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. How to prevent glucocorticoid induced bone loss
Pt with significant organ involvement and have incomplete response to prednisone alone
Malignancy - infection - vertebral fracture
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Supplementation ca and vitamin D

2. colchicine
Viral arthritis or RA
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

3. anti-ds DNA antibody
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
C for c ; crest syndrome
Specific of dx of SLE

4. When to start DMARD in RA
Abx -bedrest - exercise
Increased serum ferritin (acute phase protein)
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

5. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Hyperflexion of both wrists--characteristic pain in one min
Viral arthritis or RA

6. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Deposition of cholesterol in the periorbital skin
Decrease urate secretion from kidney
Patello femoral pain syndrome
Pseudogout/hemochromatosis;

7. management of LBP
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
PMR and giant cell arteritis; can be seen both together;
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

8. cylosporin used after renal transplantation
Viral arthritis or RA
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Decrease urate secretion from kidney
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

9. when SLE patient needs steroid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ESR; polymyalgia rheumatica; tx prednisone

10. proximal muscle weakness; decreased tendon reflex; normal creat and ck
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
ESRD
Prophylactic agent to prevent recurrent attack; not given during acute attack
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

11. role HLA B27 in dx of ankylosing spondylitis
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

12. Raynauds phenomenon
Xray every 3m
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Arthritic sweling of DIP
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

13. How glucocorticoid leads to bone loss
Check pedal pulses; in claudication pulses should diminish
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
If symptoms persist >6weeks
Abx -bedrest - exercise

14. caplan syndrom
Hyper triglyceridemia
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Nodular lung densitieis with RA;

15. who gets reiters syndrome after chlamydia infection
If person is HLA B27 positive
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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
Hypertriglyceridamia and hypercholesterolemia

16. What should be chekcked before starting infliximab
Pseudogout/hemochromatosis;
Specific of dx of SLE
PMR and giant cell arteritis; can be seen both together;
PPD

17. How to differential lumbar spinal stenosis and disc herniation pain?
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
PMR and giant cell arteritis; can be seen both together;

18. conjunctivitis - urethritis - and spondyloarthopathy

Warning: Invalid argument supplied for foreach() in /var/www/html/basicversity.com/show_quiz.php on line 183

19. Gait in spinal stenosis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pseudogout/hemochromatosis;
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

20. allpurinol
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Prophylactic agent to prevent recurrent attack; not given during acute attack
Disseminated gonoccal infection

21. Tx of lupus nephritis
Prednisone and cyclophosphamide
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
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Order LFT - heat fractionation (bone burns and liver lives) - GGT

22. xanthelasma
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Deposition of cholesterol in the periorbital skin
Primary biliary cirrhosis
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

23. What is heliotrope sign
Dorsum of hands and the Achilies tendon
Erythematous-violaceous rash on the eyelids
Symmetrical proximal weakness; increased CPK
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

24. Use of allopurinol after kidney transplant
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

25. criteria for AS
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Osteoarthirit (bouchard at pip - b comes first);

26. glucocorticoid therapy
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
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
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

27. spondyloarthopathy
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
High incidence of opportunistitc infection; reactivation of TB;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

28. bouchard 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
Disseminated gonoccal infection
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

29. Finding of MRI in stenosis
Pseudogout/hemochromatosis;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

30. Tx of reiter
Xray every 3m
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Abx -bedrest - exercise
Pseudogout/hemochromatosis;

31. anti-mitochondrial
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Viral arthritis or RA
Malignancy - infection - vertebral fracture
Primary biliary cirrhosis

32. anterior shoulder 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.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pt with significant organ involvement and have incomplete response to prednisone alone

33. pagets in xray
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Measure ca and ALP; increased ALP and normal ca for dx;
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

34. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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

35. gemfibrozil
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Abx -bedrest - exercise
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Hyper triglyceridemia

36. patient pw groin pain; on steroid
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

37. heberdeen nodes
Hyper triglyceridemia
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Arthritic sweling of DIP
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

38. inflamed tendons in wrist - ankle - arms; sexual history
If symptoms persist >6weeks
Disseminated gonoccal infection
Patello femoral pain syndrome
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

39. complications of anti-cytokine therapy
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Dorsum of hands and the Achilies tendon
Xray every 3m
High incidence of opportunistitc infection; reactivation of TB;

40. Tx of gout in patient with ESRD or hx GI bleeding
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ESR; polymyalgia rheumatica; tx prednisone
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

41. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Malignancy - infection - vertebral fracture
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
AS; sometime only symptom is uveitis;

42. When to order MRI in LBP
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
If symptoms persist >6weeks
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

43. postoeriod shoulder pain
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Hyper triglyceridemia
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

44. night back pain
Malignancy - infection - vertebral fracture
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Measure ca and ALP; increased ALP and normal ca for dx;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

45. SLE patient p/w MI - vent fibrillation
Coronary atherosclerosis due to SLE
Deposition of cholesterol in the periorbital skin
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

46. Use of antibiotic in RA
Supplementation ca and vitamin D
ESRD
Minocyclin - inhibits metalloproteases and slows joint damage
SLE - only minutes; RA; hours;

47. probenecid
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
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

48. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Measure ca and ALP; increased ALP and normal ca for dx;

49. MCP joint involvement
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

50. Tx of inflammatory myositis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`