tx of gout in patient with ESRD or hx GI bleeding
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
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
Measure ESR; polymyalgia rheumatica; tx prednisone

40. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
High incidence of opportunistitc infection; reactivation of TB;
Xray every 3m
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

41. anti-ds DNA antibody
PMR and giant cell arteritis; can be seen both together;
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
Specific of dx of SLE

42. Tx of gout
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If person is HLA B27 positive
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

43. colchicine
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Prednisone and cyclophosphamide
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Symmetrical proximal weakness; increased CPK

44. common valvular abnormalities with AS?
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
A for aortic regurg; s for prolapSe (MVP)
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

45. painless ulcer over glans penis and inflammatory arthritis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Viral arthritis or RA

46. When to stop statin if cpk elevated
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Dorsum of hands and the Achilies tendon
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

47. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw 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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
PMR and giant cell arteritis; can be seen both together;
If symptoms persist >6weeks

48. Tx of inflammatory myositis
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.
ESRD
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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

49. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Symmetrical proximal weakness; increased CPK
If person is HLA B27 positive

50. anti-mitochondrial
Primary biliary cirrhosis
PMR and giant cell arteritis; can be seen both together;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA