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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. Use of antibiotic in RA
Deposition of cholesterol in the periorbital skin
Minocyclin - inhibits metalloproteases and slows joint damage
A for aortic regurg; s for prolapSe (MVP)
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

2. complications of anti-cytokine therapy
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Pseudogout/hemochromatosis;
Arthritic sweling of DIP
High incidence of opportunistitc infection; reactivation of TB;

3. 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
If person is HLA B27 positive
Pseudogout/hemochromatosis;

4. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Osteoarthirit (bouchard at pip - b comes first);
Pseudogout/hemochromatosis;
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
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

5. painless ulcer over glans penis and inflammatory arthritis
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
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)

6. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
High incidence of opportunistitc infection; reactivation of TB;
Minocyclin - inhibits metalloproteases and slows joint damage
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

7. Tx of gout
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
ESRD
Hypertriglyceridamia and hypercholesterolemia

8. 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
C for c ; crest syndrome
Minocyclin - inhibits metalloproteases and slows joint damage
Increased serum ferritin (acute phase protein)

9. How to prevent glucocorticoid induced bone loss
Prophylactic agent to prevent recurrent attack; not given during acute attack
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Supplementation ca and vitamin D

10. pain in shoulder and pelvic girdle
Measure ESR; polymyalgia rheumatica; tx prednisone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
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. criteria for AS
High incidence of opportunistitc infection; reactivation of TB;
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
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.

12. primary muscle disease
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Symmetrical proximal weakness; increased CPK
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

13. DIP joint involvement

14. How to perform schober test
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Specific of dx of SLE
C for c ; crest syndrome

15. SLE with pleural effusion
Xray every 3m
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Specific of dx of SLE
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

16. inflammatory myositis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
A for aortic regurg; s for prolapSe (MVP)
Increased serum ferritin (acute phase protein)
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

17. Tx of lupus nephritis
Primary biliary cirrhosis
Prednisone and cyclophosphamide
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Minocyclin - inhibits metalloproteases and slows joint damage

18. night back pain
Malignancy - infection - vertebral fracture
Erythematous-violaceous rash on the eyelids
Hyper triglyceridemia
C for c ; crest syndrome

19. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Hypertriglyceridamia and hypercholesterolemia
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
Hyperflexion of both wrists--characteristic pain in one min

20. anti-centromere ab
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
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
Pseudogout/hemochromatosis;
C for c ; crest syndrome

21. carpal tunnel syndrom
Think about reiter (cannot see - cannot pee - cannot climb a tree)
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Symmetrical proximal weakness; increased CPK
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

22. SLE patient p/w MI - vent fibrillation
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Minocyclin - inhibits metalloproteases and slows joint damage
Measure ca and ALP; increased ALP and normal ca for dx;
Coronary atherosclerosis due to SLE

23. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)

24. How to differentiate radicular pain with claudication
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Disseminated gonoccal infection
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
Check pedal pulses; in claudication pulses should diminish

25. nicotinic acid
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Deposition of cholesterol in the periorbital skin
Hypertriglyceridamia and hypercholesterolemia
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

26. Gait in spinal stenosis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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

27. When to stop statin if cpk elevated
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
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
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

28. Tx of reiter
Abx -bedrest - exercise
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
Measure ESR; polymyalgia rheumatica; tx prednisone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

29. Management of HTN during acute gout
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
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
C for c ; crest syndrome

30. inflamed tendons in wrist - ankle - arms; sexual history
Primary biliary cirrhosis
Supplementation ca and vitamin D
Disseminated gonoccal infection
Increased serum ferritin (acute phase protein)

31. How to monitor disease activity in SLE
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Check pedal pulses; in claudication pulses should diminish
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS

32. morning stiffness hand joints
High incidence of opportunistitc infection; reactivation of TB;
SLE - only minutes; RA; hours;
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

33. What should be chekcked before starting infliximab
Nodular lung densitieis with RA;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
PPD
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

34. pagets in xray
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
A for aortic regurg; s for prolapSe (MVP)
Pt with significant organ involvement and have incomplete response to prednisone alone
Measure ca and ALP; increased ALP and normal ca for dx;

35. mcp and PIP joint involvement
Viral arthritis or RA
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Increased serum ferritin (acute phase protein)
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

36. proximal muscle weakness; decreased tendon reflex; normal creat and ck
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Supplementation ca and vitamin D
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel

37. anti-mitochondrial
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Primary biliary cirrhosis

38. 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
Measure ca and ALP; increased ALP and normal ca for dx;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

39. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
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

40. When to give methotrexate in SLE
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
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.
High incidence of opportunistitc infection; reactivation of TB;
Pt with significant organ involvement and have incomplete response to prednisone alone

41. gemfibrozil
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Dorsum of hands and the Achilies tendon
Hyper triglyceridemia

42. patient is having pain when he moves hands above shoulder
AS; sometime only symptom is uveitis;
Patello femoral pain syndrome
Decrease urate secretion from kidney
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

43. Tx of inflammatory myositis
Check pedal pulses; in claudication pulses should diminish
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Deposition of cholesterol in the periorbital skin
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

44. neck mass in sjogren patient
Prednisone and cyclophosphamide
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

45. Tx of gout in patient with ESRD or hx GI bleeding
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Xray every 3m

46. Ca oxalate induced arthritis
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
ESRD
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

47. bouchard nodule
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Minocyclin - inhibits metalloproteases and slows joint damage
Viral arthritis or RA

48. anti-ds DNA antibody
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Specific of dx of SLE
Prednisone and cyclophosphamide
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

49. What marker is used to follow up disease activity in SLE
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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
Erythematous-violaceous rash on the eyelids

50. How glucocorticoid leads to bone loss
Pt with significant organ involvement and have incomplete response to prednisone alone
Abx -bedrest - exercise
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS