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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. patient pw groin pain; on steroid
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
A for aortic regurg; s for prolapSe (MVP)
Nodular lung densitieis with RA;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

2. glucocorticoid therapy
Disseminated gonoccal infection
PPD
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

3. Finding of MRI in stenosis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Patello femoral pain syndrome
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

4. anti-ds DNA antibody
Specific of dx of SLE
Order LFT - heat fractionation (bone burns and liver lives) - GGT
ESRD
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

5. What should be chekcked before starting infliximab
Prednisone and cyclophosphamide
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
PPD
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

6. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Decrease urate secretion from kidney
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

7. allpurinol
Prophylactic agent to prevent recurrent attack; not given during acute attack
Hypertriglyceridamia and hypercholesterolemia
Dorsum of hands and the Achilies tendon
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

8. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Hyperflexion of both wrists--characteristic pain in one min
Disseminated gonoccal infection
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

9. tx pagets
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Disseminated gonoccal infection

10. When to order MRI in LBP
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Measure ESR; polymyalgia rheumatica; tx prednisone
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
If symptoms persist >6weeks

11. schirmer test
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.
Deposition of cholesterol in the periorbital skin
Arthritic sweling of DIP

12. pagets in xray
PMR and giant cell arteritis; can be seen both together;
Measure ca and ALP; increased ALP and normal ca for dx;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
AS; sometime only symptom is uveitis;

13. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

14. heberdeen nodes
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
Arthritic sweling of DIP

15. anti-centromere ab
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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
C for c ; crest syndrome
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

16. How often disease activity is monitored in AS?
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
A for aortic regurg; s for prolapSe (MVP)
AS; sometime only symptom is uveitis;
Xray every 3m

17. management of LBP
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

18. How to prevent glucocorticoid induced bone loss
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.
Supplementation ca and vitamin D
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

19. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Specific of dx of SLE
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
PMR and giant cell arteritis; can be seen both together;

20. What is heliotrope sign
Erythematous-violaceous rash on the eyelids
Pseudogout/hemochromatosis;
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-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

21. colchicine
A for aortic regurg; s for prolapSe (MVP)
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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
Decrease urate secretion from kidney

22. spondyloarthopathy
Malignancy - infection - vertebral fracture
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
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

23. complications of anti-cytokine therapy
ESRD
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
High incidence of opportunistitc infection; reactivation of TB;
Osteoarthirit (bouchard at pip - b comes first);

24. painless ulcer over glans penis and inflammatory arthritis
Xray every 3m
Nodular lung densitieis with RA;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Think about reiter (cannot see - cannot pee - cannot climb a tree)

25. 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
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Measure ca and ALP; increased ALP and normal ca for dx;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

26. anti-mitochondrial
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Primary biliary cirrhosis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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

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

28. Tx of gout
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

29. Gait in spinal stenosis
Dorsum of hands and the Achilies tendon
Nodular lung densitieis with RA;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ESRD

30. postoeriod shoulder pain
Symmetrical proximal weakness; increased CPK
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

31. xanthomatous nodule
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Nodular lung densitieis with RA;
Dorsum of hands and the Achilies tendon
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

32. inflammatory myositis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
If symptoms persist >6weeks
Prednisone and cyclophosphamide
Increased serum ferritin (acute phase protein)

33. DIP joint involvement

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34. Tx of reiter
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
High incidence of opportunistitc infection; reactivation of TB;
Abx -bedrest - exercise
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

35. Tx of lupus nephritis
Prednisone and cyclophosphamide
AS; sometime only symptom is uveitis;
Patello femoral pain syndrome
Deposition of cholesterol in the periorbital skin

36. who gets reiters syndrome after chlamydia infection
High incidence of opportunistitc infection; reactivation of TB;
If person is HLA B27 positive
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

37. PIP joint involment
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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
Osteoarthirit (bouchard at pip - b comes first);
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

38. Management of HTN during acute gout
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
If person is HLA B27 positive
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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

39. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
A for aortic regurg; s for prolapSe (MVP)
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

40. when SLE patient needs steroid
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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
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
PMR and giant cell arteritis; can be seen both together;

41. What marker is used to follow up disease activity in SLE
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
Minocyclin - inhibits metalloproteases and slows joint damage
Arthritic sweling of DIP

42. How glucocorticoid leads to bone loss
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ESRD
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Malignancy - infection - vertebral fracture

43. MCP joint involvement
High incidence of opportunistitc infection; reactivation of TB;
If symptoms persist >6weeks
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

44. How to differential lumbar spinal stenosis and disc herniation pain?
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
Symmetrical proximal weakness; increased CPK
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Decrease urate secretion from kidney

45. night back pain
Malignancy - infection - vertebral fracture
Measure ESR; polymyalgia rheumatica; tx prednisone
Check pedal pulses; in claudication pulses should diminish
Primary biliary cirrhosis

46. Raynauds phenomenon
Measure ca and ALP; increased ALP and normal ca for dx;
Disseminated gonoccal infection
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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.

47. Ca oxalate induced arthritis
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Supplementation ca and vitamin D
ESRD
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

48. neck mass in sjogren patient
Minocyclin - inhibits metalloproteases and slows joint damage
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

49. Use of antibiotic in RA
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Minocyclin - inhibits metalloproteases and slows joint damage
Primary biliary cirrhosis

50. Use of allopurinol after kidney transplant
Abx -bedrest - exercise
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Increased serum ferritin (acute phase protein)
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