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USMLE Step3 Rheumatology

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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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. Ca oxalate induced arthritis
ESRD
Increased serum ferritin (acute phase protein)
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

2. Tx of gout
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Coronary atherosclerosis due to SLE
Decrease urate secretion from kidney
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

3. inflammatory myositis
PPD
Increased serum ferritin (acute phase protein)
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

4. What should be chekcked before starting infliximab
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
A for aortic regurg; s for prolapSe (MVP)
Viral arthritis or RA
PPD

5. when SLE patient needs steroid
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;
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
Xray every 3m

6. MCP joint involvement
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

7. postoeriod shoulder pain
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Pt with significant organ involvement and have incomplete response to prednisone alone
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Malignancy - infection - vertebral fracture

8. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Decrease urate secretion from kidney
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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

9. conjunctivitis - urethritis - and spondyloarthopathy

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10. What marker is used to follow up disease activity in SLE
Hyperflexion of both wrists--characteristic pain in one min
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Increased serum ferritin (acute phase protein)
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

11. anti-ds DNA antibody
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Erythematous-violaceous rash on the eyelids
Specific of dx of SLE

12. night back pain
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Malignancy - infection - vertebral fracture
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

13. SLE with pleural effusion
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Pt with significant organ involvement and have incomplete response to prednisone alone
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Prophylactic agent to prevent recurrent attack; not given during acute attack

14. Tx of reiter
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
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
Viral arthritis or RA
Abx -bedrest - exercise

15. common valvular abnormalities with AS?
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
A for aortic regurg; s for prolapSe (MVP)

16. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
C for c ; crest syndrome
ESRD
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

17. right anterior knee pain and provoked by climbing stairs or prolong sitting
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
Patello femoral pain syndrome
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pseudogout/hemochromatosis;

18. bouchard nodule
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Deposition of cholesterol in the periorbital skin
High incidence of opportunistitc infection; reactivation of TB;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

19. mcp and PIP joint involvement
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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.
Viral arthritis or RA

20. anti-mitochondrial
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Increased serum ferritin (acute phase protein)
Primary biliary cirrhosis

21. caplan syndrom
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Pseudogout/hemochromatosis;
Nodular lung densitieis with RA;

22. nicotinic acid
Symmetrical proximal weakness; increased CPK
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hypertriglyceridamia and hypercholesterolemia
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

23. When to stop statin if cpk elevated
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
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
Prednisone and cyclophosphamide
Nodular lung densitieis with RA;

24. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
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
Arthritic sweling of DIP

25. Tx of RA
Increased serum ferritin (acute phase protein)
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pt with significant organ involvement and have incomplete response to prednisone alone

26. Tx of gout in patient with ESRD or hx GI bleeding
Hyper triglyceridemia
If person is HLA B27 positive
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

27. anti-centromere ab
SLE - only minutes; RA; hours;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
C for c ; crest syndrome

28. patient pw groin pain; on steroid
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Viral arthritis or RA
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

29. gemfibrozil
Viral arthritis or RA
Erythematous-violaceous rash on the eyelids
Check pedal pulses; in claudication pulses should diminish
Hyper triglyceridemia

30. What is heliotrope sign
C for c ; crest syndrome
PMR and giant cell arteritis; can be seen both together;
Arthritic sweling of DIP
Erythematous-violaceous rash on the eyelids

31. xanthelasma
Measure ca and ALP; increased ALP and normal ca for dx;
Osteoarthirit (bouchard at pip - b comes first);
Deposition of cholesterol in the periorbital skin
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

32. When to order MRI in LBP
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
If symptoms persist >6weeks
Viral arthritis or RA
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

33. Rayanaud's disease vs phenomenon
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
A for aortic regurg; s for prolapSe (MVP)
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

34. carpal tunnel syndrom
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Minocyclin - inhibits metalloproteases and slows joint damage
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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

35. management of LBP
Malignancy - infection - vertebral fracture
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Abx -bedrest - exercise
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

36. heberdeen nodes
Arthritic sweling of DIP
Xray every 3m
Viral arthritis or RA
AS; sometime only symptom is uveitis;

37. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
C for c ; crest syndrome

38. Tx of lupus nephritis
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Prednisone and cyclophosphamide
Order LFT - heat fractionation (bone burns and liver lives) - GGT
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

39. xanthomatous nodule
Check pedal pulses; in claudication pulses should diminish
Dorsum of hands and the Achilies tendon
SLE - only minutes; RA; hours;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

40. When to start DMARD in RA
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

41. How to prevent glucocorticoid induced bone loss
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
Supplementation ca and vitamin D
Osteoarthirit (bouchard at pip - b comes first);
High incidence of opportunistitc infection; reactivation of TB;

42. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
C for c ; crest syndrome
Prophylactic agent to prevent recurrent attack; not given during acute attack
High incidence of opportunistitc infection; reactivation of TB;

43. PIP joint involment
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Osteoarthirit (bouchard at pip - b comes first);
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
A for aortic regurg; s for prolapSe (MVP)

44. glucocorticoid therapy
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Malignancy - infection - vertebral fracture
Deposition of cholesterol in the periorbital skin
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

45. who gets reiters syndrome after chlamydia infection
Check pedal pulses; in claudication pulses should diminish
If person is HLA B27 positive
Osteoarthirit (bouchard at pip - b comes first);
ESRD

46. DIP joint involvement

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47. tx pagets
Deposition of cholesterol in the periorbital skin
Abx -bedrest - exercise
Xray every 3m
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

48. carpal tunnel
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

49. When to give methotrexate in SLE
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Check pedal pulses; in claudication pulses should diminish
Nodular lung densitieis with RA;
Pt with significant organ involvement and have incomplete response to prednisone alone

50. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Xray every 3m
Pseudogout/hemochromatosis;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

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USMLE Step3 Rheumatology

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