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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. Tx of reiter
A for aortic regurg; s for prolapSe (MVP)
ESRD
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Abx -bedrest - exercise

2. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Xray every 3m
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

3. carpal tunnel syndrom
Increased serum ferritin (acute phase protein)
Deposition of cholesterol in the periorbital skin
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

4. Ca oxalate induced arthritis
ESRD
A for aortic regurg; s for prolapSe (MVP)
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

5. morning stiffness hand joints
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
SLE - only minutes; RA; hours;
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

6. Rayanaud's disease vs phenomenon
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Xray every 3m

7. phalen test
Primary biliary cirrhosis
Hyperflexion of both wrists--characteristic pain in one min
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Dermatomyositis - in adult 2ndary to malignancy eg lung ca

8. Raynauds phenomenon
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
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Coronary atherosclerosis due to SLE

9. Gait in spinal stenosis
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Deposition of cholesterol in the periorbital skin
Patello femoral pain syndrome

10. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
AS; sometime only symptom is uveitis;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Xray every 3m

11. Use of antibiotic in RA
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
Minocyclin - inhibits metalloproteases and slows joint damage
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

12. Management of HTN during acute gout
ESRD
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Arthritic sweling of DIP

13. When to start DMARD in RA
Malignancy - infection - vertebral fracture
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

14. What should be chekcked before starting infliximab
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
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
PPD
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

15. who gets reiters syndrome after chlamydia infection
ESRD
PPD
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.
If person is HLA B27 positive

16. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
A for aortic regurg; s for prolapSe (MVP)
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

17. How to monitor disease activity in SLE
Prophylactic agent to prevent recurrent attack; not given during acute attack
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

18. night back pain
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Malignancy - infection - vertebral fracture

19. patient is having pain when he moves hands above shoulder
Check pedal pulses; in claudication pulses should diminish
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
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.

20. 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
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Coronary atherosclerosis due to SLE
Pt with significant organ involvement and have incomplete response to prednisone alone

21. anti-centromere ab
C for c ; crest syndrome
Increased serum ferritin (acute phase protein)
Nodular lung densitieis with RA;
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

22. management of LBP
High incidence of opportunistitc infection; reactivation of TB;
Pseudogout/hemochromatosis;
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;

23. PIP joint involment
Patello femoral pain syndrome
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Osteoarthirit (bouchard at pip - b comes first);

24. When to order MRI in LBP
If symptoms persist >6weeks
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
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

25. conjunctivitis - urethritis - and spondyloarthopathy

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26. DIP joint involvement

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27. right anterior knee pain and provoked by climbing stairs or prolong sitting
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
AS; sometime only symptom is uveitis;
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
Patello femoral pain syndrome

28. Use of allopurinol after kidney transplant
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
If symptoms persist >6weeks
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Patello femoral pain syndrome

29. SLE with pleural effusion
High incidence of opportunistitc infection; reactivation of TB;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Patello femoral pain syndrome
Symmetrical proximal weakness; increased CPK

30. primary muscle disease
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Symmetrical proximal weakness; increased CPK
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

31. gemfibrozil
ESRD
Increased serum ferritin (acute phase protein)
Hyper triglyceridemia
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle

32. heberdeen nodes
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
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

33. How to differentiate radicular pain with claudication
Measure ca and ALP; increased ALP and normal ca for dx;
Check pedal pulses; in claudication pulses should diminish
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

34. carpal tunnel
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Prednisone and cyclophosphamide
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

35. cylosporin used after renal transplantation
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Decrease urate secretion from kidney
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

36. pain in shoulder and pelvic girdle
SLE - only minutes; RA; hours;
Measure ca and ALP; increased ALP and normal ca for dx;
Measure ESR; polymyalgia rheumatica; tx prednisone
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

37. bouchard nodule
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
Disseminated gonoccal infection
Increased serum ferritin (acute phase protein)

38. patient pw groin pain; on steroid
Decrease urate secretion from kidney
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Patello femoral pain syndrome

39. What marker is used to follow up disease activity in SLE
If person is HLA B27 positive
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-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
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite

40. nicotinic acid
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Hypertriglyceridamia and hypercholesterolemia
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

41. anterior shoulder pain
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
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
Malignancy - infection - vertebral fracture

42. role HLA B27 in dx of ankylosing spondylitis
Check pedal pulses; in claudication pulses should diminish
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.
Measure ca and ALP; increased ALP and normal ca for dx;

43. complications of anti-cytokine therapy
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
High incidence of opportunistitc infection; reactivation of TB;
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

44. pagets in xray
If symptoms persist >6weeks
Measure ca and ALP; increased ALP and normal ca for dx;
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
Osteoarthirit (bouchard at pip - b comes first);

45. inflamed tendons in wrist - ankle - arms; sexual history
Abx -bedrest - exercise
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
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA

46. common valvular abnormalities with AS?
Specific of dx of 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
A for aortic regurg; s for prolapSe (MVP)
Arthritic sweling of DIP

47. SLE patient p/w MI - vent fibrillation
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Coronary atherosclerosis due to SLE

48. How to prevent glucocorticoid induced bone loss
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Supplementation ca and vitamin D
Abx -bedrest - exercise

49. Tx of lupus nephritis
Prednisone and cyclophosphamide
Coronary atherosclerosis due to SLE
Nodular lung densitieis with RA;
SLE - only minutes; RA; hours;

50. caplan syndrom
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
Nodular lung densitieis with RA;
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm