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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. right anterior knee pain and provoked by climbing stairs or prolong sitting
Symmetrical proximal weakness; increased CPK
Patello femoral pain syndrome
PMR and giant cell arteritis; can be seen both together;
AS; sometime only symptom is uveitis;

2. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Pt with significant organ involvement and have incomplete response to prednisone alone
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.
Decrease urate secretion from kidney

3. patient pw groin pain; on steroid
Deposition of cholesterol in the periorbital skin
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Measure ESR; polymyalgia rheumatica; tx prednisone
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

4. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Primary biliary cirrhosis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
PMR and giant cell arteritis; can be seen both together;

5. Tx of reiter
Abx -bedrest - exercise
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
Minocyclin - inhibits metalloproteases and slows joint damage

6. cylosporin used after renal transplantation
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Decrease urate secretion from kidney
SLE - only minutes; RA; hours;

7. Use of antibiotic in RA
Minocyclin - inhibits metalloproteases and slows joint damage
Prophylactic agent to prevent recurrent attack; not given during acute attack
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

8. How to perform schober test
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
Dorsum of hands and the Achilies tendon
Hyperflexion of both wrists--characteristic pain in one min

9. How to differentiate radicular pain with claudication
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Check pedal pulses; in claudication pulses should diminish

10. xanthelasma
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Measure ca and ALP; increased ALP and normal ca for dx;
Deposition of cholesterol in the periorbital skin
PPD

11. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Erythematous-violaceous rash on the eyelids
If symptoms persist >6weeks
Increased serum ferritin (acute phase protein)

12. Raynauds phenomenon
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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
Xray every 3m

13. Use of allopurinol after kidney transplant
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
PPD

14. anti-mitochondrial
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Malignancy - infection - vertebral fracture
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Primary biliary cirrhosis

15. Tx of inflammatory myositis
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
If symptoms persist >6weeks
Minocyclin - inhibits metalloproteases and slows joint damage
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

16. primary muscle disease
Symmetrical proximal weakness; increased CPK
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Pt with significant organ involvement and have incomplete response to prednisone alone

17. proximal muscle weakness; decreased tendon reflex; normal creat and ck
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Disseminated gonoccal infection

18. tinel sign
A for aortic regurg; s for prolapSe (MVP)
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Coronary atherosclerosis due to SLE
Viral arthritis or RA

19. inflamed tendons in wrist - ankle - arms; sexual history
Disseminated gonoccal infection
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Symmetrical proximal weakness; increased CPK
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid

20. nicotinic acid
Decrease urate secretion from kidney
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
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Hypertriglyceridamia and hypercholesterolemia

21. schirmer test
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Symmetrical proximal weakness; increased CPK
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.
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

22. Tx of lupus nephritis
Disseminated gonoccal infection
Prednisone and cyclophosphamide
Hyper triglyceridemia
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

23. Tx of gout in patient with ESRD or hx GI bleeding
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
Arthritic sweling of DIP
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
PPD

24. pagets in xray
PPD
Measure ca and ALP; increased ALP and normal ca for dx;
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

25. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Pt with significant organ involvement and have incomplete response to prednisone alone
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

26. common valvular abnormalities with AS?
Xray every 3m
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
A for aortic regurg; s for prolapSe (MVP)

27. Gait in spinal stenosis
Measure ca and ALP; increased ALP and normal ca for dx;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
If person is HLA B27 positive

28. Management of HTN during acute gout
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
AS; sometime only symptom is uveitis;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

29. How to differential lumbar spinal stenosis and disc herniation pain?
If symptoms persist >6weeks
Prednisone and cyclophosphamide
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Osteoarthirit (bouchard at pip - b comes first);

30. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Erythematous-violaceous rash on the eyelids
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

31. heberdeen nodes
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Viral arthritis or RA
SLE - only minutes; RA; hours;
Arthritic sweling of DIP

32. inflammatory myositis
Measure ca and ALP; increased ALP and normal ca for dx;
Increased serum ferritin (acute phase protein)
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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

33. anti-ds DNA antibody
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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
Specific of dx of SLE
Viral arthritis or RA

34. How often disease activity is monitored in AS?
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
AS; sometime only symptom is uveitis;
Xray every 3m
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. What marker is used to follow up disease activity in SLE
Deposition of cholesterol in the periorbital skin
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
Pseudogout/hemochromatosis;
Supplementation ca and vitamin D

36. when SLE patient needs steroid
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
AS; sometime only symptom is uveitis;
Malignancy - infection - vertebral fracture
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

37. anterior shoulder pain
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Nodular lung densitieis with RA;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

38. caplan syndrom
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Nodular lung densitieis with RA;
ESRD

39. conjunctivitis - urethritis - and spondyloarthopathy

40. night back pain
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Malignancy - infection - vertebral fracture

41. criteria for AS
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

42. PIP joint involment
Osteoarthirit (bouchard at pip - b comes first);
Specific of dx of SLE
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Primary biliary cirrhosis

43. Low back pain
Symmetrical proximal weakness; increased CPK
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
PMR and giant cell arteritis; can be seen both together;
Osteoarthirit (bouchard at pip - b comes first);

44. complications of anti-cytokine therapy
C for c ; crest syndrome
High incidence of opportunistitc infection; reactivation of TB;
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Specific of dx of SLE

45. What should be chekcked before starting infliximab
Pseudogout/hemochromatosis;
PPD
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
AS; sometime only symptom is uveitis;

46. anti-centromere ab
High incidence of opportunistitc infection; reactivation of TB;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
C for c ; crest syndrome
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

47. How glucocorticoid leads to bone loss
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.
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Disseminated gonoccal infection
If person is HLA B27 positive

48. SLE patient p/w MI - vent fibrillation
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Coronary atherosclerosis due to SLE
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

49. Rayanaud's disease vs phenomenon
Primary biliary cirrhosis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

50. MCP joint involvement
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
If person is HLA B27 positive
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