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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. caplan syndrom
Erythematous-violaceous rash on the eyelids
C for c ; crest syndrome
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Nodular lung densitieis with RA;

2. night back pain
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Malignancy - infection - vertebral fracture
Specific of dx of SLE
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. increased ALP; liver or bone origin?
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
AS; sometime only symptom is uveitis;
Viral arthritis or RA

4. pain in shoulder and pelvic girdle
Primary biliary cirrhosis
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
Measure ESR; polymyalgia rheumatica; tx prednisone

5. inflamed tendons in wrist - ankle - arms; sexual history
Check pedal pulses; in claudication pulses should diminish
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
Disseminated gonoccal infection

6. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Supplementation ca and vitamin D
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

7. When to give methotrexate in SLE
High incidence of opportunistitc infection; reactivation of TB;
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Pt with significant organ involvement and have incomplete response to prednisone alone

8. criteria for AS
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pseudogout/hemochromatosis;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Hyper triglyceridemia

9. pagets in xray
Measure ca and ALP; increased ALP and normal ca for dx;
Osteoarthirit (bouchard at pip - b comes first);
Patello femoral pain syndrome
Deposition of cholesterol in the periorbital skin

10. management of LBP
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Prophylactic agent to prevent recurrent attack; not given during acute attack
Minocyclin - inhibits metalloproteases and slows joint damage
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

11. Ca oxalate induced arthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
ESRD
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
C for c ; crest syndrome

12. heberdeen nodes
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Hypertriglyceridamia and hypercholesterolemia
Arthritic sweling of DIP
Pseudogout/hemochromatosis;

13. What is heliotrope sign
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
Patello femoral pain syndrome
Erythematous-violaceous rash on the eyelids

14. When to start DMARD in RA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Coronary atherosclerosis due to SLE

15. How glucocorticoid leads to bone loss
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Think about reiter (cannot see - cannot pee - cannot climb a tree)

16. How to differentiate radicular pain with claudication
AS; sometime only symptom is uveitis;
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
C for c ; crest syndrome
Check pedal pulses; in claudication pulses should diminish

17. cylosporin used after renal transplantation
Decrease urate secretion from kidney
Measure ca and ALP; increased ALP and normal ca for dx;
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
ESRD

18. glucocorticoid therapy
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
Supplementation ca and vitamin D
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

19. probenecid
Malignancy - infection - vertebral fracture
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pseudogout/hemochromatosis;

20. How to monitor disease activity in SLE
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Deposition of cholesterol in the periorbital skin
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

21. conjunctivitis - urethritis - and spondyloarthopathy

22. complications of anti-cytokine therapy
Malignancy - infection - vertebral fracture
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Prophylactic agent to prevent recurrent attack; not given during acute attack
High incidence of opportunistitc infection; reactivation of TB;

23. Finding of MRI in stenosis
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Hyperflexion of both wrists--characteristic pain in one min
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Prophylactic agent to prevent recurrent attack; not given during acute attack

24. patient is having pain when he moves hands above shoulder
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pseudogout/hemochromatosis;

25. who gets reiters syndrome after chlamydia infection
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hyper triglyceridemia
If person is HLA B27 positive

26. when SLE patient needs steroid
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Viral arthritis or RA
Decrease urate secretion from kidney
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

27. neck mass in sjogren patient
Patello femoral pain syndrome
Disseminated gonoccal infection
Deposition of cholesterol in the periorbital skin
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

28. common valvular abnormalities with 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
PMR and giant cell arteritis; can be seen both together;
A for aortic regurg; s for prolapSe (MVP)
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

29. DIP joint involvement

30. Tx of reiter
Specific of dx of SLE
Abx -bedrest - exercise
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
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

31. mcp and PIP joint involvement
Viral arthritis or RA
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Pseudogout/hemochromatosis;
Xray every 3m

32. xanthelasma
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
If person is HLA B27 positive
Arthritic sweling of DIP
Deposition of cholesterol in the periorbital skin

33. anti-mitochondrial
Decrease urate secretion from kidney
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
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Primary biliary cirrhosis

34. right anterior knee pain and provoked by climbing stairs or prolong sitting
Patello femoral pain syndrome
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Measure ESR; polymyalgia rheumatica; tx prednisone
PMR and giant cell arteritis; can be seen both together;

35. primary muscle disease
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Symmetrical proximal weakness; increased CPK
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine

36. SLE patient p/w MI - vent fibrillation
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Coronary atherosclerosis due to SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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

37. allpurinol
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 ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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

38. anti-centromere ab
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
C for c ; crest syndrome
Primary biliary cirrhosis

39. What should be chekcked before starting infliximab
Malignancy - infection - vertebral fracture
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
If person is HLA B27 positive
PPD

40. How to prevent glucocorticoid induced bone loss
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Supplementation ca and vitamin D
Deposition of cholesterol in the periorbital skin
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. Tx of gout in patient with ESRD or hx GI bleeding
PMR and giant cell arteritis; can be seen both together;
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
If symptoms persist >6weeks
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

42. nicotinic acid
Hypertriglyceridamia and hypercholesterolemia
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

43. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Nodular lung densitieis with RA;
Dorsum of hands and the Achilies tendon
Pseudogout/hemochromatosis;
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

44. painless ulcer over glans penis and inflammatory arthritis
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If symptoms persist >6weeks
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

45. Use of allopurinol after kidney transplant
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
Supplementation ca and vitamin D

46. colchicine
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
High incidence of opportunistitc infection; reactivation of TB;
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.
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

47. Tx of lupus nephritis
C for c ; crest syndrome
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
If symptoms persist >6weeks
Prednisone and cyclophosphamide

48. How to differential lumbar spinal stenosis and disc herniation pain?
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

49. Low back pain
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
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
Arthritic sweling of DIP
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

50. How to perform schober test
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Abx -bedrest - exercise