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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. SLE patient p/w MI - vent fibrillation
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
Coronary atherosclerosis due to SLE
Pt with significant organ involvement and have incomplete response to prednisone alone

2. common valvular abnormalities with AS?
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
Xray every 3m
A for aortic regurg; s for prolapSe (MVP)
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

3. What is heliotrope sign
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Erythematous-violaceous rash on the eyelids
Minocyclin - inhibits metalloproteases and slows joint damage
Abx -bedrest - exercise

4. gemfibrozil
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Hyper triglyceridemia
Think about reiter (cannot see - cannot pee - cannot climb a tree)
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine

5. When to order MRI in LBP
If symptoms persist >6weeks
Abx -bedrest - exercise
C for c ; crest syndrome
Supplementation ca and vitamin D

6. tx pagets
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Xray every 3m
Dermatomyositis - in adult 2ndary to malignancy eg lung ca
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;

7. anterior shoulder pain
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Biceps tendinitis; seen in patients with acromioclavicular or glenohumeral joint osteoarthritis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Measure ESR; polymyalgia rheumatica; tx prednisone

8. colchicine
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Check pedal pulses; in claudication pulses should diminish
Order LFT - heat fractionation (bone burns and liver lives) - GGT

9. Tx of gout in patient with ESRD or hx GI bleeding
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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
Dorsum of hands and the Achilies tendon

10. when SLE patient needs steroid
Malignancy - infection - vertebral fracture
Hyperflexion of both wrists--characteristic pain in one min
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
Tx ca channel blocker if no improvement look for systemic disease and order ANA - RF CBC - blood

11. anti-centromere ab
Erythematous-violaceous rash on the eyelids
Deposition of cholesterol in the periorbital skin
C for c ; crest syndrome
ESRD

12. bilater shoulder and thigh pain with prolonged morning stiffness - intermitted headache and jaw pain
PMR and giant cell arteritis; can be seen both together;
Supplementation ca and vitamin D
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
Hypertriglyceridamia and hypercholesterolemia

13. When to give methotrexate in SLE
Pt with significant organ involvement and have incomplete response to prednisone alone
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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

14. probenecid
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Osteoarthirit (bouchard at pip - b comes first);
PMR and giant cell arteritis; can be seen both together;
Deposition of cholesterol in the periorbital skin

15. pagets in xray
Patello femoral pain syndrome
Referred pain from cervical spine; due to nerve impingmement due to disc herniation; spinal stenosis at cervical spine levle
Measure ca and ALP; increased ALP and normal ca for dx;
If symptoms persist >6weeks

16. patient pw groin pain; on steroid
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat
Lateral or deltoid shoulder pain; caused by rotator cuff tenditnitis; or tear - impingemen t syndrom or frozen shoulder.

17. How to differential lumbar spinal stenosis and disc herniation pain?
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Viral arthritis or RA
Stenosis; pain improves with flexion or sittiing worse in extension; disc herniation opposite
Dorsum of hands and the Achilies tendon

18. MCP joint involvement
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
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
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm

19. tinel sign
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
C for c ; crest syndrome
Prednisone and cyclophosphamide
Prophylactic agent to prevent recurrent attack; not given during acute attack

20. How often disease activity is monitored in AS?
Patello femoral pain syndrome
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.
Xray every 3m
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

21. bouchard nodule
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Arthritis swelling of PIP (remember b comes first or proximal); present both in RA and OA
Hyper triglyceridemia
Order LFT - heat fractionation (bone burns and liver lives) - GGT

22. How to differentiate radicular pain with claudication
Specific of dx of SLE
Check pedal pulses; in claudication pulses should diminish
ESRD
Decrease urate secretion from kidney

23. cylosporin used after renal transplantation
Hyperflexion of both wrists--characteristic pain in one min
Decrease urate secretion from kidney
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`

24. spondyloarthopathy
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
If symptoms persist >6weeks

25. morning stiffness hand joints
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
SLE - only minutes; RA; hours;
High incidence of opportunistitc infection; reactivation of TB;
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;

26. postoeriod shoulder pain
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
Nodular lung densitieis with RA;
PMR and giant cell arteritis; can be seen both together;

27. PIP joint involment
PPD
Osteoarthirit (bouchard at pip - b comes first);
Erythematous-violaceous rash on the eyelids
PMR and giant cell arteritis; can be seen both together;

28. What marker is used to follow up disease activity in SLE
Arthritic sweling of DIP
Order LFT - heat fractionation (bone burns and liver lives) - GGT
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
High incidence of opportunistitc infection; reactivation of TB;

29. role HLA B27 in dx of ankylosing spondylitis
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Decrease urate secretion from kidney
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
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

30. Tx of lupus nephritis
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
Give calcium and vitamine D therapy ; bisphosphonate may be added if the risk highl bone densitometry
Prednisone and cyclophosphamide

