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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. colchicine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
AS; sometime only symptom is uveitis;

2. when SLE patient needs steroid
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
If symptoms persist >6weeks
Symmetrical proximal weakness; increased CPK

3. inflammatory myositis
Increased serum ferritin (acute phase protein)
Disseminated gonoccal infection
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Erythematous-violaceous rash on the eyelids

4. When to start DMARD in RA
Supplementation ca and vitamin D
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Erythematous-violaceous rash on the eyelids
R/o myopathy; cannot be excluded by ck and creat; next step EMG; then muscle bx

5. management of LBP
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Malignancy - infection - vertebral fracture
SLE - only minutes; RA; hours;

6. Tx of reiter
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
Abx -bedrest - exercise
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

7. anti-mitochondrial
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
AS; sometime only symptom is uveitis;
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Primary biliary cirrhosis

8. tinel sign
Hyperflexion of both wrists--characteristic pain in one min
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Osteoarthirit (bouchard at pip - b comes first);
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

9. What should be chekcked before starting infliximab
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
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
PPD
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion

10. How to monitor disease activity in SLE
Measure ca and ALP; increased ALP and normal ca for dx;
C for c ; crest syndrome
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Think about reiter (cannot see - cannot pee - cannot climb a tree)

11. gemfibrozil
Viral arthritis or RA
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.
A for aortic regurg; s for prolapSe (MVP)
Hyper triglyceridemia

12. mcp and PIP joint involvement
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Supplementation ca and vitamin D
Arthritic sweling of DIP
Viral arthritis or RA

13. How to differentiate radicular pain with claudication
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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.
Check pedal pulses; in claudication pulses should diminish
High incidence of opportunistitc infection; reactivation of TB;

14. SLE patient p/w MI - vent fibrillation
Measure ESR; polymyalgia rheumatica; tx prednisone
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Coronary atherosclerosis due to SLE
If symptoms persist >6weeks

15. 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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood
Arthritic sweling of DIP
Viral arthritis or RA

16. pagets in xray
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
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
PPD

17. Use of antibiotic in RA
Hypertriglyceridamia and hypercholesterolemia
Specific of dx of SLE
Minocyclin - inhibits metalloproteases and slows joint damage
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

18. SLE with pleural effusion
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Prophylactic agent to prevent recurrent attack; not given during acute attack
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis

19. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Dorsum of hands and the Achilies tendon
Specific of dx of SLE
High incidence of opportunistitc infection; reactivation of TB;

20. phalen test
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.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
Hyperflexion of both wrists--characteristic pain in one min
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt

21. allpurinol
Measure ESR; polymyalgia rheumatica; tx prednisone
PPD
Increased serum ferritin (acute phase protein)
Prophylactic agent to prevent recurrent attack; not given during acute attack

22. morning stiffness hand joints
SLE - only minutes; RA; hours;
Viral arthritis or RA
Dorsum of hands and the Achilies tendon
Prophylactic agent to prevent recurrent attack; not given during acute attack

23. heberdeen nodes
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.
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
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

24. anterior shoulder pain
Arthritic sweling of DIP
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

25. Use of allopurinol after kidney transplant
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Decrease urate secretion from kidney
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Specific of dx of SLE

26. How to differential lumbar spinal stenosis and disc herniation pain?
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Viral arthritis or RA
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
AS; sometime only symptom is uveitis;

27. scaly eczema over knuckles-gottron's sign; proximal muscle weakness
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
Nodular lung densitieis with RA;
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

28. What marker is used to follow up disease activity in SLE
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
A for aortic regurg; s for prolapSe (MVP)
Minocyclin - inhibits metalloproteases and slows joint damage
PPD

29. Tx of gout
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
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
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
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

30. caplan syndrom
Nodular lung densitieis with RA;
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
If person is HLA B27 positive
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

31. painless ulcer over glans penis and inflammatory arthritis
Decrease urate secretion from kidney
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
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Primary biliary cirrhosis

32. carpal tunnel syndrom
Order LFT - heat fractionation (bone burns and liver lives) - GGT
Increased serum ferritin (acute phase protein)
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

33. glucocorticoid therapy
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Measure ESR; polymyalgia rheumatica; tx prednisone
Check pedal pulses; in claudication pulses should diminish
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry

34. conjunctivitis - urethritis - and spondyloarthopathy

35. inflamed tendons in wrist - ankle - arms; sexual history
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Disseminated gonoccal infection
Measure ca and ALP; increased ALP and normal ca for dx;
Measure ESR; polymyalgia rheumatica; tx prednisone

36. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
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;
Symmetrical proximal weakness; increased CPK
High incidence of opportunistitc infection; reactivation of TB;

37. patient pw groin pain; on steroid
PMR and giant cell arteritis; can be seen both together;
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
SLE - only minutes; RA; hours;

38. criteria for AS
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
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
AS; sometime only symptom is uveitis;
High incidence of opportunistitc infection; reactivation of TB;

39. bouchard nodule
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
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
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

40. Tx of inflammatory myositis
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Disseminated gonoccal infection
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;

41. anti-ds DNA antibody
Specific of dx of SLE
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

42. patient is having pain when he moves hands above shoulder
PMR and giant cell arteritis; can be seen both together;
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

43. spondyloarthopathy
Arthritic sweling of DIP
Supplementation ca and vitamin D
Prophylactic agent to prevent recurrent attack; not given during acute attack
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis

44. Tx of RA
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Hyper triglyceridemia
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
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;

45. schirmer 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
Malignancy - infection - vertebral fracture
Hyper triglyceridemia
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.

46. Management of HTN during acute gout
A for aortic regurg; s for prolapSe (MVP)
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
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
Early in the course of disease; methotrexate doc; if response no adequate add other dmard

47. night back pain
Increased serum ferritin (acute phase protein)
Malignancy - infection - vertebral fracture
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
C for c ; crest syndrome

48. anti-centromere ab
C for c ; crest syndrome
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Minocyclin - inhibits metalloproteases and slows joint damage
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

49. who gets reiters syndrome after chlamydia infection
Think about reiter (cannot see - cannot pee - cannot climb a tree)
If person is HLA B27 positive
Measure ESR; polymyalgia rheumatica; tx prednisone
C for c ; crest syndrome

50. How often disease activity is monitored in AS?
Pseudogout/hemochromatosis;
Xray every 3m
Measure ca and ALP; increased ALP and normal ca for dx;
Azathioprine dose need to be reduced. azathiprine decrease activity xanthine oxidase which also metabolize azathioprine