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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-centromere ab
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
C for c ; crest syndrome
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

2. schirmer test
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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
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.
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

3. caplan syndrom
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
Nodular lung densitieis with RA;
PPD
Prophylactic agent to prevent recurrent attack; not given during acute attack

4. MCP joint involvement
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Deposition of cholesterol in the periorbital skin
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

5. morning stiffness hand joints
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
SLE - only minutes; RA; hours;
Hypertriglyceridamia and hypercholesterolemia
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

6. Ca oxalate induced arthritis
AS; sometime only symptom is uveitis;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
ESRD

7. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Viral arthritis or RA
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

8. xanthomatous nodule
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
Dorsum of hands and the Achilies tendon
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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

9. pain in shoulder and pelvic girdle
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ESR; polymyalgia rheumatica; tx prednisone

10. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Dorsum of hands and the Achilies tendon
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

11. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Decrease urate secretion from kidney
Hyper triglyceridemia
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

12. Rayanaud's disease vs phenomenon
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Nodular lung densitieis with RA;
Symmetrical proximal weakness; increased CPK

13. pagets in xray
Erythematous-violaceous rash on the eyelids
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
Disseminated gonoccal infection

14. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
Xray every 3m

15. role HLA B27 in dx of ankylosing spondylitis
If person is HLA B27 positive
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If symptoms persist >6weeks

16. Tx of gout in patient with ESRD or hx GI bleeding
Hyperflexion of both wrists--characteristic pain in one min
PMR and giant cell arteritis; can be seen both together;
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

17. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Minocyclin - inhibits metalloproteases and slows joint damage
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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

18. heberdeen nodes
Arthritic sweling of DIP
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Abx -bedrest - exercise
Patello femoral pain syndrome

19. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Coronary atherosclerosis due to SLE
Arthritic sweling of DIP
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

20. PIP joint involment
SLE - only minutes; RA; hours;
ESRD
Minocyclin - inhibits metalloproteases and slows joint damage
Osteoarthirit (bouchard at pip - b comes first);

21. when SLE patient needs steroid
ESRD
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
Prednisone and cyclophosphamide
Hypertriglyceridamia and hypercholesterolemia

22. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Supplementation ca and vitamin D
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

23. phalen test
Hyperflexion of both wrists--characteristic pain in one min
Primary biliary cirrhosis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric 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

24. cylosporin used after renal transplantation
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
If person is HLA B27 positive
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Decrease urate secretion from kidney

25. anti-ds DNA antibody
Osteoarthirit (bouchard at pip - b comes first);
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Specific of dx of SLE
PMR and giant cell arteritis; can be seen both together;

26. mcp and PIP joint involvement
If person is HLA B27 positive
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Viral arthritis or RA

27. What should be chekcked before starting infliximab
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
PPD
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

28. complications of anti-cytokine therapy
Supplementation ca and vitamin D
High incidence of opportunistitc infection; reactivation of TB;
Patello femoral pain syndrome
Specific of dx of SLE

29. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Specific of dx of SLE
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Think about reiter (cannot see - cannot pee - cannot climb a tree)

30. When to stop statin if cpk elevated
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
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.
Check pedal pulses; in claudication pulses should diminish
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

31. colchicine
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
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. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
Measure ca and ALP; increased ALP and normal ca for dx;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Abx -bedrest - exercise

33. probenecid
ESRD
SLE - only minutes; RA; hours;
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
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

34. When to order MRI in LBP
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
If symptoms persist >6weeks
Hyperflexion of both wrists--characteristic pain in one min
Nodular lung densitieis with RA;

35. How to prevent glucocorticoid induced bone loss
Supplementation ca and vitamin D
Xray every 3m
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
Check pedal pulses; in claudication pulses should diminish

36. neck mass in sjogren patient
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Arthritic sweling of DIP
A for aortic regurg; s for prolapSe (MVP)

37. night back pain
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Malignancy - infection - vertebral fracture
Disseminated gonoccal infection
PMR and giant cell arteritis; can be seen both together;

38. tx pagets
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Order LFT - heat fractionation (bone burns and liver lives) - GGT
C for c ; crest syndrome
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

39. How glucocorticoid leads to bone loss
Think about reiter (cannot see - cannot pee - cannot climb a tree)
SLE - only minutes; RA; hours;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

40. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Xray every 3m

41. How to monitor disease activity in SLE
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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;

42. How to perform schober test
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pseudogout/hemochromatosis;
PMR and giant cell arteritis; can be seen both together;
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

43. Use of allopurinol after kidney transplant
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
SLE - only minutes; RA; hours;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible

44. right anterior knee pain and provoked by climbing stairs or prolong sitting
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Patello femoral pain syndrome
Nodular lung densitieis with RA;
Think about reiter (cannot see - cannot pee - cannot climb a tree)

45. Use of antibiotic in RA
Xray every 3m
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
High incidence of opportunistitc infection; reactivation of TB;
Minocyclin - inhibits metalloproteases and slows joint damage

46. gemfibrozil
Hyper triglyceridemia
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
If symptoms persist >6weeks
AS; sometime only symptom is uveitis;

47. When to start DMARD in RA
Patello femoral pain syndrome
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Primary biliary cirrhosis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

48. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
SLE - only minutes; RA; hours;
Supplementation ca and vitamin D
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

49. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

50. SLE with pleural effusion
PPD
Viral arthritis or RA
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Erythematous-violaceous rash on the eyelids