31. morning stiffness <30min; 2nd and 3rd metacarpohalengeal joint - osteopenia - hook like osteophytes; aspiration cppd crystal
Erythematous-violaceous rash on the eyelids
Pseudogout/hemochromatosis;
Calcitonin or bisphosphonate to decrease bone turnover; hearing loss not reversible
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis

32. When to start DMARD in RA
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
1RA look for morning stiffness >30m - joint erosion in radiography - acute onset; pseudogout--stiffness <30min - comorbid conditions eg. hemochromatosis - dm
Early in the course of disease; methotrexate doc; if response no adequate add other dmard
Pt with significant organ involvement and have incomplete response to prednisone alone

33. Ca oxalate induced arthritis
ESRD
PPD
Measure ca and ALP; increased ALP and normal ca for dx;
Xray every 3m

34. Tx of RA
Tx methotrexate - disesase modifying drugs; if no improvemnet after 6m - anti-cytokine drug infliximab - etanercept;
Prophylactic agent to prevent recurrent attack; not given during acute attack
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss
Decrease urate secretion from kidney

35. caplan syndrom
Symmetrical proximal weakness; increased CPK
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Nodular lung densitieis with RA;
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications

36. When to stop statin if cpk elevated
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
Dorsum of hands and the Achilies tendon
Think about reiter (cannot see - cannot pee - cannot climb a tree)
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. pain in shoulder and pelvic girdle
ARBs and clonidine CI: HCTZ - furosemide - increases serum uric acid levels; aspirin decreases renal excretion of uric acid
Measure ESR; polymyalgia rheumatica; tx prednisone
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia
Measure ca and ALP; increased ALP and normal ca for dx;

38. Use of antibiotic in RA
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
Anti-dSdna and complement levels; they are deposited in mesangium or subendotherlial space and fixed with neutrophil;
Minocyclin - inhibits metalloproteases and slows joint damage

39. SLE with pleural effusion
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
Abx -bedrest - exercise
High dose corticosteroid (prednisone 1mg/kg) if fails - add immunosuppresant`
Decrease ca absorption in the gut; cause renal calcium wasting; direct anti anabolic efects on bone - suppress GnRH-->central hypogonadism--bone loss

40. Finding of MRI in stenosis
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;
Encroaching osteophytes; hypertrophy of ligamentum flavum - protrusion of intervertevra disks;
Pain - paresthesia in the medial n distribution; thumb - first two fingers; tx continuous wrist spint-reduce pressure on the nerve.

41. How to perform schober test
Presence not specific since it is present in other spondyloarthopathies but absence exclude AS
Measure ca and ALP; increased ALP and normal ca for dx;
Malignancy - infection - vertebral fracture
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

42. xanthomatous nodule
Dorsum of hands and the Achilies tendon
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Pseudogout/hemochromatosis;
A for aortic regurg; s for prolapSe (MVP)

43. painless ulcer over glans penis and inflammatory arthritis
MRI to eval osteonecrosis of femoral head; may also affect humeral head - femoral condyles - vertebra - hands and feet; tx total hip replacemebt
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.
Measure ca and ALP; increased ALP and normal ca for dx;

44. carpal tunnel
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
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
Used in acute attack. contraindicated when patient is taking azathioprine; s/e leukopenia

45. schirmer test
Inflammatory involvement of axial joints; first step - xray lumbosacral spine to demonstate sacrolitis and spondylitis
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.
Supplementation ca and vitamin D
Specific of dx of SLE

46. unilateral eye pain - photophobia - blurry vision young patients wih lumbar pain
AS; sometime only symptom is uveitis;
If person is HLA B27 positive
Tinel for tapping; reproduction of symptoms upon tapping or percussing over median n; phalen more sensitive than tinel
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

47. neck mass in sjogren patient
If symptoms persist >6weeks
Hydroxychloroquine and prednison; hydroxychloroquine effective against future damage kidneys and CNS - arthralgia - serositis and cutaneous symptomes. low dose prednisone until hydroxychloroquine ine effect.
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.
B cell lymphom; sjogren results in polyclonal B cell activation and infiltration in salivary gland; increased lymphocyte activation results in b cell lymphoma

48. management of LBP
Pain control and physical therapy - if fails - ESR -CRP - lumbar xray;
Spaghetti legs - walking like a drunken sailor; coz patient cannot extend spine
Abx -bedrest - exercise
Erythematous-violaceous rash on the eyelids

49. Low back pain
Gout - Reiter's syndrome-->urethritis/conjunctivitis; psoriasis
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
Disseminated gonoccal infection
Uricosuric. need creatinin clearance >350 or else ineffective; contraindicated in renal failure or post-transplnat

50. Rayanaud's disease vs phenomenon
Disease when it is idiopathic; phenomenon when 2ndary to connective tissue disease - vascular lesions - medications
Search for fever - hx cancer - IVDA - osteoporois; bowel/bladder incontinece/saddle anesthesia-->suspicion of cauda equina syndrome;
LBP with morning stiffness; limitation of lumbar spine ROM; limitation of chest expansion
Early in the course of disease; methotrexate doc; if response no adequate add other dmard