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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. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Pseudogout/hemochromatosis;
Supplementation ca and vitamin D
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Order LFT - heat fractionation (bone burns and liver lives) - GGT

2. painless ulcer over glans penis and inflammatory arthritis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

3. common valvular abnormalities with AS?
A for aortic regurg; s for prolapSe (MVP)
PMR and giant cell arteritis; can be seen both together;
Arthritic sweling of DIP
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

4. MCP joint involvement
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

5. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
PPD
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
AS; sometime only symptom is uveitis;

6. How often disease activity is monitored in AS?
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma
Xray every 3m
If symptoms persist >6weeks

7. What marker is used to follow up disease activity in SLE
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Measure ca and ALP; increased ALP and normal ca for dx;
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;

8. phalen test
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Hyperflexion of both wrists--characteristic pain in one min
Hyper triglyceridemia
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

9. 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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Measure ca and ALP; increased ALP and normal ca for dx;
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

10. DIP joint involvement

11. caplan syndrom
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Disseminated gonoccal infection
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Nodular lung densitieis with RA;

12. pagets in xray
Specific of dx of SLE
Nodular lung densitieis with RA;
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;

13. Tx of lupus nephritis
Measure ca and ALP; increased ALP and normal ca for dx;
Erythematous-violaceous rash on the eyelids
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Prednisone and cyclophosphamide

14. tx pagets
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
A for aortic regurg; s for prolapSe (MVP)

15. What should be chekcked before starting infliximab
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
PPD

16. carpal tunnel syndrom
Arthritic sweling of DIP
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
PPD
Prednisone and cyclophosphamide

17. allpurinol
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
Disseminated gonoccal infection
Prophylactic agent to prevent recurrent attack; not given during acute attack

18. complications of anti-cytokine therapy
Increased serum ferritin (acute phase protein)
High incidence of opportunistitc infection; reactivation of TB;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Malignancy - infection - vertebral fracture

19. bouchard nodule
SLE - only minutes; RA; hours;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Coronary atherosclerosis due to SLE
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

20. Gait in spinal stenosis
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
High incidence of opportunistitc infection; reactivation of TB;
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

21. primary muscle disease
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
ESRD
High incidence of opportunistitc infection; reactivation of TB;
Symmetrical proximal weakness; increased CPK

22. probenecid
High incidence of opportunistitc infection; reactivation of TB;
Check pedal pulses; in claudication pulses should diminish
ESRD
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

23. Low back pain
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
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
If symptoms persist >6weeks
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

24. How to differentiate radicular pain with claudication
Osteoarthirit (bouchard at pip - b comes first);
Check pedal pulses; in claudication pulses should diminish
Specific of dx of SLE
A for aortic regurg; s for prolapSe (MVP)

25. Use of antibiotic in RA
Prednisone and cyclophosphamide
Minocyclin - inhibits metalloproteases and slows joint damage
Erythematous-violaceous rash on the eyelids
Check pedal pulses; in claudication pulses should diminish

26. Tx of gout in patient with ESRD or hx GI bleeding
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Check pedal pulses; in claudication pulses should diminish

27. anti-mitochondrial
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Primary biliary cirrhosis
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
Hypertriglyceridamia and hypercholesterolemia

28. xanthomatous nodule
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.
Dorsum of hands and the Achilies tendon
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.
SLE - only minutes; RA; hours;

29. glucocorticoid therapy
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Osteoarthirit (bouchard at pip - b comes first);
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

30. SLE with pleural effusion
SLE - only minutes; RA; hours;
AS; sometime only symptom is uveitis;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
If person is HLA B27 positive

31. conjunctivitis - urethritis - and spondyloarthopathy

32. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
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
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
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. mcp and PIP joint involvement
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
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
Viral arthritis or RA
Disseminated gonoccal infection

34. gemfibrozil
Hyper triglyceridemia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

35. inflammatory myositis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
Hyperflexion of both wrists--characteristic pain in one min
Increased serum ferritin (acute phase protein)

36. night back pain
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Malignancy - infection - vertebral fracture
Measure ca and ALP; increased ALP and normal ca for dx;
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

37. xanthelasma
Deposition of cholesterol in the periorbital skin
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

38. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Symmetrical proximal weakness; increased CPK
Supplementation ca and vitamin D
Measure ESR; polymyalgia rheumatica; tx prednisone

39. anti-ds DNA antibody
Xray every 3m
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Specific of dx of SLE
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

40. patient is having pain when he moves hands above shoulder
Measure ca and ALP; increased ALP and normal ca for dx;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Prednisone and cyclophosphamide
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

41. How to differential lumbar spinal stenosis and disc herniation pain?
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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

42. Tx of gout
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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

43. When to order MRI in LBP
If symptoms persist >6weeks
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

44. How to monitor disease activity in SLE
Deposition of cholesterol in the periorbital skin
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
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.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

45. spondyloarthopathy
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Osteoarthirit (bouchard at pip - b comes first);
Symmetrical proximal weakness; increased CPK

46. carpal tunnel
Decrease urate secretion from kidney
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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

47. pain in shoulder and pelvic girdle
Viral arthritis or RA
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx
Measure ESR; polymyalgia rheumatica; tx prednisone
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

48. increased ALP; liver or bone origin?
Pt with significant organ involvement and have incomplete response to prednisone alone
Erythematous-violaceous rash on the eyelids
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Order LFT - heat fractionation (bone burns and liver lives) - GGT

49. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
If symptoms persist >6weeks
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

50. inflamed tendons in wrist - ankle - arms; sexual history
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
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
Disseminated gonoccal infection
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications